Mental Health Final

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Sophie is 11 years old and has a diagnosis of ADHD. Her parents report and provide documentation from her teachers that Sophie is distracted easily and is unable to complete classroom activities, even in the presence of minimal stimulation. A nursing diagnosis of noncompliance with task expectations has been determined, with a shortterm goal that Sophie will participate in and cooperate during therapeutic activities. Which nursing intervention is most appropriate?

Provide an environment for task efforts that is as free of distractions as possible.

____________________ aggression is associated with impulsivity and is more common among people who have a history of being abused.

Reactive

Why would a nurse establish goals for a client diagnosed with ADHD presenting with low frustration tolerance and short attention span that allow the client to complete part of the task, rewarding each step completion with a break for physical activity?

Short-term goals are not so overwhelming for clients with a short attention span

. The nurse would recognize which of the following as contributing factors to a client's development of ADHD? Select all that apply

The client has a sibling diagnosed with ADHD

After being found in an alley, Theresa was taken to a nearby emergency room. Upon her arrival, police notified the nurse that Theresa was a suspected rape victim, which Theresa confirmed. The doctor orders a rape kit to retrieve any DNA that may still be present on or in the victim. Which intervention by the nurse is appropriate?

Try to have as few people as possible collecting immediate evidence.

The nurse is caring for a 16-year-old client with ASD who is receiving risperidone for agitation. For which effects would the nurse monitor the client? Select all that apply.

Weight gain of 20 lb in 1 month Elevated blood glucose level Uncontrolled jaw movements

____________________ is defined by federal law as "a commercial sex act induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age."

human trafficking

The psychiatric-mental health nurse understands the goal of milieu therapy is which of the following?

To structure the environment to ensure a therapeutic experience

. The nurse determines that the goal has been met when the client with anger issues is able to___________________.

Transfer tension into artwork.

Which types of care would the interdisciplinary team of hospice provide? Select all that apply.

Physical care available on a 24-7 basis Discussions related to death and dying Assistance with obtaining spiritual support and guidance

Stress and its effect on the immune system are associated with which concepts? Select all that apply.

Physical illness Severity of depression Schizophrenia

3. A client diagnosed with major depressive disorder with psychotic features hears voices commanding self-harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time? Obtaining an order for locked seclusion until client is no longer suicidal Conducting 15-minute checks to ensure safety Placing the client on one-to-one observation while monitoring suicidal ideations Encouraging client to express feelings related to suicide

Placing the client on one-to-one observation while monitoring suicidal ideations

Which diagnostic imaging procedure would the nurse prepare the client for to determine neurotransmitter-receptor interaction?

Positron emission tomography (PET) scan

The nurse has realized that growing up in an alcoholic family may affect his or her ability to care for an individual client. This task is part of what phase of the therapeutic nurse-client relationship?

Preinteraction phase

A client who was discharged 2 weeks ago sends a thank-you card to the psychiatricmental health nurse and finds season tickets to the city's professional football team. Which of the following must the nurse consider when deciding whether to keep the tickets?

Professional boundaries

Which is associated with premenstrual dysphoric disorder (PMDD)? 1. Norepinephrine 2. Serotonin 3. Progesterone 4. Acetylcholine

Progesterone

Per behavioral theory, the treatment of phobic symptoms involves which action?

Progressive exposure of the phobia to the actual experience

Which of the following student statements about the complications of hepatic encephalopathy indicate further student teaching is needed? Select all that appl

"A diet rich in protein will promote hepatic healing." "In this condition, blood accumulates in the abdominal cavity."

The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? Select all that apply.

"Are you thinking about hurting yourself or someone else?" "Where do you keep your gun?" "Have you thought about how you would hurt yourself?"

17. A nursing instructor is teaching about suicide. Which student statement indicates that learning has occurred? "Suicidal threats and gestures should be considered manipulative and/or attention- seeking." "Suicide is the act of a psychotic person." "All suicidal individuals are mentally ill." "Between 50 and 80 percent of all people who kill themselves have a history of a previous attempt."

"Between 50 and 80 percent of all people who kill themselves have a history of a previous attempt."

Students in a community health nursing class recently attended a lecture regarding tobacco use. Which student statement reflects the lecturer's teaching was effective? 1. "The percentage of adult men who smoke is higher than that of women and adolescents."

"Clients with severe mental illness have higher rates of smoking than those without mental illness."

After years of dialysis, an 84-year-old states, "I'm exhausted, depressed, and done with these attempts to keep me alive." Which question should the nurse ask the spouse when preparing a discharge plan of care? "Have there been any changes in appetite or sleep?" "How often is your spouse left alone?" "Has your spouse been following a diet and exercise program consistently?" "How would you characterize your relationship with your spouse?"

"How often is your spouse left alone?" This client has many risk factors for suicide. The client should have increased supervision to decrease likelihood of self-harm.

Which of the following nursing statements exemplifies important insights to promote effective intervention with clients diagnosed with substance use disorders? Select all that apply

"I am easily manipulated and need to work on this prior to caring for these clients." "Because of my parent's alcoholism, I need to examine my attitude toward these clients." "Opioid addicts are typically uneducated, unrefined individuals who will need a lot of education and social skills training."

9. Prayer group members at a local Baptist church are meeting with a poor, homeless family they are supporting. Which member statement is an example of Yalom's curative group factor of altruism?

"I can give you all of my baby clothes for your little one." Yalom's curative group factor of altruism occurs when group members provide assistance and support to each other creating a positive self-image and promoting self-growth. Individuals increase self-esteem through mutual caring and concern.

After a teenager reveals that he is gay, his parent responds by beating him. The next morning, the teenager is found to have committed suicide. Which parental grief responses should a nurse anticipate? Select all that apply

"I can't believe this is happening." "If only I had been more understanding." "How dare he do this to me!" "Well, that was a selfish thing to do."

During a group discussion, members freely interact with each other. Which member statement is an example of Yalom's curative group factor of imparting information?

"I found a Web site explaining the different types of brain tumors and their treatment." Yalom's curative group factor of imparting information involves sharing knowledge gained through formal instruction as well as by the sharing of advice and suggestions by other group members.

During a group session, which client statement demonstrates that the group has progressed to the middle, or working, phase of group development?

"I think Joe's Antabuse suggestion is a good one and might work for me." The nurse should determine that group members have progressed to the working phase of group development when members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and then use it constructively to foster change.

Jillian is a client on a psychiatric unit for medication management related to her diagnosis of BPD. The nurse evaluates Jillian's care plan and confirms Jillian has reached her outcome goals when she makes which statement? Select all that apply

"I think my therapist is the best health-care professional in the world even though we didn't always see eye-to-eye." "I now understand that so much of my anger is due to the beatings I sustained as a child." "I had a strong urge to scratch myself yesterday, and when this happened I came looking for you.

Which statement describes the development of trust between the nurse and client?

"I will listen if you would like to tell me about your day.

A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to the nurse that discharge teaching about this medication has been successful? Select all that apply

"I'll have to let my surgeon know about this medication before surgery." "Guess I will have to give up my glass of red wine with dinner." "I'll have to be very careful about reading food and medication labels." "I'll be sure not to stop this medication abruptly."

Which client statement indicates the nurse's teaching about the effect of circadian rhythms is effective?

"I'm a morning person, so I get my best work done in the a.m."

Which of the following client statements would appear in a nursing assessment of a person exhibiting the appropriate expression of anger?

"I'm sick and tired of my family asking me how I am doing. How do they think I'm doing?"

A client is admitted to an inpatient psychiatric unit with the diagnosis of paranoid personality disorder. Which statement made by the client to the nurse reinforces the diagnosis? Select all that apply.

"It isn't my fault that I have a temper. I inherited it from my abusive parent." "I could have gone to nursing school like you, but I never had good science teachers." "My roommate doesn't talk to me unless she wants something

The psychiatric-mental health nurse is counseling a client whose infant recently died from sudden infant death syndrome. Which nursing response demonstrates empathy?

"It must have been frightening when you realized something was wrong."

13. A suicidal client says to a nurse, "There's nothing to live for anymore." Which is the most appropriate nursing reply? "Why don't you consider doing volunteer work in a homeless shelter?" "Let's discuss the negative aspects of your life." "Things will look better in the morning." "It sounds like you are feeling pretty hopeless."

"It sounds like you are feeling pretty hopeless."

Which statement indicates that the nurse is acting as an advocate for a client who was hospitalized after a suicide attempt and is now nearing discharge?

"Let's review the resources that you may need after discharge."

A nursing instructor is teaching students about self-help groups like Alcoholics Anonymous (AA). Which student statement indicates that learning has occurred?

"Members themselves run the group, with leadership usually rotating among the members." The student indicates an understanding of self-help groups when stating, "Members themselves run the group, with leadership usually rotating among the members." Nurses may or may not be involved in self-help groups. These groups allow members to talk about feelings and reduce feelings of isolation while receiving support from others undergoing similar experiences.

Which statement made by the nursing student indicates an understanding regarding the role of the social worker?

"My client cannot afford medications when they are discharged, so the social worker is arranging some assistance."

14. A new nursing graduate asks the psychiatric nurse manager how to best classify suicide. Which is the nurse manager's best reply? "Suicide is a DSM-5 diagnosis." "Suicide is a mental disorder." "Suicide is a behavior." "Suicide is an antisocial affliction."

"Suicide is a behavior."

A stockbroker commits suicide after being convicted of insider trading. In speaking with the family, which statement by the nurse demonstrates accurate and appropriate sharing of information? "Your grieving will subside within 1 year; until then I recommend antidepressants." "Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area." "The only way to deal effectively with this kind of grief is to write a letter to the brokerage firm to express your anger with them." "Since stigmatization often occurs in these situations, it would be best if you avoid discussing the suicide with anyone."

"Support groups are available specifically for survivors of suicide, and I would be glad to help you locate one in this area."

Which nursing statements demonstrate useful feedback? Select all that apply.

"The hospital has a support group on Tuesdays for those who want to quit smoking." "It appears you want to sit near the nurses' station when the morning meeting starts." "I noticed you participated in group more this afternoon than this morning."

A client diagnosed with major depressive disorder asks, "Which part of my brain controls my emotions?" Which nursing response is best?

"The limbic system is largely responsible for one's emotional state."

Which student statement indicates that teaching has been effective regarding the function of the monoamine category of neurotransmitters?

"These regulate mood, cognition, and perception."

The emergency department nurse is providing discharge instructions to a 23-year-old man who was injured in a motor vehicle crash. The client stated, "My heart was racing when I saw the car coming through the red light was going to hit me. I didn't know my heart could go that fast!" Which is the nurse's best response?

"Your body responded to the stress of knowing the car was going to hit you."

1. A nurse discovers a client's suicide note that details the time, place, and means to commit suicide. What should be the priority nursing intervention and the rationale for this action? -Administering lorazepam (Ativan) prn, because the client is angry about the discovery of the note -Establishing room restrictions, because the client's threat is an attempt to manipulate the staff -Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide -Calling an emergency treatment team meeting, because the client's threat must be addressed

-Placing this client on one-to-one suicide precautions, because the more specific the plan, the more likely the client will attempt suicide

A client has undergone psychological testing. With which member of the interdisciplinary team would a nurse collaborate to review these results?

. Clinical psychologist

What is likely to happen if anger is communicated passive-aggressively or aggressively?

. Conflict escalates, and the problem that created the conflict goes unresolved

Nursing care of a client with a diagnosis of substance-induced anxiety disorder must take into consideration the nature of the substance and if the symptoms are in the context of which of the following? Select all that apply

. Intoxication. Withdrawal

A client tells the nurse she is anxious and loudly demands the nurse give her lorazepam right now. The nurse replies, "I understand you are having anxiety; however, demanding medication in a loud voice is unacceptable behavior." Which type of intervention is the nurse implementing?

. Limit setting

. Which neurotransmitter is associated with the fight-or-flight response of a restless, agitated client?

. Norepinephrine

An instructor is teaching nursing students about Worden's grief process. Which client behaviors serve to delay or prolong the grieving process? Select all that apply

. Refusing to allow self to think painful thoughts Using alcohol and drugs Idealizing the object of loss

Neurological tests have ruled out pathology in a client's sudden lower-extremity paralysis. Which nursing care would be included for this client? 1. Deal with physical symptoms in a detached manner. 2. Challenge the validity of physical symptoms. 3. Meet dependency needs until the physical limitations subside. 4. Encourage a discussion of feelings about the lower-extremity problem.

The family of a client diagnosed with conversion disorder asks the nurse, "Will his paralysis ever go away?" Which response by the nurse is evidence based? 1. "Most symptoms of conversion disorder resolve within a few weeks." 2. "Typically, people who have conversion disorder symptoms that include paralysis will be paralyzed for the rest of their lives." 3. "The only people who recover are those who develop conversion disorder symptoms without a precipitating stressful event." 4. "Technically, he could walk now since he is intentionally feigning paralysis."

The nurse documents assessment findings of a client who is unable to recall all specifics related to compound childhood traumas. Which disorder is the client experiencing? 1. Localized amnesia 2. Selective amnesia 3. Generalized amnesia 4. Retrograde amnesia

The nurse is educating a client diagnosed with Munchausen syndrome. Which statement made by the nurse is correct? 1. "A characteristic of your disorder is that you fabricate signs and symptoms of illness." 2. "Having your condition means that you hear voices that guide your actions." 3. "Your condition causes you to experience a change in body function that cannot be explained." 4. "Your symptom of memory loss is very common in your condition."

The nurse is working with a client diagnosed with somatic symptom disorder. Which predominant symptoms would the nurse expect to assess? 1. Disproportionate and persistent thoughts about the seriousness of one's symptoms 2. Amnestic episodes in which the client is pain free 3. Excessive time spent discussing psychosocial stressors 4. Lack of physical symptoms

Which scenario best describes Munchausen by proxy? 1. A wife makes her husband ill so she can be seen as the hero when bringing him to the emergency department. 2. A client uses three personalities to block out the trauma of sexual abuse experienced as a child. 3. A former soldier thinks back to an experience and sees himself observing from a distance and wonders what he would do in that situation. 4. A client has a strong desire to be pregnant and has morning sickness and symptoms associated with pregnancy but has a negative pregnancy test.

Which student statement about clients diagnosed with this disorder indicates that learning has occurred regarding the etiology of dissociative disorders from a psychoanalytical perspective? 1. "Dissociative behaviors occur when individuals repress distressing mental information from their conscious awareness." 2. "When their physical symptoms relieve them from stressful situations, their amnesia is reinforced. 3. "People with dissociative disorders typically have strong egos." 4. "There is clear and convincing evidence of a familial predisposition to this disorder."

The nurse has been caring for a client diagnosed with GAD. Which of the following nursing interventions address this client's symptoms? Select all that apply

1. Encourage the client to recognize the signs of escalating anxiety 3. Encourage the client to employ newly learned relaxation techniques. 4. Encourage the client to reframe cognitively thoughts about situations that generate anxiety. 5. Encourage the client to avoid caffeinated products.

9. The nurse is teaching parents of a 14-year-old client diagnosed with anorexia nervosa about prescribed medications. Which carries a black-box warning? 1. Fluoxetine 2. Phenelzine 3. Topiramate 4. Amitriptyline

1. This is correct. Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), carries a black-box warning about the risk of increased suicidal ideation in adolescents.

A client is diagnosed with a dissociative disorder. Which actions would the nurse take when teaching the client about her disorder? Select all that apply. 1. The nurse should determine if the client is anxious. 2. The nurse should explore the client's fears. 3. The nurse should ask the physician to explain test results to the client. 4. The nurse should ask the family to engage in role-play.

1, 2

A client is diagnosed with somatic symptom disorder. Which question will help the nurse develop nursing diagnoses for this client's plan of care? Select all that apply. 1. "Have you had thoughts of self-harm?" 2. "How many physicians have you seen in the past 6 months?" 3. "Do you take medication for anxiety as prescribed?" 4. "When did you last feel detached from your environment?" 5. "How long have you had these memory problems?"

1, 2, 3

A 56-year-old is brought to the emergency department by the police because she was found wandering confusedly in a busy shopping center several miles from her home. The nurse assesses the client and finds that she has been the victim of domestic violence for 32 years and has recently been beaten by her spouse. Her recollection of current events is hazy and she is not able to give the nurse a detailed account of the abuse. Which of the client's symptoms cause the nurse to suspect that she is suffering from dissociative fugue? Select all that apply. 1. Her trip to a shopping center several miles from her home 2. The client's confused wandering 3. Her ability to stay with an abuser all these years 4. The client's inability to offer details about the domestic abuse

1, 2, 4

A client is diagnosed with illness anxiety disorder. Which symptoms is the client most likely to exhibit? Select all that apply. 1. Obsessive-compulsive traits 2. Pseudocyesis 3. Disabling fear of having a serious illness 4. Multiple pronounced physical symptoms 5. Depression

1, 3, 5

A client is exhibiting symptoms of generalized amnesia. Which questions would the nurse ask to confirm this diagnosis? Select all that apply. 1. "Can you tell me your name and where you live?" 2. "Have you ever traveled suddenly or unexpectedly away from home?" 3. "Have you recently experienced any traumatic event?" 4. "Have you ever felt detached from your environment?" 5. "Have you had any history of memory problems?"

1, 5

A client with depression and substance abuse has an interrupted sleep pattern. She demands that her psychiatrist prescribe her a sedative. What teaching would the nurse provide about the rationale for the use of nonpharmacological interventions instead? 1. "Sedative-hypnotics are potentially addictive and gradually lose their effectiveness as one builds up tolerance to them." 2. "Sedative-hypnotics work best in combination with other techniques." 3. "Sedative-hypnotics are not permitted for use in patients with substance abuse disorders." 4. "Sedative-hypnotics are not as effective as the antidepressant medications for treating sleep disturbances."

1. "Sedative-hypnotics are potentially addictive and gradually lose their effectiveness as one builds up tolerance to them."

A client who has been diagnosed with a phobic disorder asks the nurse if there are any medications that would be beneficial in treating phobic disorders. Which of the following responses by the nurse are accurate? Select all that apply.

1. "Some antianxiety agents have been successful in treating social phobias." 2. "Some antidepressant agents have been successful in diminishing symptoms of agoraphobia and social anxiety disorder (social phobia)." 3. "Specific phobias are generally not treated with medication unless accompanied by panic attacks." 4. "Beta blockers have been used successfully to treat phobic responses to public performance."

Joey, age 8 years, takes methylphenidate (Ritalin) for attention deficit/hyperactivity disorder. His mother complains to the nurse that Joey has a very poor appetite, and she struggles to help him gain weight. What teaching will the nurse provide? 1. Administer Joey's medication immediately after meals. 2. Administer Joey's medication at bedtime. 3. Skip a dose of the medication when Joey does not eat anything. 4. Assure Joey's mother that Joey will eat when he is hungry.

1. Administer Joey's medication immediately after meals.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which potentially fatal side effect will the nurse teach the client about? 1. Agranulocytosis 2. Akathisia 3. Dystonia 4. Akinesia

1. Agranulocytosis

Which statements regarding antisocial personality disorder are true? Select all that apply.

1. Antisocial personality disorder is more common in men than in women and among the lower socioeconomic classes. 2. Clients with antisocial personality disorder have difficulty maintaining relationships and remaining employed

A client diagnosed with DID has likely been diagnosed with which disorders in the past? Select all that apply. 1. Attention deficit-hyperactivity disorder 2. Depression 3. Bipolar Disorder 4. Epilepsy 5. Oppositional Defiant Disorder 6. Schizophrenia

2, 3, 4, 6

The client is a young adult who has been arrested for several petty crimes in the past. Recently, the client was arrested for physically assaulting a patron in a bar after they exchanged aggressive words. Upon evaluation, he is diagnosed with antisocial personality disorder. The nurse caring for him includes the nursing diagnosis "risk for other-directed violence" in his care plan. Which nursing intervention is most appropriate for the client? Select all that apply.

1. Keeping all promises made to the client 2. Turning down the client's light after care is completed 4. Encouraging the client to exercise when he becomes frustrated

The nurse is preparing to assess a client before the physician prescribes a regimen of psychopharmacological therapy. Which components will the nurse assess? (Select all that apply.) 1. Medical history 2. Physical examination findings 3. Ethnocultural characteristics 4. Current medication

1. Medical history 2. Physical examination findings 3. Ethnocultural characteristics 4. Current medication (ALL)

A psychiatrist prescribes a MAOI for a client. When teaching the client about the effects of tyramine, which foods will the nurse caution the client to avoid? 1. Pepperoni pizza and red wine 2. Bagels with cream cheese and tea 3. Apple pie and coffee 4. Potato chips and Diet Coke

1. Pepperoni pizza and red wine Both these foods are high in tyramine.

Which information suggests that caution is necessary in prescribing a benzodiazepine to an anxious client? 1. The client has a history of alcohol dependence. 2. The client has a history of diabetes mellitus. 3. The client has a history of schizophrenia. 4. The client has a history of hypertension.

1. The client has a history of alcohol dependence. Tolerance and psychological dependence are common problems with the long-term use of benzodiazepines. They should be used cautiously with clients who have a history of substance abuse.

2. The nurse is preparing an education program regarding early identification of students at risk for developing anorexia nervosa. Which client does the nurse recognize as having the highest risk of developing an eating disorder? 1. Female ballet dancer 2. Female cheerleader 3. Male wrestler 4. Male swimmer

1. This is correct. A ballet dancer has a seven times greater risk of developing anorexia nervosa among females

17. Which statement does the nurse recognize as exemplifying the level of cognitive function of a client experiencing mild anxiety? 1. "Right now I feel as sharp as a tack." 2. "I'm having a tough time focusing." 3. "Sometimes I feel like I'm having an out-of-body experience." 4. "All I seem to focus on is my anger."

1. This is correct. A client experiencing mild anxiety has enhanced cognitive ability. Mild anxiety prepares the individual for heightened responses to environmental stimuli.

15. A nursing instructor is teaching about dichotomous thinking. Which student statement indicates learning has occurred? 1. "Dichotomous thinking is when an individual views a situation as being good or bad or black or white." 2. "Dichotomous thinking is when an individual takes complete responsibility for situations without considering other circumstances." 3. "Dichotomous thinking is when an individual exaggerates the negative significance of an event." 4. "Dichotomous thinking is when an individual undervalues the positive significance of an event."

1. This is correct. An individual who is using dichotomous thinking views situations in terms of all or nothing, good or bad, or black or white.

10. Beck's original concept for cognitive behavior therapy has been expanded by many theorists, but the foundation remains. Which of the following best describes the historical foundation of cognitive behavior therapy? 1. Rejection of passive listening used in psychoanalysis in favor of active, direct dialogues with clients. 2. Utilization of the psychoanalytic view of seeing depression as "anger turned inward." 3. Recognition that cognitive behavior therapy works for depression but not for other emotional disorders. 4. Cognitive behavior therapy has been the forefront of the Freudian framework of psychoanalysis.

1. This is correct. Beck was trained in the Freudian psychoanalytic view of depression but began to observe a common theme of negative cognitive processing in thoughts and dreams of his depressed clients.

1. Which of the following best defines the basis of cognitive behavior therapy? 1. Cognitive behavior therapy is based on the concept that distorted thoughts are the foundation of many emotional, mental, and behavioral disorders. 2. Cognitive behavior therapy is based on the concept that higher education can prevent emotional, mental, and behavioral disorders. 3. Cognitive behavior therapy is based on the concept that a contingency contract can help a client develop adaptive behaviors. 4. Cognitive behavior therapy is based on a reward system of positive reinforcement of positive self-statements.

1. This is correct. Cognitive behavior therapy is based on the theory that distorted perceptions, or cognition, are the foundation of many emotional, mental, and behavioral disorders

18. The nurse assigns the nursing diagnosis "ineffective coping related to feelings of helplessness" to a client diagnosed with bulimia nervosa. Which is the most appropriate outcome related to this nursing diagnosis? 1. Exhibits ability to use adaptive strategies to cope with emotional issues 2. Achieves and maintains an expected BMI for weight and age 3. Demonstrates positive self-esteem by verbalizing positive aspects of self 4. Identifies consequences of fluid loss caused by self-induced vomiting

1. This is correct. Emotional issues must be resolved if these maladaptive responses are to be eliminated. Identifying alternative methods to deal with isolation will provide the client with healthier coping strategies.

7. An advanced practice nurse is counseling a client diagnosed with generalized anxiety disorder. The nurse plans to use activity scheduling to address this client's concerns. What is the purpose of this nursing intervention? 1. To identify important areas needing concentration during therapy 2. To increase self-esteem and decrease feelings of helplessness 3. To modify maladaptive behaviors using role-play 4. To divert away from intrusive thoughts and depressive ruminations

1. This is correct. In activity scheduling, the client is asked to keep a daily log of activities and rate them for mastery and pleasure to identify recurring daily patterns that can be addressed in therapy.

10. A nursing instructor is teaching students about eating disorders. Which statement indicates that a student understands the differences between anorexia nervosa and bulimia nervosa? 1. "Clients diagnosed with anorexia nervosa exhibit malnutrition and dehydration." 2. "Hyperkalemia and hyponatremia are associated with anorexia nervosa." 3. "Signs of bulimia nervosa include hypotension, edema, and erosion of tooth enamel." 4. "Amenorrhea and parotid gland enlargement are symptoms of bulimia nervosa."

1. This is correct. Individuals diagnosed with anorexia nervosa exhibit nutritional deficits, malnutrition, and dehydration due to caloric restriction.

3. A successful business executive continually thinks her job accomplishments are not adequate. The nurse recognizes the client's thinking reflects which cognitive error? 1. Minimization 2. Dichotomous thinking 3. Arbitrary inference 4. Personalization

1. This is correct. Minimization is the cognitive error that undervalues positive events and experiences. The client cannot give credit for personal strengths.

24. A nurse practitioner uses cognitive behavior therapy with depressed clients. The nurse asks clients to keep a daily record of dysfunctional thoughts (DRDT). Which of the following are appropriate nursing replies to a client asking about the purpose of this exercise? Select all that apply. 1. "The purpose of this exercise is to identify automatic thoughts." 2. "The purpose of this exercise is to identify rational alternatives." 3. "The purpose of this exercise is to modify cognitive errors." 4. "The purpose of this exercise is to eliminate irrational beliefs."

1. This is correct. The DRDT is a tool commonly used in cognitive behavior therapy to help clients identify automatic thoughts. 2. This is correct. The DRDT is a tool commonly used in cognitive behavior therapy to help clients generate rational alternatives. 3. This is correct. The DRDT is a tool commonly used in cognitive behavior therapy to help clients modify thinking.

11. A high-school basketball player sustains a serious knee injury and states to the school nurse, "I will never get into college if I don't receive a basketball scholarship." Which nursing reply would assist the student to see a broader range of possibilities? 1. "Let's look at the alternatives for funding your college education." 2. "I know you are feeling helpless now, but you are looking at this from only one perspective." 3. "Can your family afford knee surgery?" 4. "You now need to prioritize your academics and not focus on basketball."

1. This is correct. The cognitive technique of generating alternatives will help the student see a broader range of possibilities.

19. Using a cognitive approach, which intervention would the nurse choose to assist clients in managing anger without the use of violence? 1. Assist the client in identifying thoughts that trigger anger and substitute reality-based thinking. 2. Provide consequences, such as removal from group therapy, in response to angry outbursts. 3. Administer antipsychotic medications and use limit setting, such as a room restriction. 4. Administer antianxiety medication, and encourage participation in a group on medication actions.

1. This is correct. The nurse can help the client to alter dysfunctional beliefs that predispose the client to distort experiences by assisting the client in identifying thoughts that trigger anger and encourage the substitution of reality-based thinking

9. A nursing student evaluates her group project partner as irresponsible because of minimal participation in planning. When told of this situation, the nursing instructor plans to use the cognitive technique of examining the evidence. Which response by the nursing instructor exemplifies this technique? 1. "Let's look at the potential reasons why your partner has not participated." 2. "How do you define irresponsibility?" 3. "Has it occurred to you that your partner may be working on the project at home?" 4. "Are you telling me that you feel totally responsible for this project?"

1. This is correct. The nursing instructor uses the technique of examining evidence to help review data that supports or contradicts the accuracy of the student beliefs

In the treatment of anxiety disorders, benzodiazepines (such as Ativan and Xanax) are indicated for_________ use and have__________ abuse potential. 1. short-term; high 2. long-term; high 3. short-term; low 4. long-term; low

1. short-term; high Because tolerance to these medications occurs, there is high risk for abuse. Therefore, they should be used as a short-term intervention for anxiety.

A healthy adolescent client with no history of substance abuse presents to the mental health clinic. This client tells the nurse that she has experienced several episodes where she feels like she is watching a movie of herself where she is floating above and watching herself as an outside observer. She asks the nurse what is wrong with her. Which statement made by the nurse is most appropriate? 1. "You have derealization disorder and must be treated for this immediately." 2. "These may be symptoms of depersonalization disorder, but I'm going to suggest you meet with the psychiatrist for a diagnosis." 3. "You must be schizophrenic. I'm going to ask the psychiatrist to run some tests on you." 4. "I wouldn't worry about these symptoms. These are typical for female teenagers who are experiencing hormonal changes."

Which outcome is appropriate when planning care for an inpatient client diagnosed with somatic symptom disorder? 1. The client will admit to fabricating physical symptoms to gain benefits by day 3. 2. The client will list three potential adaptive coping strategies to deal with stress by day 2. 3. The client will comply with medical treatments for physical symptoms by day 3. 4. The client will openly discuss physical symptoms with staff by day 4.

Which statement accurately describes dissociative fugue? 1. Dissociative fugue is not precipitated by stressful events. 2. Dissociative fugue is characterized by sudden, unexpected travel or bewildered wandering with inability to recall some or all of one's past. 3. Dissociative amnesia and dissociative fugue are completely different types of disorders. 4. Dissociative fugue is characterized by a sense of observing oneself from outside the body.

A client was recently admitted to the inpatient unit after a suicide attempt and has not responded to SSRIs or tricyclic antidepressants. The client asks the nurse, "I heard about monoamine oxidase inhibitors (MAOIs). Why can't they be added to what I am on now? Wouldn't adding one help?" Which is the appropriate nursing response? 1. "Electroconvulsive therapy is your best option at this point." 2. "Combined use can lead to a life-threatening condition called hypertensive crisis." 3. "There is no reason why an MAOI couldn't be added to your therapy." 4. "They can't be used together because their mechanisms of action are very different."

2. "Combined use can lead to a life-threatening condition called hypertensive crisis."

A client was recently admitted to the inpatient unit after a suicide attempt. He has been placed on a tricyclic antidepressant. In terms of medication, what steps should be taken to maintain the client's safety when he is discharged? 1. Provide a 6-month supply to ensure long-term compliance. 2. Provide a 1-week supply of medication, with refills authorized only after he visits his provider. 3. Encourage him to increase fluid intake to counteract the common side effect of diarrhea. 4. Educate him not to eat foods that contain tyramine.

2. Provide a 1-week supply of medication, with refills authorized only after he visits his provider. To prevent suicide through overdose on antidepressant medication, a limited supply should be given at discharge. Clients with a history of depression who have a lifting of mood may have an increased risk for suicide. Giving the client a larger supply of antidepressant medication increases the chances of overdose.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which signs and symptoms of a potentially fatal side effect will the nurse teach the client about? 1. Blurring vision and muscular weakness 2. Sore throat, fever, and malaise 3. Tremor, shuffling gait, and rigidity 4. Fine tremor, tinnitus, and nausea

2. Sore throat, fever, and malaise

Which statement about the tricyclic group of antidepressant medications is accurate? 1. Strong or aged cheese should not be eaten while taking them. 2. Their full therapeutic potential may not be reached until 4 weeks. 3. They may cause hypomania or recent memory impairment. 4. They should not be given with antianxiety agents.

2. Their full therapeutic potential may not be reached until 4 weeks.

14. The director of nursing (DON) sets up a meeting with the newly appointed nurse manager who has been doing an excellent job. The DON anticipates that the nurse manager plans to resign. Which is the best description of the DON's cognitive error? 1. Thinking from an all-or-nothing perspective 2. Always thinking the worst will occur without considering positive outcomes 3. Viewing only selected negative evidence while editing out positive aspects 4. Undervaluing the positive significance of an event

2. This is correct. Catastrophic thinking involves always thinking that the worst will occur without considering the possibility of positive outcomes. The DON quickly jumped to the conclusion that the new nurse manager plans to resign

4. While assessing a client diagnosed with bulimia nervosa, the nurse observes multiple cavities, enamel erosion, and tooth sensitivity. Which best explains the nurse's findings? 1. Electrolyte imbalances 2. Self-induced vomiting 3. Nutritional deficits 4. Dehydration

2. This is correct. Erosion of tooth enamel and dental deterioration are results of selfinduced vomiting. The acidic emesis produced during purging damages the teeth and oral mucosa.

5. Which is used as first-line outpatient psychological treatment for adolescents diagnosed with anorexia nervosa? 1. Cognitive-based therapy 2. Family-based therapy 3. Dialectical behavior therapy 4. Individual psychotherapy

2. This is correct. Evidence supports the use of family-based treatment as the first-line outpatient psychological treatment for adolescents with anorexia nervosa. CBT is used with clients diagnosed with anorexia, bulimia, and binge eating disorder (BED).

7. The nurse tells the parents of an adolescent diagnosed with anorexia nervosa, "The social worker will be contacting you to schedule a family meeting." One of the client's parents states, "Why is that necessary? Our child is the one who needs treatment." Which response by the nurse is best? 1. "We expect every client and their family to attend two family sessions." 2. "Family intervention and support are important in managing eating disorders." 3. "The sessions are used to educate all family members about eating disorders. 4.B "During the meeting you will be able to resolve conflicts with your child."

2. This is correct. Family meetings focus on the needs of the client and their family. The nurse should educate the family on the importance of family involvement and support in the treatment of anorexia nervosa.

12. The nurse is developing nursing diagnoses for a newly admitted client diagnosed with anorexia nervosa. The client has a BMI of 15.8 kg/m2 . Which is the priority nursing diagnosis? 1. Ineffective coping 2. Imbalanced nutrition 3. Obesity 4. Disturbed body image

2. This is correct. The client weighs less than 85% of expected weight and has a BMI of 15.8 kg/m2 . The BMI range for normal weight is 20 to 24.9 kg/m2 . The client is at risk of potentially life-threatening symptoms of hypothermia, bradycardia, hypotension with orthostatic changes, peripheral edema, severe electrolyte imbalances, and cardiac muscle damage.

16. The nurse in the eating disorders clinic asks a client diagnosed with bulimia nervosa, "Can you recall a time when you were able to eat without purging?" Which is the most appropriate rationale for the nurse's question? 1. Determine the severity of symptoms. 2. Identify previous coping strategies. 3. Determine triggers for purging episodes. 4. Establish realistic treatment goals.

2. This is correct. The nurse is identifying the client's previous coping strategies to develop interventions that enable the client to utilize adaptive coping skills.

20. Which is the priority nursing intervention when caring for a client diagnosed with an eating disorder? 1. Accompany the client to the bathroom. 2. Remain with the client at least 1 hour after meals. 3. Encourage the client to keep a diary of food intake. 4. Discuss feelings and emotions associated with eating

2. This is correct. The nurse should remain with the client at least 1 hour after meals, as the client may use this time to discard food that has been stashed from the food tray or to engage in self-induced vomiting

The nurse is assessing a client who has a diagnosis of schizophrenia and takes an antipsychotic agent daily. Which finding requires further nursing assessment? 1. Respirations of 22 beats/minute 2. Weight gain of 8 lbs. in 2 months 3. Temperature of 101 F 4. Excess salivation

3. Temperature of 101 F

23. A nursing instructor is lecturing about cognitive behavior therapy. Which of the following are objectives of implementation of this therapy? Select all that apply. 1. To modify automatic thoughts to promote minimization of negative cognitions 2. To apply a variety of methods to create change in an individual's thinking 3. To apply cognitive principles to change an individual's basic schema 4. To modify belief systems to bring about emotional change 5. To modify belief systems to bring about behavioral change

2. This is correct. The objective of cognitive behavior therapy involves using a variety of methods to create change in a client's thinking. 4. This is correct. The objective of cognitive behavior therapy is to create change in a client's belief system to bring about lasting emotional changes. 5. This is correct. The objective of cognitive behavior therapy is to create change in a client's belief system to bring about lasting behavioral changes.

14. A 20-year-old client tells the nurse in the outpatient clinic, "I am so disgusted with myself. For the past month, there are times when I eat everything I can find. I want to vomit it all back up, but I have never been able to." Which is the nurse's best reply? 1. "It's normal to feel depressed after eating so much." 2. "Tell me about relationships with the people in your life." 3. "I am not surprised to hear you feel so disgusted with yourself." 4. "Have you ever been diagnosed with clinical depression?"

2. This is correct. The statement "Tell me about relationships with the people in your life" is the best reply. The nurse should gain more assessment data before teaching (a nursing intervention). The client demonstrates symptoms of BED, which are similar to those with bulimia nervosa; however, BED does not include compensatory purging. Interpersonal stressors, low self-esteem, and boredom are identified as possible triggers.

A physician prescribes an additional medication for a client taking an antipsychotic agent. The medication is to be administered "prn for EPS." When will the nurse plan to give this medication? 1. When the client's white blood cell count falls below 3,000/mm3 2. When the client exhibits tremors and a shuffling gait 3. When the client complains of dry mouth 4. When the client experiences a seizure

2. When the client exhibits tremors and a shuffling gait

When used in combination with anxiolytic medication, alcohol leads to _____________ effects, and caffeine leads to _______________ effects. 1. increased; increased 2. increased; decreased 3. decreased; decreased 4. decreased; increased

2. increased; decreased Anxiolytic medications work through depression of certain central nervous system (CNS) functions. Alcohol, which is a CNS depressant, would increase/potentiate their effects. Caffeine, which is a CNS stimulant, would decrease/inhibit their effects.

A client diagnosed with DID switches personalities when confronted with destructive behavior. The nurse recognizes that this dissociation serves which function? 1. It is a means to attain secondary gain. 2. It is a means to explore feelings of excessive and inappropriate guilt. 3. It serves to isolate painful events so that the primary self is protected. 4. It serves to establish personality boundaries and limit inappropriate impulses.

A client has been diagnosed with somatic symptom disorder. As the nurse is talking with this client and her family, which statement suggests primary or secondary gains that the physical symptoms are providing for the client? 1. The family agrees that the client began having physical symptoms after she lost her job. 2. The client states that even though medical tests have not found anything wrong, she is convinced her headaches are indicative of a brain tumor. 3. The client's mother reports that someone from the family stays with her each night because the physical symptoms are incapacitating. 4. The client states she noticed feeling hotter than usual the last time she had a headache.

An inpatient client is newly diagnosed with DID stemming from severe childhood sexual abuse. Which nursing intervention is the priority? 1. Encourage exploration of sexual abuse. 2. Encourage guided imagery. 3. Establish trust and rapport. 4. Administer antianxiety medications.

Which student statement indicates an understanding regarding dissociative identity disorder (DID)? 1. "I suspect my client inherited this disease from his parent." 2. "It is unlikely my client had a diagnosis of schizophrenia before DID, since the two do not go hand in hand." 3. "My client experiences periods of blackouts, or lost time where he doesn't know what happened during that time frame." 4. "I assume my client has other personalities because he doesn't want to deal with real life."

Which would the nurse recognize as an example of localized amnesia? 1. A client cannot relate any lifetime memories, including personal identity. 2. A client can relate family memories but has no recollection of a particular brother. 3. A client cannot remember events surrounding a fatal car accident. 4. A client whose home was destroyed by a tornado only remembers waking up in the hospital.

An aging client with chronic schizophrenia takes a beta-adrenergic blocking agent (propranolol) for hypertension and an antipsychotic. Given the combined side effects of these drugs, what teaching should the nurse provide? 1. "Make sure you concentrate on taking slow, deep, cleansing breaths." 2. "Watch your diet and try to engage in some regular physical activity." 3. "Rise slowly when you change position from lying to sitting or sitting to standing." 4. "Wear sunscreen and try to avoid midday sun exposure."

3. "Rise slowly when you change position from lying to sitting or sitting to standing."

A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago and asks why he has gained 12 lbs. since then. Which is the appropriate nursing response? 1. "I'm surprised you have gained; weight loss is the typical pattern when taking lithium." 2. "Your weight gain is more likely related to food intake than medication." 3. "Weight gain is a common, but troubling side effect. Let's talk about some strategies for safely improving your nutrition and exercise habits." 4. "There's not much you can do about the weight gain. It's better than being emotionally unstable, though."

3. "Weight gain is a common, but troubling side effect. Let's talk about some strategies for safely improving your nutrition and exercise habits."

Which medication is most likely to be prescribed for the extrapyramidal side effects of antipsychotic medications? 1. Diazepam (Valium) 2. Amitriptyline (Elavil) 3. Benztropine (Cogentin) 4. Methylphenidate (Ritalin)

3. Benztropine (Cogentin)

3. The nurse is developing a care plan for a client diagnosed with anorexia nervosa and determines "disturbed body image" is the priority nursing diagnosis. Which is the most appropriate outcome criterion? 1. Achieve and maintain expected body mass index (BMI). 2. Verbalize understanding of maladaptive eating behaviors. 3. Exhibit decreased preoccupation with own appearance. 4. Discuss feelings and emotions associated with eating.

3. This is correct. "Disturbed body image" is defined as "confusion in mental picture of one's physical self." The most important outcome criterion for the client to demonstrate is an increase in self-esteem as manifested by verbalizing positive aspects of self and exhibiting decreased preoccupation with their own appearance.

18. Which statement demonstrates that the nurse is using a cognitive approach when teaching a client about panic disorder? 1. "You might want to stay in the house when you notice the symptoms beginning." 2. "Medications such as lorazepam (Ativan) should be taken when symptoms start." 3. "Remind yourself that symptoms of a panic attack are time limited and will end." 4. "Keep a journal to note feelings surrounding the panic attacks."

3. This is correct. By teaching the client that symptoms of a panic attack are time limited and will end, the nurse is using the cognitive approach of presenting rational thinking

1. The nurse is reviewing the plan of care for a 15-year-old client diagnosed with anorexia nervosa. The treatment team plans to implement cognitive behavior therapy (CBT). Which is the best rationale for the use of CBT for clients diagnosed with anorexia nervosa? 1. Recognize maladaptive eating patterns as defense mechanisms. 2. Promote autonomy and control over eating behaviors. 3. Eliminate emotional components of maladaptive eating patterns. 4. Allow client to establish goals of the treatment plan.

3. This is correct. CBT strives to eliminate the emotional components associated with unhealthy eating patterns by confronting irrational thinking patterns and associated feelings.

8. The student comes in to the instructor's office and reports that they wish to drop out of nursing school due to the overwhelming work. The instructor advises the student to write assignments and due dates on a calendar to help break down what needs to be done and when. What technique is the instructor using? 1. Activity scheduling 2. Distraction 3. Graded task assignments 4. Behavioral rehearsal

3. This is correct. Graded task assignments are used to break down the task into subtasks that the client can complete one step at a time. Using a calendar with the assignments and due dates may help the student/client increase self-esteem and decrease feeling of helplessness.

11. The clinic nurse is reviewing assessment findings of a client diagnosed with anorexia nervosa. Which of the following indicate that the client requires immediate hospitalization? 1. Body temperature of 98.6ºF 2. Potassium level above 3.5 mmol/L 3. BMI less than 75% of expected 4. Weight less than 90% of expected

3. This is correct. Hospitalization is indicated when the median BMI is less than 75% of that expected for the client's age and sex.

8. A client diagnosed with bulimia nervosa has been receiving CBT at the eating disorders clinics. Which of the following client actions indicates to the nurse that the client is making progress toward using adaptive eating behaviors? 1. Gains 2 lb in 1 week 2. Verbalizes importance of adequate nutrition 3. Identifies feelings associated with desire to binge 4. Takes antidepressant medications as prescribed

3. This is correct. Identifying feelings associated with the desire to binge indicates the client is making progress. Unresolved emotional issues contribute to binging and purging behaviors. Identifying these emotions enables client to replace unhealthy coping behaviors with adaptive behaviors.

12. A labor and delivery nurse listens to a new mother relate thoughts regarding her healthy, 8-lb baby. Which statement by the mother indicates to the nurse the use of the cognitive error of selective abstraction? 1. "My baby is refusing to nurse, and I know it's because she already hates me." 2. "My baby needs to be under the 'bilirubin lights,' but I resent her time away from me." 3. "My baby is wonderful, but I'm depressed because I had my heart set on having twins." 4. "My baby has an elevated bilirubin; I know it will get worse, and she will die."

3. This is correct. In selective abstraction, the individual focuses attention on evidence that is viewed as a failure (not having twins) rather than any successes (a healthy baby) that have occurred.

4. A nursing student states, "The instructor gave me a failing grade on my research paper. I know it's because the instructor doesn't like me." Which cognitive error does the nurse recognize in this student's statement? 1. Dichotomous thinking 2. Catastrophic thinking 3. Magnification 4. Overgeneralization

3. This is correct. Magnification is exaggerating the negative significance of an event

19. The nurse on the eating disorder unit schedules group therapy sessions immediately after meals. Which is the best rationale for scheduling group therapy at this time? 1. Limit time allotted for meals. 2. Identify maladaptive eating behaviors. 3. Discuss feelings associated with eating behaviors. 4. Focus on regaining control.

3. This is correct. The best for scheduling group therapy immediately after meals is to address the emotional issues related to eating behavior, as it enables the nurse to observe clients following meals. Clients may use the time to after meals discard food that has been stashed from the food tray or to engage in self-induced vomiting.

22. A client diagnosed with borderline personality disorder states, "Get out of here. No one cares about me or my situation!" Which nursing reply is an example of a cognitive intervention? 1. "You have an antianxiety medication ordered. It may make you feel better." 2. "It sounds like you are feeling really frustrated." 3. "Can you explain further your thinking about your situation?" 4. "No one cares about you?"

3. This is correct. The nurse is using a cognitive approach to assessment by asking for an explanation about the client's thinking. The focus of cognitive interventions is on the modification of distorted cognitions and maladaptive behaviors.

2. A psychiatric-mental health nurse is counseling a client who has thought patterns consisting of rapid responses to a situation without rational analysis. Which assessment data will the nurse document? 1. "Thought patterns are triggered by specific stressful stimuli." 2. "Thought patterns contain the client's fundamental beliefs and assumptions." 3. "Thought patterns are flexible and based on personal experience." 4. "Thought patterns include a predominance of automatic thoughts."

4. This is correct. Automatic thoughts consist of rapid responses to a situation without rational analysis. These thoughts are often negative and based on erroneous logic.

25. Which of the following statements regarding role-playing is correct? Select all that apply. 1. Role-playing is a type of distractor from negative thinking. 2. The client assumes the role of the antagonist that produces the maladaptive response. 3. The situation is played out to help the client recognize their automatic thinking. 4. Role-play is limited to strong relationships between client and therapist. . Role-play teaching increases awareness of controlled breathing.

3. This is correct. The situation is played out to elicit recognition of automatic thinking on the part of the client. 4. This is correct. Role-play is a technique that should be used only when the relationship between client and therapist is strong and there is little likelihood of maladaptive transference.

20. A client recovering from alcohol toxicity is using minimization. Which statement reflects this cognitive distortion? 1. "I can't give up alcohol right now because I just gave up smoking." 2. "I just read that red wine has health benefits." 3. "I may have a minor problem, but I can handle it." 4. "I don't drink as much as my spouse, and nobody thinks she has a problem."

3. This is correct. This statement is an example of the cognitive distortion of minimization, where an individual undervalues the positive significance of an event.

13. The nurse in the outpatient clinic determines the priority nursing diagnosis for a client diagnosed with anorexia nervosa is "imbalanced nutrition: less than body requirements." Which is the most appropriate short-term goal for the client? 1. Demonstrate adaptive eating behaviors. 2. Discuss fears and anxieties. 3. Gain 2 lb per week. ' 4. Exhibit no signs of malnutrition and dehydration.

3. This is correct. Weight gain to restore homeostasis is the priority. Excessive weight loss leads to life-threatening malnutrition, dehydration, severe electrolyte imbalances, hypotension, bradycardia, and cardiac arrhythmias.

A client is diagnosed with DID. Which statement describes the primary goal of therapy for this client? 1. To recover memories and improve thinking patterns 2. To prevent social isolation 3. To decrease anxiety and the need for secondary gain 4. To collaborate among subpersonalities to improve functioning

The nurse is caring for a client diagnosed with conversion disorder. Which statement made by the nurse is most therapeutic for this client? 1. "I think you could get over this condition if you tried hard enough. A positive outlook can change everything." 2. "I'm so sorry that your back hurts so much. Yes, I'm happy to get you a wheelchair so you don't have to walk to meals." 3. "I think that your symptoms are just in your head. Therapy can help you get rid of them." 4. "I am pleased to hear you say that you recognize that your anxiety may be the cause of your swallowing difficulties.'

As part of discharge teaching, which guideline regarding lithium therapy will the nurse plan to include? 1. Avoid excessive use of beverages containing caffeine. 2. Maintain a consistent sodium intake. 3. Consume at least 2,500 to 3,000 mL of fluid per day. 4. All of the above

4. All of the above

Which medication does not require periodic blood-level monitoring? 1. Eskalith (lithium carbonate) 2. Depakote (valproic acid) 3. Clozaril (clozapine) 4. Paxil (paroxetine)

4. Paxil (paroxetine)

A client was recently admitted to the inpatient unit after a suicide attempt and is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse teaches the client about serotonin syndrome. Which of the following is a symptom of serotonin syndrome? 1. Change in mental status 2. Myoclonus 3. Blood pressure lability 4. Priapism

4. Priapism

A client takes a maintenance dosage of lithium carbonate for a bipolar disorder. She has come to the community health clinic, stating that she "has had the flu for over a week." She describes her symptoms as coughing, runny nose, chest congestion, fever, and gastrointestinal upset. Her temperature is 100.9°F. What situation does the nurse anticipate? 1. She has consumed some foods high in tyramine. 2. She has stopped taking her lithium carbonate. 3. She has probably developed a tolerance to the lithium carbonate. 4. The lithium carbonate may be producing symptoms of toxicity.

4. The lithium carbonate may be producing symptoms of toxicity. Blurred vision, gastrointestinal upset, and tinnitus are symptoms of lithium toxicity.

A client has been diagnosed with major depression and is prescribed imipramine (Tofranil). What information specifically related to this class of antidepressants will the nurse plan to include in client and family education? 1. The medication may cause dry mouth. 2. The medication may cause nausea. 3. The medication should not be discontinued abruptly. 4. The medication may cause photosensitivity.

4. The medication may cause photosensitivity.

A client is experiencing a psychotic episode. He is in good physical health but has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Which antipsychotic medication would be contraindicated for the client? 1. Haloperidol, because it is used only in elderly patients 2. Clozapine, because it is incompatible with desipramine 3. Risperidone, because it exacerbates symptoms of depression 4. Thioridazine, because of cross-sensitivity among phenothiazines

4. Thioridazine, because of cross-sensitivity among phenothiazines There may be cross-sensitivity among phenothiazines. Both prochlorperazine (Compazine) and thioridazine (Mellaril) are phenothiazines. Since the client has a known allergy to one phenothiazine, he should not be given another phenothiazine.

6. The nurse is assessing an adolescent who was brought to the emergency department after collapsing during Olympic figure skating training. The adolescent is diagnosed with severe malnutrition due to anorexia nervosa. Which client statement supports the use of a family-based approach? 1. "I just didn't drink enough water during practice." 2. "I eat just as much as everyone else on the team." 3. "I have to practice until my skating routine is perfect." 4. "I'm tired of fighting with my parents about eating."

4. This is correct. "I'm tired of fighting with my parents about eating" indicates there is conflict in the family around the client's eating behaviors. Conflicts arise in a family when a child is starving themself. The AED stands firmly against any model of eating disorders in which family influences are seen as the primary cause of eating disorders, condemns statements that blame families for their child's illness, and recommends that families be included in the treatment. Family-based approaches, such as the Maudsley approach, are supported by clinical evidence.

5. An advanced practice nurse recommends that a client participate in cognitive behavior therapy. The client asks, "What's cognitive behavior therapy, and how can it help me?" Which is the nurse's best reply? 1. "It is a system of techniques in which you use positive thinking to improve your mood." 2. "It is a long-term interpersonal approach that emphasizes the role of early childhood experiences." 3. "It is an interpersonal treatment approach that specifically targets magical thinking." 4. "It is a focused treatment for the modification of distorted thinking and maladaptive behaviors.

4. This is correct. Cognitive behavior therapy is a time-limited intervention in which the therapist works in collaboration with the client to modify thinking to eliminate cognitive errors that reinforce emotional disturbances.

16. A client states, "I keep having horrible nightmares about the car accident that killed my child. I shouldn't have taken her with me to the store." Using a cognitive approach, which nursing reply is most therapeutic? 1. "Are other issues from your past affecting your ability to move on?" 2. "Describe your current feelings about your loss." 3. "Let's talk about something that will help you move on." 4. "Can anyone predict when a car accident will happen?"

4. This is correct. Reframing thoughts is the most therapeutic cognitive approach. Cognitive behavior therapy facilitates problem-solving skills to guide clients' thinking.

15. An experienced nurse on the eating disorders unit is explaining to a newly hired nurse the rationale for setting limits with clients. Which is the nurse's most appropriate explanation? 1. It encourages awareness of emotional issues. 2. It encourages understanding of behavior modification plan. 3. It promotes sense of control unhealthy eating behaviors. 4. It prevents power struggles with staff.

4. This is correct. Restrictions and limits must be established and carried out consistently to avoid power struggles, encourage patient compliance with therapy, and ensure patient safety.

6. A welder has been selected as employee of the year. The welder wants to ask for a promotion but is hampered by poor self-esteem. Which is the best technique for the employee health nurse to use to help the employee request the promotion? 1. Socratic questioning 2. Activity scheduling 3. Distraction 4. Cognitive rehearsal

4. This is correct. The employee health nurse can utilize cognitive rehearsal before the employee requests the promotion. Cognitive rehearsal helps an individual identify and modify any dysfunctional thoughts.

21. A client is experiencing auditory hallucinations. Using a cognitive strategy, the nurse would encourage the client to do which of the following? 1. "Try singing 'Happy Birthday' until the voices are gone." 2. "Document what the voices are saying to note cause and effect." 3. "Try listening to music using headphones for distraction." 4. "Remind yourself that the voices are symptoms of your disease."

4. This is correct. The focus of cognitive behavior therapy is on the modification of distorted cognitions and maladaptive behaviors.

13. A client admitted to a Veterans Administration hospital with a diagnosis of major depressive disorder tells the nurse, "I failed my battalion by giving the wrong order. Fortunately, no one was injured." Which nursing diagnosis will the nurse assign this client? 1. Chronic low self-esteem 2. Risk for self-directed violence 3. Powerlessness 4. Situational low self-esteem

4. This is correct. The nursing diagnosis of situational low self-esteem is used with individuals who have a negative perception of self-worth in response to a current situation. This client's low self-esteem is related to the emotional response, which led to the client's cognitive appraisal of the situation. The psychiatric diagnosis of major depressive disorder is based on the client's depressive symptoms (emotional response).

17. The nurse is reviewing assessment data of a client diagnosed with anorexia nervosa. The client's BMI dropped from 17 to 15.5 kg/m2 over the past 3 months. Which client statement best supports the assessment data? 1. "I'm glad I don't make myself throw up." 2. "My hair started falling out last week." 3. "You don't know what it's like to be fat." 4. "At least I am not gaining any weight."

4. This is correct. The subjective statement, "At least I am not gaining any weight" supports the BMI (objective data). According to DSM-5 criteria, the client's illness has progressed from mild (BMI of 17 kg/m2 or greater) to severe (BMI of 15 to 15.99 kg/m2 ). Anorexia nervosa is characterized by a morbid fear of obesity and gross distortion of body image even when an individual is obviously underweight or emaciated.

A client with schizophrenia has recently begun a new medication, clozapine (Clozaril). Which blood cell counts would reveal a potentially fatal side effect of this medication? 1. WBCs, >3,000/mm3; granulocytes, >2,000/mm3 2. WBCs, <3,000/mm3; granulocytes, >2,000/mm3 3. WBCs, >3,000/mm3; granulocytes, <2,000/mm3 4. WBCs, <3,000/mm3; granulocytes, <2,000/mm3

4. WBCs, <3,000/mm3; granulocytes, <2,000/mm3

A client was admitted with major depression that was a single episode and moderate. During her stay, she was started on Prozac (fluoxetine) at 40 mg orally every day. The nurse's discharge teaching should include all of the following except: 1. Continue taking Prozac as prescribed. You will continue to see improvement over the next few weeks. 2. Make sure that you follow up with outpatient psychotherapy as you and the social worker have arranged. 3. You may be able to discontinue the medication within 6 months to 1 year, but only under a doctor's supervision. However, there is a chance of recurring episodes. 4. You should avoid foods with tyramine, including beer, beans, processed meats, and red wine.

4. You should avoid foods with tyramine, including beer, beans, processed meats, and red wine. This is true regarding MAOIs, not an SSRI antidepressant, such as fluoxetine.

The psychiatric-mental health nurse is creating a plan of care for a child diagnosed with a depressive disorder. The parents report the child does not seem to know how to make friends and does not seem to be doing as well in school as a family member who is in the same grade. Recently, their child started picking fights while waiting for the bus. The nurse recognizes that the child's depressive symptoms occur among which age group?

6 to 8 years

A client diagnosed with schizophrenia receives fluphenazine decanoate (Prolixin Decanoate) from a home health nurse. The client refuses medication at one regularly scheduled home visit. Which nursing intervention is ethically appropriate? A. Allow the client to decline the medication and document. B. Tell the client that if the medication is refused, hospitalization will occur. C. Arrange with a relative to add medication to the clients morning orange juice. D. Call for help to hold the client down while the injection is administered.

10. After assertiveness training, a formerly passive client appropriately confronts a peer in group therapy. The group leader states, "I'm so proud of you for being assertive. You are so good!" Which communication technique has the leader employed? A. The nontherapeutic technique of giving approval B. The nontherapeutic technique of interpreting C. The therapeutic technique of presenting reality D. The therapeutic technique of making observations

17. Which example of a therapeutic communication technique would be effective in the planning phase of the nursing process? A. "We've discussed past coping skills. Let's see if these coping skills can be effective now." B. "Please tell me in your own words what brought you to the hospital." C. "This new approach worked for you. Keep it up." D. "I notice that you seem to be responding to voices that I do not hear."

2. Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." A. Restatement B. Offering general leads C. Focusing D. Accepting

21. A client is struggling to explore and solve a problem. Which nursing statement would verbalize the implication of the client's actions? A. "You seem to be motivated to change your behavior." B. "How will these changes affect your family relationships?" C. "Why don't you make a list of the behaviors you need to change." D. "The team recommends that you make only one behavioral change at a time."

24. A student nurse is learning about the appropriate use of touch when communicating with clients diagnosed with psychiatric disorders. Which statement by the instructor best provides information about this aspect of therapeutic communication? A. "Touch carries a different meaning for different individuals." B. "Touch is often used when deescalating volatile client situations." C. "Touch is used to convey interest and warmth." D. "Touch is best combined with empathy when dealing with anxious clients."

27. During a nurse-client interaction, which nursing statement may belittle the client's feelings and concerns? A. "Don't worry. Everything will be alright." B. "You appear uptight." C. "I notice you have bitten your nails to the quick." D. "You are jumping to conclusions."

29. Which nursing response is an example of the nontherapeutic communication block of requesting an explanation? A. "Can you tell me why you said that?" B. "Keep your chin up. I'll explain the procedure to you." C. "There is always an explanation for both good and bad behaviors." D. "Are you not understanding the explanation I provided?"

7. A nurse is assessing a client diagnosed with schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of making observations? A. "You appear to be talking to someone I do not see." B. "Please describe what you are seeing." C. "Why do you continually look in the corner of this room?" D. "If you hum a tune, the voices may not be so distracting."

A client requests information on several medications in order to make an informed choice about management of depression. A nurse should provide this information to facilitate which ethical principle? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

A psychiatric nurse working on an inpatient unit receives a call asking if an individual has been a client in the facility. Which nursing response reflects appropriate legal and ethical obligations? A. Refusing to give any information to the caller, citing rules of confidentiality B. Refusing to give any information to the caller by hanging up C. Affirming that the person has been seen at the facility but providing no further information D. Suggesting that the caller speak to the clients therapist

What is the legal significance of a nurses action when a nurse threatens a demanding client with restraints? A. The nurse can be charged with assault. B. The nurse can be charged with negligence. C. The nurse can be charged with malpractice. D. The nurse can be charged with beneficence.

An inpatient client, whom the treatment team has determined to be a danger to self, gives notice of intention to leave the hospital. What information should the nurse recognize as having an impact on the treatment teams next action? A. State law determines how long a psychiatric facility can hold a client. B. Federal law determines if the client is competent. C. The clients family involvement will determine if discharge is possible. D. Hospital policies will determine treatment team actions.

Which client statement demonstrates improvement in anger/aggression management? A. I realize I have a problem expressing my anger appropriately. B. I know I cant use physical force anymore, but I can intimidate someone with my words. C. Its bad to feel as angry as I feel. Im working on eliminating this poisonous emotion entirely. D. Because my wife seems to be the one to set me off, Ive decided to remain separated from her.

Without authorization, a nurse administers an extra dose of narcotic tranquilizer to an agitated client. The nurses coworker observes this action but does nothing for fear of repercussion. What is the ethical interpretation of the coworkers lack of involvement? A. Taking no action is still considered an action by the coworker. B. Taking no action releases the coworker from ethical responsibility. C. Taking no action is advised when potential adverse consequences are foreseen. D. Taking no action is acceptable, because the coworker is only a bystander.

Electroconvulsive therapy (ECT) is considered the treatment of choice for which client?

A 67-year-old man explaining a recent suicide attempt

Which of the following client behaviors would lead the nurse to evaluate a member as assuming a maintenance group role? Select all that apply.

A client decreases conflict within the group by encouraging compromise. A client offers recognition and acceptance of others. A client listens attentively to group interaction

Which client would benefit most from working with a dietitian?

A client with pica

Which individuals are communicating a message? Select all that apply.

A parent spanking her child for playing with matches A teenager isolating himself and playing loud music A biker sporting an eagle tattoo on a bicep A teenager writing, "No one understands me"

A 36-year-old is admitted to the emergency department at 2:20 a.m. with a severe laceration to her forehead and incoherent speech. Paramedics report that they picked up the client at a local bar, and the bartender onsite said, "She seemed just fine when she came in. She must have had a lot to drink before she came here." Witness reports onsite confirmed that the woman fell off a bar stool and hit her head on the bar rail. Based on the information provided, a blood alcohol test was administered, and her blood alcohol content was 0.01%. The client's weight was recorded at 145 lbs. Incoherent speech is most likely attributed to which of the following?

A secondary NCD

The nurse is leading a bereavement group. Which group members would the nurse identify as being at high risk for having difficulty grieving? Select all that apply.

A widower who has recently experienced the death of two good friends A man whose spouse died suddenly after a cerebrovascular accident A woman who had a competitive relationship with her recently deceased sibling A young couple whose child recently died of a genetic disorder

Which situation will most likely lead to maladaptive grief in the survivor?

A woman loses her spouse, who was the primary breadwinner of the family.

The nurse notes elevated levels of prolactin while reviewing the laboratory results of a client diagnosed with schizophrenia. Which symptoms should the nurse expect to assess? Select all that apply. 1. Apathy 2. Social withdrawal 3. Anhedonia 4. Galactorrhea 5. Gynecomastia

ANS 4. Galactorrhea 5. Gynecomastia

A 16-year-old client diagnosed with schizophrenia is experiencing auditory command hallucinations. The client reports the voices are telling him to harm others. The client's parents ask the nurse, "Where do the voices come from?" Which is the nurse's most appropriate reply? 1. "Auditory hallucinations are caused by increased dopamine levels in the brain." 2. "Hallucinations can be caused by medication interactions." 3. "Hallucinations occur when there is not enough serotonin in the brain." 4. "Auditory hallucinations are mainly due to abnormal hormonal changes."

ANS 1. "Auditory hallucinations are caused by increased dopamine levels in the brain."

Which statement indicates to the nurse that a client is experiencing a delusion? 1. "Spies are watching everything I do." 2. "There is a worm on the back of the television." 3. "Bugs are crawling all over me." 4. "I really don't feel like going to group today."

ANS 1. "Spies are watching everything I do."

The psychiatric-mental health nurse is evaluating the care of a client recovering from an episode of psychosis. Which is the most appropriate long-term goal for the client? 1. Define and test reality. 2. Participate in social activities. 3. Maintain appropriate eye contact. 4. Verbalize feelings of anxiety

ANS 1. Define and test reality.

When planning care for clients diagnosed with schizophrenia, which of the following should the nurse recognize as an integral part of a rehabilitative program? Select all that apply. 1. Group therapy 2. Medication management 3. Deterrent therapy 4. Supportive family therapy 5. Social skills training

ANS 1. Group therapy 2. Medication management ' 4. Supportive family therapy ' 5. Social skills training

The nurse is assessing a new client diagnosed with schizophrenia. The client states "Those people behind the desk won't stop laughing at me." The nurse determines the client is experiencing which symptom? 1. Ideas of reference 2. Loose associations 3. Delusion of influence 4. Tangentiality

ANS 1. Ideas of reference

The nurse expects a client experiencing prodromal symptoms of schizophrenia to demonstrate which of the following? 1. Significant deterioration in functioning 2. Poor relationships with peers 3. Disturbances in thought processing 4. Disorganized motor behavior

ANS 1. Significant deterioration in functioning

The nurse is administering risperidone to a client diagnosed with schizophrenia. The nurse anticipates the mediation to have a therapeutic effect on which symptoms? Select all that apply. 1. Somatic delusions 2. Social isolation 3. Gustatory hallucinations 4. Flat affect 5. Clang associations

ANS 1. Somatic delusions 3. Gustatory hallucinations5. Clang associations

A client diagnosed with schizophrenia tells the nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is the correct charting entry to describe this client's statement? 1. "The client is speaking with clang associations." 2. "The client is expressing feelings with a neologism." 3. "The client demonstrates paranoid thinking." 4. "The client is communicating with a word salad."

ANS 2. "The client is expressing feelings with a neologism."

A client exhibits paranoia, bizarre behaviors, neologisms, and delusions of persecution. While eating breakfast in the dayroom, the client starts yelling at others. Which is the nurse's first action? 1. Ensure client is swallowing each dose of medication. 2. Ask other clients to step out of the dayroom. 3. Call the provider for an order to place the client in restraints. 4. Escort the client to a less-stimulating environment.

ANS 2. Ask other clients to step out of the dayroom.

The nurse is admitting a client to the inpatient psychiatric unit. Which intervention is most appropriate to reduce the client's delusional thinking? 1. Provide evidence to orient the client to reality. 2. Explore the client's feelings about the delusions 3. Use logical explanations to address the delusions. 4. Encourage the client to provide reasons for the delusions.

ANS 2. Explore the client's feelings about the delusions

The nurse is administering medications to a client experiencing acute psychosis. The client's medication orders include haloperidol 50 mg PO bid; benztropine 1 mg PO daily, and zolpidem 10 mg PO at bedtime daily. The nurse administers benztropine to address which of the following? 1. Tactile hallucinations 2. Involuntary facial movements 3. Psychomotor retardation 4. Pacing back and forth

ANS 2. Involuntary facial movements

The nurse assesses a client who exhibits a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement indicates the nurse understands the characteristics of positive and negative symptoms of schizophrenia? 1. Paranoia, anhedonia, and anergia are positive symptoms. 2. Paranoia, neologisms, and echolalia are positive symptoms. 3. Paranoia, anergia, and echolalia are negative symptoms. 4. Paranoia, flat affect, and anhedonia are negative symptoms

ANS 2. Paranoia, neologisms, and echolalia are positive symptoms.

Which does the Patient Self-Determination Act require? Select all that apply

All health care facilities must advise clients of their rights to refuse treatment. Advance directives are made available to clients on admission. Records of whether a client has an advance directive or designated health care proxy exist.

The nurse is caring for a college student who started hearing voices, has not attended classes for the past 4 weeks, was yelling accusations at others, and has stopped communicating with family and friends. Which is the nurse's priority nursing diagnosis? 1. Altered thought processes related to (R/T) hearing voices as evidenced by (AEB) increased anxiety 2. Risk for other-directed violence R/T yelling accusations 3. Social isolation R/T paranoia AEB absence from classes 4. Risk for self-directed violence R/T depressed mood

ANS 2. Risk for other-directed violence R/T yelling accusations

The nurse is obtaining the mental health history of a client diagnosed with schizophrenia. The client's family reports that the client is hearing voices and cannot stay focused on the topic of a discussion. The nurse recognizes the client is demonstrating which symptom? 1. Delusions of reference 2. Tangentiality 3. Neologism 4. Loose associations

ANS 2. Tangentiality

The nursing instructor asks a nursing student to describe concepts of the Recovery Model. Which concepts should the nursing student include? Select all that apply. 1. Employs positive and negative reinforcement 2. Uses personal values to determine meaning in life 3. Focuses on interactions within a social environment 4. Centers on improving adherence to prescribed medications 5. Allows client primary control over care decisions

ANS 2. Uses personal values to determine meaning in life 5. Allows client primary control over care decisions

A client diagnosed with schizophrenia says, "Can't you hear him? The devil keeps telling me I'm going to hell!" Which is the nurse's most appropriate reply? 1. "Did you take your medication this morning?" 2. "You are a good person, and you are not going to hell." 3. "It must be scary to hear that, but I don't hear a voice." 4. "The devil only talks to people who are receptive to his influence."

ANS 3. "It must be scary to hear that, but I don't hear a voice."

The nurse is providing discharge teaching to an elderly client diagnosed with schizophrenia. The client's medications include an antipsychotic (risperidone) and a beta-adrenergic blocking agent (propranolol). Which statement indicates the nurse understands the combined side effects of these medications? 1. "Concentrate on taking slow, deep, cleansing breaths." 2. "Limit your intake of foods that are high in sugar." 3. "Move slowly when you change from a lying down or sitting position." 4. "Always wear sunscreen and a hat when you are exposed to the sun."

ANS 3. "Move slowly when you change from a lying down or sitting position."

A client diagnosed with psychosis asks the nurse to make the voices stop talking so he can go to sleep. Which is the most important nursing intervention? 1. Ask the client whether the voices seem familiar. 2. Guide the client to bed and gently rub their back. 3. Ask the client what the voices are saying. 4. Suggest the client tell the voices to go away.

ANS 3. Ask the client what the voices are saying.

A client states, "The voices keep saying I am evil." Which outcome criteria is most important to include in the client's plan of care? 1. Demonstrates the ability to perceive the environment correctly 2. Uses appropriate verbal communication when interacting with others 3. Identifies factors that increase anxiety and illicit hallucinations 4. Demonstrates the ability to relate satisfactorily to others

ANS 3. Identifies factors that increase anxiety and illicit hallucinations

A client diagnosed with brief psychotic disorder states, "The voices keep telling me I must kill the president." Which is the priority nursing diagnosis? 1. Disturbed sensory perception 2. Disturbed thought processes 3. Risk for violence: other directed 4. Impaired verbal communication

ANS 3. Risk for violence: other directed

The nurse observes that a client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication does the nurse anticipate the provider will prescribe? 1. Benztropine 2. Clonazepam ' 3. Risperidone 4. Sertraline

ANS 3. Risperidone

A newly admitted client exhibits symptoms of paranoia and hallucinations. The client's spouse states, "I don't understand. My spouse hasn't hallucinated since the doctor prescribed thioridazine 2 years ago." The nurse recognizes which as the most likely explanation for the recurrence of the client's symptoms? 1. The client has developed tolerance to the medication. 2. The client has been taking the medication with food. 3. The client has not been taking the medication as prescribed. 4. The client has been drinking alcohol with the medication.

ANS 3. The client has not been taking the medication as prescribed.

A client diagnosed with schizoaffective disorder is admitted for social skills training. Which information should the nurse teach the client? 1. Side effects of medications 2. Deep breathing techniques 3. Ways to make eye contact when communicating 4. Techniques to improve memory and attention

ANS 3. Ways to make eye contact when communicating

The nurse is educating the parents of a child diagnosed with schizophrenia on how to reply when their child experiences auditory hallucinations. Which is the nurse's best reply? 1. "Tell him to stop talking about the voices." 2. "Ask him what the voices are saying to him." 3. "Tell him you know the voices are real to him." 4. "Encourage him not to worry about the voices."

ANS 4. "Encourage him not to worry about the voices."

The nurse is assessing a client diagnosed with schizophrenia and asks, "Do you ever get messages through things, like the television or microwave?" Which symptom of schizophrenia is the nurse assessing for? 1. Illusions 2. Circumstantiality 3. Hallucinations 4. Delusions of reference

ANS 4. Delusions of reference

The nurse is administering clozapine to a client diagnosed with schizophrenia. Which symptoms require the nurse to intervene immediately? 1. Sore throat, fever, and malaise 2. Akathisia and hypersalivation 3. Akinesia and insomnia 4. Dry mouth and urinary retention

ANS 4. Dry mouth and urinary retention

The nurse notices a client is becoming very agitated. Which nursing intervention is most appropriate? 1. Instruct the client to watch television in the dayroom. 2. Maintain continuous eye contact when talking to the client. 3. Hold the client's hand while walking in the hallway. 4. Provide the client with adequate personal space.

ANS 4. Provide the client with adequate personal space.

The nurse is reviewing the provider's orders for a client experiencing acute psychosis. The client's family tells the nurse the client has allergies to penicillin, prochlorperazine, and bee stings. Which medication order should the nurse question? 1. Haloperidol 5 mg intramuscularly every 4 hours as needed 2. Clozapine 150 mg PO twice daily 3. Risperidone 2 mg PO twice daily 4. Thioridazine 100 mg PO three times daily

ANS 4. Thioridazine 100 mg PO three times daily

Which nursing action is most appropriate to establish trust with a suspicious client? 1. Maintain consistent staff assignments. 2. Reinforce and focus on reality. 3. Maintain low environmental stimuli. 4. Use a passive communication approach.

ANS 4. Use a passive communication approach.

In response to a students question regarding choosing a psychiatric specialty, a charge nurse states, Mentally ill clients need special care. If I were in that position, Id want a caring nurse also. From which ethical framework is the charge nurse operating? A. Kantianism B. Christian ethics C. Ethical egoism D. Utilitarianism

30. Which nursing statement reflects a common characteristic of a client diagnosed with paranoid personality disorder? A. This client consistently criticizes care and has difficulty getting along with others. B. This client is shy and fades into the background. C. This client expects special treatment, and setting limits will be necessary. D. This client is expressive during group and is very pleased with self.

ANS: A A client diagnosed with paranoid personality disorder has a pervasive distrust and suspiciousness of others. Anticipating humiliation and betrayal, the paranoid individual characteristically learns to attack first.

16. According to Peplau, which nursing intervention is most appropriate when the nurse is functioning in the role of a surrogate? A. The nurse functions as a nurturing parent in order to build a trusting relationship. B. The nurse plays cards with a small group of clients. C. The nurse discusses childhood events that may affect personality development. D. The nurse provides a safe social environment.

ANS: A According to Peplau, when a client is acutely ill, he or she may incur the role of infant or child, while the nurse is perceived as the mother surrogate.

26. When a client on an acute care psychiatric unit demonstrates behaviors and verbalizations indicating a lack of guilt feelings, which nursing intervention would help the client to meet desired outcomes? A. Provide external limits on client behavior. B. Foster discussions of rationales for behavioral change. C. Implement interventions consistently by only one staff member. D. Encourage the client to involve self in care.

ANS: A Because the client, due to a lack of guilt, cannot or will not impose personal limits on maladaptive behaviors, these limits must be delineated and enforced by staff.

27. Which characteristics should a nurse recognize as being exhibited by individuals diagnosed with any personality disorder? A. These clients accept and are comfortable with their altered behaviors. B. These clients understand that their altered behaviors result from anxiety. C. These clients seek treatment to avoid interpersonal discomfort. D. These clients avoid relationships due to past negative experiences.

ANS: A Clients who are diagnosed with personality disorders accept and are comfortable with their altered behaviors. Personalities that develop in a disordered pattern remain somewhat unstable and unpredictable throughout the lifetime.

26. Most cultures label behavior as mental illness on the basis of which of the following criteria? A. Incomprehensibility and cultural relativity B. Strength of character and ethics C. Goal directedness and high energy D. Creativity and good coping skills

ANS: A Incomprehensibility and cultural relativity are most often the criteria used to define whether something is labeled mental illness. The other identified behaviors would be more associated with health than illness.

7. Arthur, who is diagnosed with obsessive-compulsive disorder, reports to the nurse that he cant stop thinking about all the potentially life threatening germs in the environment. What is the most accurate way for the nurse to document this symptom? A. Patient is expressing an obsession with germs. B. Patient is manifesting compulsive thinking. C. Patient is expressing delusional thinking about germs. D. Patient is manifesting arachnophobia of germs.

ANS: A Obsessions are unwanted, intrusive, repetitive thoughts. Compulsions are unwanted, repetitive behavior patterns in response to obsessive thoughts that are efforts to reduce anxiety.

3. A nurse is assessing 15-year-old identical twins who respond very differently to stress. One twin becomes anxious and irritable, while the other withdraws and cries. How should the nurse explain these different responses to stress to the parents? A. Reactions to stress are relative rather than absolute; individual responses to stress vary. B. It is abnormal for identical twins to react differently to similar stressors. C. Identical twins should share the same temperament and respond similarly to stress. D. Environmental influences weigh more heavily than genetic influences on reactions to stress.

ANS: A Responses to stress are variable among individuals and may be influenced by perception, past experience, and environmental factors in addition to genetic factors.

11. Which of the following are identified as psychoneurotic responses to severe anxiety as they appear in the DSM-5? A. Somatic symptom disorders B. Grief responses C. Psychosis D. Bipolar disorder

ANS: A Somatic symptom disorder is characterized by preoccupation with physical symptoms for which there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety about health concerns or illness.

9. A mental health technician asks the nurse, "How do psychiatrists determine which diagnosis to give a patient?" Which of these responses by the nurse would be most accurate? A. Psychiatrists use pre-established criteria from the APA's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). B. Hospital policy dictates how psychiatrists diagnose mental disorders. C. Psychiatrists assess the patient and identify diagnoses based on the patient's unhealthy responses and contributing factors. D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose from.

ANS: A The DSM-5 is an organized manual describing mental disorders and the criteria that determine whether a given diagnosis is appropriate. It is published by the American Psychiatric Association (APA). It intends to facilitate accurate and reliable medical diagnosis and treatment. Item C describes nursing rather than medical diagnosis.

16. A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? A. I will need scheduled bloodwork in order to monitor for toxic levels of this drug. B. I wont stop taking this medication abruptly, because there could be serious complications. C. I will not drink alcohol while taking this medication. D. I wont take extra doses of this drug because I can become addicted.

ANS: A The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.

9. A client diagnosed with panic disorder states, When an attack happens, I feel like I am going to die. Which is the most appropriate nursing reply? A. I know its frightening, but try to remind yourself that this will only last a short time. B. Death from a panic attack happens so infrequently that there is no need to worry. C. Most people who experience panic attacks have feelings of impending doom. D. Tell me why you think you are going to die every time you have a panic attack.

ANS: A The most appropriate nursing reply to the clients concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.

1. What is the most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client? A. To clarify personal attitudes, values, and beliefs B. To obtain thorough assessment data C. To determine the clients length of stay D. To establish personal goals for the interaction

ANS: A The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs. Understanding ones own attitudes, values, and beliefs is called self-awareness.

5. Which client should the nurse anticipate to be most receptive to psychiatric treatment? A. A Jewish, female journalist B. A Baptist, homeless male C. A Catholic, black male D. A Protestant, Swedish business executive

ANS: A The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely than men to seek treatment for mental health problems.

2. A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia

ANS: A The nurse should determine that an excessive fear of water is identified as aquaphobia, which is a natural environment type of phobia. Natural environmenttype phobias are fears about objects or situations that occur in the natural environment, such as a fear of heights or storms.

5. Which client response should a nurse expect during the working phase of the nurseclient relationship? A. The client gains insight and incorporates alternative behaviors. B. The client and nurse establish rapport and mutually develop treatment goals. C. The client explores feelings related to reentering the community. D. The client explores personal strengths and weaknesses that impact behaviors.

ANS: A The nurse should expect that the client would gain insight and incorporate alternative behaviors during the working phase of the nurseclient relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.

6. A new psychiatric nurse states, "This client's use of defense mechanisms should be eliminated." Which is a correct evaluation of this nurse's statement? A. Defense mechanisms can be self-protective responses to stress and need not be eliminated. B. Defense mechanisms are a maladaptive attempt of the ego to manage anxiety and should always be eliminated. C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged and not eliminated. D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.

ANS: A The nurse should know that defense mechanisms serve the purpose of reducing anxiety during times of stress. A client with no defense mechanisms may have a lower tolerance for stress, predisposing him or her to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

21. A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? A. History of alcohol dependence B. History of personality disorder C. History of schizophrenia D. History of hypertension

ANS: A The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.

9. A client has made the decision to leave her alcoholic husband. She is feeling very depressed. Which nontherapeutic statement by the nurse conveys sympathy? A. You are feeling very depressed. I felt the same way when I decided to leave my husband. B. I can understand you are feeling depressed. It was a difficult decision. Ill sit with you. C. You seem depressed. It was a difficult decision to make. Would you like to talk about it? D. I know this is a difficult time for you. Would you like a prn medication for anxiety?

ANS: A The nurses statement, You are feeling very depressed. I felt the same when I decided to leave my husband, is a nontherapeutic statement that conveys sympathy. Sympathy implies that the nurse shares what the client is feeling and by this personal expression alleviates the clients distress.

10. A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder. B. Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder. C. Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks. D. Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks.

ANS: A The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.

19. Which client statement may indicate a transference reaction? A. I need a real nurse. You are young enough to be my daughter and I dont want to tell you about my personal life. B. I deserve more than I am getting here. Do you know who I am and what I do? Let me talk to your supervisor. C. I dont seem to be able to relate to people. I would rather stay in my room and be by myself. D. My mother is the source of my problems. She has always told me what to do and what to say.

ANS: A Transference occurs when a client unconsciously displaces or transfers to the nurse feelings formed toward a person from the past.

During an assertiveness training group, a nurse suggests using "I statements." The group questions the usefulness of this communication technique. Which explanation by the nurse is most appropriate? A. "When 'I statements' are used, opinions are communicated without blaming others." B. "When 'I statements' are used, anger is displaced by using indirect means." C. "When 'I statements' are used, responsibility for one's behavior is attributed to another." D. "When 'I statements' are used, eye contact is promoted."

ANS: A "I statements" clearly state one's feelings and needs without blaming or demeaning others.

15. When scheduling electroconvulsive therapy (ECT), which client should the nurse prioritize? A. A client in bed in a fetal position who is experiencing active suicidal ideations B. A client with an irritable mood and exhibiting angry outbursts C. A client experiencing command hallucinations and delusions of reference D. A client experiencing manic episodes of bipolar disorder

ANS: A A client who is experiencing suicidal ideations is in need of an immediate intervention to prevent self-harm and must be prioritized when the nurse schedules ECT. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Safe and Effective Care Environment

9. A client scheduled for electroconvulsive therapy (ECT) at 9:00 a.m. is discovered eating breakfast at 8:00 a.m. On the basis of this observation, which is the most appropriate nursing action? A. The nurse notifies the client's physician of the situation and cancels the ECT. B. The nurse removes the breakfast tray and assists the client to the ECT procedure room. C. The nurse allows the client to finish breakfast and reschedules ECT for 10:00 a.m. D. The nurse increases the client's fluid intake to facilitate the digestive process.

ANS: A A client who is scheduled for ECT procedures is given nothing by mouth (NPO) for a minimum of 6 to 8 hours before treatment.

A nurse should recognize which intervention as most appropriate within a behavioral therapy program? A. A child is given a Popsicle for staying dry and clean. B. A child is put in time-out after soiling his or her undergarments. C. A child is allowed to remain in soiled undergarments. D. A child is taught the advantages of staying dry and clean.

ANS: A A stimulus that follows a behavior or response is called a reinforcing stimulus or reinforcer. The reward of a Popsicle is a reinforcer for the child staying dry and clean. This is an example of operant conditioning, a form of behavioral therapy. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A psychiatrist who embraces the Psychological Recovery Model tells the nurse that a client is in the Growth stage. What should the nurse expect to find when assessing this client? A. A client feeling confident about achieving goals in life. B. A client who is aware of the need to set goals in life. C. A client who has mobilized personal and external resources. D. A client who begins to actively take control of his or her life.

ANS: A Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. In the growth stage, the individual feels a sense of optimism and hope of a rewarding future. Skills that have been nurtured in the previous stages are applied with confidence, and the individual strives for higher levels of well-being. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client states, "My illness is so devastating, I feel like my life is on hold." The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates? A. Moratorium B. Awareness C. Preparation D. Rebuilding

ANS: A Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. The moratorium stage is identified by dark despair and confusion. It is called moratorium, because it seems that "life is on hold." KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Two clients are roommates on an inpatient psychiatric unit. At breakfast, client "A," who had been missing her gold locket, notices client "B" wearing it. Which should a nurse recognize as a nonassertive or passive behavioral response from client "A"? A. Client "A" ignores the situation. B. Client "A" discusses the situation with her nurse and develops a plan of action. C. Client "A" immediately approaches client "B" and pulls the necklace off her neck. D. Client "A" offers to wash client "B's" clothes and "accidentally" spills bleach in the water.

ANS: A By ignoring the situation, client "A" avoids conflict, denies her feelings, and does not assertively resolve the problem. This is an example of nonassertive behavior.

A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse? A. "This medication will help you maintain your abstinence." B. "This medication will cause uncomfortable symptoms if you combine it with alcohol." C. "This medication will decrease the effect alcohol has on your body." D. "This medication will lower your risk of experiencing a complicated withdrawal."

ANS: A Campral has been approved by the U.S. Food and Drug Administration (FDA) for the maintenance of abstinence from alcohol in clients diagnosed with alcohol dependence who are abstinent at treatment initiation.

Two clients get into a heated argument regarding TV program selections. The nurse turns off the TV and asks the clients to go to their rooms to cool off, after which they will discuss and attempt to resolve the problem. The nurse's action is an example of which assertive technique? A. Defusing B. Clouding or fogging C. Responding as a broken record D. Shifting from content to process

ANS: A Defusing is a technique that delays further discussion with an angry individual until a calm demeanor has been achieved. In the situation presented, the nurse is allowing the clients to calm down prior to addressing their issues.

4. A chronically depressed and suicidal client is admitted to a psychiatric unit. The client is scheduled for electroconvulsive therapy (ECT). During the course of ECT, a nurse should recognize the continued need for which critical intervention? A. Suicide assessment must continue throughout the ECT course. B. Antidepressant medications are contraindicated throughout the ECT course. C. Discourage expressions of hopelessness throughout the ECT course. D. Encourage a high-caloric diet throughout the ECT course.

ANS: A ECT is an intervention for major depression that often includes suicidal ideations as a symptom. Continued suicide assessment is needed because mood improvement due to ECT may cause the client to act on suicidal ideations.

6. Immediately after an initial electroconvulsive therapy (ECT) procedure, a client states, "I'm not hungry and just want to stay in bed and sleep." On the basis of this information, which is the most appropriate nursing intervention? A. Allow the client to remain in bed. B. Encourage the client to join the milieu to promote socialization. C. Obtain a physician's order for parenteral nutrition. D. Involve the client in physical activities to stimulate circulation.

ANS: A Immediately after electroconvulsive therapy a nurse should monitor pulse, respirations, and blood pressure every 15 minutes for the first hour, during which time the client should remain in bed.

A third-grader feigns illness in order to avoid doing homework. The teacher recommends an educational program that uses a token economy. How should a school nurse explain a token economy to this child's parent? A. "Your child will receive green tokens for completing homework that can be cashed in for desired rewards." B. "Your child will receive red tokens when homework is incomplete and this will result in school suspension." C. "Your child will receive a time out for each homework assignment not completed." D. "Your child, with your assistance, will envision receiving rewards for completed homework."

ANS: A In a token economy, tokens are a form of contingency contracting in that tokens immediately reinforce appropriate behavior (completed homework) and are exchanged later for a desired reward. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A mother states, "You are old enough to clean your own bedroom." Later inspection finds the floor clear, but with everything stacked in a chair. The mother praises the child for clearing the floor. This is consistent with which technique of behavior modification? A. Shaping B. Extinction C. Stimulus generalization D. Reciprocal inhibition

ANS: A In shaping, behavior is molded in a desired direction by reinforcing each small step toward the desired behavior. The child is praised for clearing the floor, the first step toward cleaning the room. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

What type of intervention would be most beneficial for clients diagnosed with cluster C personality disorders? A. Training that includes the control of emotional tone of the voice B. Training that includes incremental exposure to feared objects C. Training that includes appropriate limit setting D. Training that includes appropriate coping strategies

ANS: A The cluster C personality disorders are characterized by anxious and fearful behaviors and may benefit by assertiveness training. One part of assertiveness training is to learn control of the emotional tone of the voice when communicating with others.

A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching? A. After discharge, the client will immediately attend 90 AA meetings in 90 days. B. After discharge, the client will rely on an AA sponsor to help control alcohol cravings. C. After discharge, the client will incorporate family in AA attendance. D. After discharge, the client will seek appropriate deterrent medications through AA.

ANS: A The most appropriate client outcome for the nurse to discuss during discharge teaching is attending 90 AA meetings in 90 days after discharge. AA is a major self-help organization for the treatment of alcoholism. It accepts alcoholism as an illness and promotes total abstinence as the only cure.

9. A client diagnosed with neurocognitive disorder exhibits progressive memory loss, diminished cognitive functioning, and verbal aggression upon experiencing frustration. Which nursing intervention is most appropriate? A. Schedule structured daily routines. B. Minimize environmental lighting. C. Organize a group activity to present reality. D. Explain the consequences for aggressive behaviors.

ANS: A The most appropriate nursing intervention for this client is to schedule structured daily routines. A structured routine will reduce frustration and thereby reduce verbal aggression.

6. A nursing instructor is teaching about donepezil (Aricept). A student asks, How does this work? Will this cure Alzheimers disease (AD)? Which is the appropriate instructor reply? A. This medication delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. B. This medication encourages production of acetylcholine, a chemical in the brain necessary for memory processes. It delays the progression of the disease. C. This medication delays the destruction of dopamine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of the AD. D. This medication encourages production of dopamine, a chemical in the brain necessary for memory processes. It delays the progression of the disease.

ANS: A The most appropriate response by the instructor is to explain that donepezil (Aricept) delays the destruction of acetylcholine, a chemical in the brain necessary for memory processes. Although most effective in the early stages, it serves to delay, but not stop, the progression of AD.

18. A 10-week, prenuptial counseling group composed of five couples is terminating. At the last group meeting, a nurse notices that the two most faithful and participative couples are absent. When considering concepts of group development, what might explain this behavior? A. They are experiencing problems with termination, leading to feelings of abandonment. B. They did not think any new material would be covered at the last session. C. They were angry with the leader for not extending the length of the group. D. They were bored with the material covered in the group.

ANS: A The nurse should determine that the clients' absence from the final group meeting may indicate that they are experiencing problems with termination. The termination phase of group development may elicit feelings of abandonment and anger. Successful termination may help members develop skills to cope with future unrelated losses. PTS: 1 REF: 193 KEY: Cognitive Level: Application | Integrated Process: Assessment

A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms? A. Between 3 a.m. and 11 a.m. B. Shortly after a 24-hour period C. At the beginning of the third day D. Withdrawal is individualized and cannot be predicted.

ANS: A The nurse should expect that this client will begin experiencing withdrawal symptoms from alcohol between 3 a.m. and 11 a.m. Symptoms of alcohol withdrawal usually occur within 4 to 12 hours of cessation or reduction in heavy and prolonged alcohol use.

A newly admitted client asks, "Why do we need a unit schedule? I'm not going to these groups. I'm here to get some rest." Which is the most appropriate nursing reply? A. "Group therapy provides the opportunity to learn and practice new coping skills." B. "Group therapy is mandatory. All clients must attend." C. "Group therapy is optional. You can go if you find the topic helpful and interesting." D. "Group therapy is an economical way of providing therapy to many clients concurrently."

ANS: A The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. A basic assumption of milieu therapy is that every interaction, including group therapy, is an opportunity for therapeutic intervention.

5. After threatening to jump off a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first? A. "Are you currently thinking about harming yourself?" B. "Why do you want to harm yourself?" C. "Have you thought about the consequences of your actions?" D. "Who is your emergency contact person?"

ANS: A The nurse should first assess the client for current suicidal thoughts to minimize risk of harm and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency. The crisis team should prioritize safety by assessing the client for thoughts of self-harm. PTS: 1 REF: 242 KEY: Cognitive Level: Analysis | Integrated Process: Assessment

1. A geriatric nurse is teaching student nurses about the risk factors for development of delirium in older adults. Which student statement indicates that learning has occurred? A. Taking multiple medications may lead to adverse interactions or toxicity. B. Age-related cognitive changes may lead to alterations in mental status. C. Lack of rigorous exercise may lead to decreased cerebral blood flow. D. Decreased social interaction may lead to profound isolation and psychosis.

ANS: A The nurse should identify that taking multiple medications may lead to adverse reactions or toxicity and put an older adult at risk for the development of delirium. Symptoms of delirium include difficulty sustaining and shifting attention. The client with delirium is disoriented to time and place and may also have impaired memory.

2. Immediately after electroconvulsive therapy, in which position should a nurse place the client? A. On his or her side to prevent aspiration B. In semi-Fowler's position to promote oxygenation C. In Trendelenburg's position to promote blood flow to vital organs D. In prone position to prevent airway blockage

ANS: A The nurse should place a client who has received electroconvulsive therapy on his or her side to prevent aspiration. After the treatment, most clients will awaken within 10 to 15 minutes and will be confused and disoriented. Some clients will sleep for 1 to 2 hours. All clients require close observation following treatment.

A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions? A. Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. B. Sedative-hypnotics are expensive and have numerous side effects. C. Sedative-hypnotics interfere with necessary REM (rapid eye movement) sleep. D. Sedative-hypnotics are not as effective to promote sleep as antidepressant medications.

ANS: A The nurse should recommend nonpharmacological interventions to this client because sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance. The effects of central nervous system depressants are additive with one another and are capable of producing physiological and psychological dependence.

A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation? A. The individual is experiencing psychological dependency. B. The individual is experiencing physical dependency. C. The individual is experiencing substance dependency. D. The individual is experiencing social dependency.

ANS: A The nurse should use the term "psychological dependency" to best describe this client's situation. A client is considered to be psychologically dependent on a substance when there is an overwhelming desire to use a substance in order to produce pleasure or avoid discomfort.

What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal? A. Risk for injury R/T central nervous system stimulation B. Disturbed thought processes R/T tactile hallucinations C. Ineffective coping R/T powerlessness over alcohol use D. Ineffective denial R/T continued alcohol use despite negative consequences

ANS: A The priority nursing diagnosis for a client experiencing alcohol withdrawal should be risk for injury R/T central nervous system stimulation. Alcohol withdrawal may include the following symptoms: course tremors of hands, tongue, or eyelids; seizures; nausea or vomiting; malaise or weakness; tachycardia; sweating; elevated blood pressure; anxiety; depressed mood; hallucinations; headache; and insomnia.

To promote self-reliance, how should a psychiatric nurse best conduct medication administration? A. Encourage clients to request their medications at the appropriate times. B. Refuse to administer medications unless clients request them at the appropriate times. C. Allow the clients to determine appropriate medication times. D. Take medications to the clients' bedside at the appropriate times.

ANS: A The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times. Nurses are responsible for the management of medication administration on inpatient psychiatric units; however, nurses must work with clients to foster independence and provide experiences that would foster increased self-esteem.

20. Which nursing action demonstrates the role of the teacher in a therapeutic milieu? A. The nurse implements a self-affirmation exercise during a one-to-one client interaction. B. The nurse holds a group meeting to present common side effects of psychiatric medications. C. The nurse introduces the concept of fair play while playing cards with a group of clients. D. The nurse models adaptive and effective coping mechanisms with clients on the psychiatric unit.

ANS: B The nurse, in the role of teacher, identifies learning needs and provides information required by the client or family to improve the clients health.

One nurse confronts another and says, "You are always so talkative in the meetings. I don't know why you can't stay quiet sometimes." Which reply by the other nurse reflects the technique of "clouding/fogging?" A. "You're right. I do speak up a lot." B. "Sounds to me like you're agitated and we need to talk. What are you truly angry about?" C. "Are you offended that I speak up, or because my thoughts are in opposition to yours?" D. "I have the right to express my opinion."

ANS: A This response reflects the use of clouding/fogging. When clouding/fogging is used, it concurs with the critic's argument without becoming defensive and without agreeing to change.

A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess? A. Gross tremors, delirium, hyperactivity, and hypertension B. Disorientation, peripheral neuropathy, and hypotension C. Oculogyric crisis, amnesia, ataxia, and hypertension D. Hallucinations, fine tremors, confabulation, and orthostatic hypotension

ANS: A Withdrawal is defined as the physiological and mental readjustment that accompanies the discontinuation of an addictive substance. Symptoms can include gross tremors, delirium, hyperactivity, hypertension, nausea, vomiting, tachycardia, hallucinations, and seizures.

33. Which statements represent positive outcomes for clients diagnosed with narcissistic personality disorder? Select all that apply. A. The client will relate one empathetic statement toward another client in group, by day 2. B. The client will identify one personal limitation by day 1. C. The client will acknowledge one strength that another client possesses by day 2. D. The client will list four personal strengths by day 3. E. The client will list two lifetime achievements by discharge.

ANS: A, B, C The nurse should determine that appropriate outcomes for a client diagnosed with narcissistic personality disorder include relating empathetic statements to other clients, identifying one personal limitation, and acknowledging one strength in another client. An exaggerated sense of self-worth, a lack of empathy, and exploitation of others are characteristics of narcissistic personality disorder.

17. A nurse should recognize that electroconvulsive therapy (ECT) would potentially improve the symptoms of clients with which of the following diagnoses? Select all that apply. A. Major depressive disorder B. Bipolar I disorder: manic episode C. Schizoaffective disorder D. Obsessive-compulsive disorder E. Body dysmorphic disorder

ANS: A, B, C ECT has been shown to be effective in the treatment of severe depression, acute mania, and acute schizophrenia, particularly if it is accompanied by catatonic or affective (depression or mania) symptomatology. ECT has also been tried with other disorders, such as obsessive-compulsive disorder (OCD) and anxiety disorders, but little evidence exists to support its efficacy in the treatment of these conditions. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter

11. Which of the following nursing statements and/or questions represent appropriate communication to assess an individual in crisis? (Select all that apply.) A. "Tell me what happened." B. "What coping methods have you used, and did they work?" C. "Describe to me what your life was like before this happened." D. "Let's focus on the current problem." E. "I'll assist you in selecting functional coping strategies."

ANS: A, B, C In the assessment phase, the nurse should gather information regarding the precipitating stressor and the resulting crisis. Focusing on the current problem and selecting functional coping strategies are nursing interventions rather than assessments. PTS: 1 REF: 243 KEY: Cognitive Level: Application | Integrated Process: Assessment

A nurse is caring for four clients. Which of the following clients should the nurse identify as most likely to experience difficulty in being assertive? (Select all that apply.) A. A 20-year-old woman who was recently raped B. A 69-year-old widow who is socially isolated C. A 17-year-old boy with conduct disorder D. A 45-year-old successful executive E. A 50-year-old diagnosed with narcissistic personality disorder

ANS: A, B, C The woman who has been raped may feel vulnerable; the widow who is socially isolated may lack the necessary skills to communicate her needs; and the boy is likely to demonstrate aggressive behaviors. The business executive and an individual diagnosed with narcissistic personality disorder are the least likely to have difficulty being assertive.

19. During a course of 12 electroconvulsive therapy (ECT) procedures, an anxious client diagnosed with major depression refuses to bathe or attend group therapy. He reports some memory problems and says he has trouble figuring out what time of day it is. At this time, which of the following nursing diagnoses should be assigned to this client? Select all that apply. A. Anxiety R/T post-ECT confusion and memory loss B. Risk for injury R/T post-ECT confusion and memory loss C. Risk for activity intolerance R/T post-ECT confusion and memory loss D. Altered sensory perception R/T post-ECT confusion and memory loss E. Social isolation R/T post-ECT confusion and memory loss

ANS: A, B, C, E Because of the post-ECT thought alterations of confusion and memory loss, the client is anxious, is accident prone, and has socially isolated self. Altered sensory perception is related to psychotic thoughts of a sensory nature such as hallucinations, and because this client is diagnosed with major depression, not schizophrenia, altered sensory perception would not be anticipated. KEY: Cognitive Level: Analysis | Integrated Process: Nursing Process: Analysis | Client Need: Psychosocial Integrity

Which of the following has the SAMHSA described, as major dimensions of support for a life of recovery? Select all that apply. A. Health B. Community C. Home D. Religious affiliation E. Purpose

ANS: A, B, C, E SAMHSA suggests that a life in recovery is supported by four major dimensions: health, home, purpose, and community. Religious affiliation is not included in the listed dimensions. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse uses the commitments of the Tidal Model of Recovery in psychiatric nursing practice. Which of the following nursing actions reflect the use of the Develop Genuine Curiosity commitment? Select all that apply. A. The nurse expresses interest in the client's story. B. The nurse asks for clarification of certain points. C. The nurse encourages the client to speak his own words in his own unique way. D. The nurse assists the client to unfold the story at his or her own rate. E. The nurse provides the clients with copies of all documents relevant to care.

ANS: A, B, D Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Develop Genuine Curiosity commitment, by expressing interest, asking for clarification, and assisting the client to unfold the story at his or her own rate. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

20. Which of the following conditions would place a client at risk for injury during electroconvulsive therapy (ECT)? Select all that apply. A. Severe osteoporosis B. Acute and chronic pulmonary disorders C. Hypothyroidism D. Recent cardiovascular accident E. Prostatic hypertrophy

ANS: A, B, D Severe osteoporosis, acute and chronic pulmonary disorders, and a recent history of cardiovascular accident (CVA) can render clients at high risk for injury during electroconvulsive therapy. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Physiological Integrity: Reduction of Risk Potential

12. Which of the following are effective interventions that a nurse should utilize when caring for an inpatient client who expresses anger inappropriately? (Select all that apply.) A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid "I" statements related to expression of feelings.

ANS: A, B, D The nurse should determine that when working with an inpatient client who expresses anger inappropriately, it is important to maintain a calm demeanor, clearly define the consequences, and set limits on the behavior. The use of therapeutic touch may not be appropriate and could escalate the client's anger. PTS: 1 REF: 244 KEY: Cognitive Level: Application | Integrated Process: Implementation

18. Which assessment results should a nurse evaluate and report in the process of clearing a client for electroconvulsive therapy (ECT)? Select all that apply. A. Electrocardiographic records B. Pulmonary function study results C. Electroencephalogram analysis D. Complete blood count values E. Urinalysis results

ANS: A, B, D, E A nurse should evaluate electrocardiographic records, pulmonary function study results, complete blood count, and urinalysis results and report any abnormalities to the client's physician. The client must be medically cleared prior to ECT. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Safe and Effective Care Environment

34. A nurse is caring for a group of clients within the DSM-5 Cluster B category of personality disorders. Which factors should the nurse consider when planning client care? Select all that apply. A. These clients have personality traits that are deeply ingrained and difficult to modify. B. These clients need medications to treat the underlying physiological pathology. C. These clients use manipulation, making the implementation of treatment problematic. D. These clients have poor impulse control that hinders compliance with a plan of care. E. These clients commonly have secondary diagnoses of substance abuse and depression.

ANS: A, C, D, E The nurse should consider that individuals diagnosed with cluster Btype personality disorders have deeply ingrained personality traits, use manipulation, have poor impulse control, and often have secondary diagnoses of substance abuse and/or depression. This cluster includes antisocial, borderline, histrionic, and narcissistic personality disorders.

A client diagnosed with obsessive-compulsive disorder states, "I really think my future will improve because of my successful treatment choices. I'm going to make my life better." Which guiding principle of recovery has assisted this client? A. Recovery emerges from hope. B. Recovery is person-driven. C. Recovery occurs via many pathways. D. Recovery is holistic.

ANS: A. The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This client has internalized hope. This hope is the catalyst of the recovery process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

20. A client presents in the emergency department with complaints of overwhelming anxiety. Which of the following is a priority for the nurse to assess? A. Risk for suicide B. Cardiac status C. Current stressors D. Substance use history

ANS: B Although all of the listed aspects of assessment are important, the priority is to evaluate cardiac status since a person having an MI, CHF, or mitral valve prolapse can present with symptoms of anxiety.

15. A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.

ANS: B An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.

26. A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose? A. When the client has a knowledge deficit related to the effects of the drug B. When the client combines the drug with alcohol C. When the client takes the drug on an empty stomach D. When the client fails to follow dietary restrictions

ANS: B Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an additive effect and can suppress the respiratory system, leading to respiratory arrest and death.

32. A client diagnosed with Cluster C traits sits alone and ignores others attempts to converse. When ask to join a group the client states, No, thanks. In this situation, which should the nurse assign as an initial nursing diagnosis? A. Fear R/T hospitalization B. Social isolation R/T poor self-esteem C. Risk for suicide R/T to hopelessness D. Powerlessness R/T dependence issues

ANS: B Clients diagnosed with Cluster C traits are described as anxious and fearful. The DSM-5 divides Cluster C personality disorders into three categories: avoidant, dependent, and obsessive-compulsive. Anxiety and fear contribute to social isolation.

29. While improving, a client demands to have a phone installed in the intensive care unit (ICU) room. When a nurse states, This is not allowed; it is a unit rule, the client angrily demands to see the doctor. Which approach should the nurse use in this situation? A. Provide an explanation for the necessity of the unit rule. B. Assist the client to discuss anger and frustrations. C. Call the physician and relay the request. D. Arrange for a phone to be installed in the clients unit room.

ANS: B Clients who demand special privileges may be diagnosed with narcissistic personality disorder. The best approach in this situation is for the nurse to identify the function that anger, frustration, and rage serve for the client. The verbalization of feelings may help the client to gain insight into his or her behavior.

10. The nurse is preparing to provide medication instruction for a patient. Which of the following understandings about anxiety will be essential to effective instruction? A. Learning is best when anxiety is moderate to severe. B. Learning is enhanced when anxiety is mild. C. Panic level anxiety helps the nurse teach better. D. Severe anxiety is characterized by intense concentration and enhances the attention span.

ANS: B Mild anxiety sharpens the senses, increases the perceptual field, and results in heightened awareness of the environment. Learning is enhanced. As anxiety increases, attention span decreases and learning becomes more difficult.

25. A nurse is educating a patient about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health? A. Mental health is the absence of any stressors. B. Mental health is successful adaptation to stressors in the internal and external environment. C. Mental health is incongruence between thoughts, feelings, and behavior D. Mental health is a diagnostic category in the DSM-5.

ANS: B Several definitions of mental health exist, but this definition highlights concepts of successful adaptation to stressors, including thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms.

24. Which should the nurse recognize as a DSM-5 disorder? A. Obesity B. Generalized anxiety disorder C. Hypertension D. Grief

ANS: B The DSM-5 identifies several disorders that are related to anxiety, including generalized anxiety disorder, somatic symptom disorder, and dissociative disorders.

18. What is the main goal of the working phase of the nurseclient therapeutic relationship? A. Role modeling to improve interaction with others B. Resolution of the clients problems C. Using therapeutic communication to clarify perceptions D. Helping the client access outpatient treatment

ANS: B The goal of the working phase of the nurseclient therapeutic relationship is to resolve client problems by promoting behavioral change.

19. A nursing student questions an instructor regarding the order for fluvoxamine (Luvox), 300 mg daily, for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate? A. High doses of tricyclic medications will be required for effective treatment of OCD. B. Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD. C. The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia. D. The dosage of Luvox is outside the therapeutic range and needs to be questioned.

ANS: B The most accurate instructor response is that SSRI doses in excess of what is effective for treating depression may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.

11. A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, Should I seek psychiatric help for my mother? Which is an appropriate nursing reply? A. My mother also worries unnecessarily. I think it is part of the aging process. B. Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning. C. From what you have told me, you should get her to a psychiatrist as soon as possible. D. Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications.

ANS: B The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.

2. A hungry, homeless client, diagnosed with schizophrenia, refuses to participate in an admission interview. When the nurse postpones the admission interview, verbally assures safety, and provides a warm meal, he or she is promoting which of the following? A. Sympathy B. Trust C. Veracity D. Manipulation

ANS: B The nurse is promoting trust by postponing the admission interview, assuring safety, and providing a warm meal. Trust implies a feeling of confidence that a person is reliable and sincere and has integrity and veracity. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the client.

2. At what point should the nurse determine that a client is at risk for developing a mental disorder? A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria B. When maladaptive responses to stress are coupled with interference in daily functioning C. When the client communicates significant distress D. When the client uses defense mechanisms as ego protection

ANS: B The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The client's ability to communicate distress would be considered a positive attribute.

13. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, "I know she wants me." This statement reflects which defense mechanism? A. Displacement B. Projection C. Rationalization D. Sublimation

ANS: B The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection refers to the attribution of one's unacceptable feelings or impulses to another person. When the client "passes the blame" of the undesirable feelings, anxiety is reduced. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

6. A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain to the spouse the etiology of this fear? A. Your spouse may be unable to resolve internal conflicts, which result in projected anxiety. B. Your spouse may be experiencing a distorted and unrealistic appraisal of the situation. C. Your spouse may have a genetic predisposition to overreacting to potential danger. D. Your spouse may have high levels of brain chemicals that may distort thinking.

ANS: B The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.

11. If an individual is two-faced, which characteristic essential to the development of a therapeutic relationship should a nurse identify as missing? A. Respect B. Genuineness C. Sympathy D. Rapport

ANS: B The nurse should identify that genuineness is missing in the relationship. Genuineness refers to an individuals ability to be open and honest and maintain congruence between what is felt and what is communicated. Genuineness is essential to establishing trust in a relationship.

20. According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse? A. A client rudely complaining about limited visiting hours B. A client exhibiting aggressive behavior toward another client C. A client stating that no one cares D. A client verbalizing feelings of failure

ANS: B The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow's hierarchy of needs and must be fulfilled before other, higher-level needs can be met. Clients who complain, have feelings of failure, or state that no one cares are struggling with higher-level needs such as the need for love and belonging or the need for self-esteem.

13. A client diagnosed with paranoid schizophrenia becomes agitated when asked to play a game. The client responds, Do you want to be my girlfriend? Which nursing response is most appropriate? A. You are upset now. It would be best if you go to your room until you feel better. B. Remember, we have a professional relationship. Are you feeling uncomfortable? C. We have discussed this before. I am not allowed to date clients. D. I think you should discuss your fantasies with your therapist.

ANS: B The nurse should promote the clients insight and perception of reality by confirming appropriate roles in the nurseclient relationship and identifying what is troubling the client in this situation.

4. A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, "I work hard to provide for my family. I don't see why I can't drink to relax." The nurse recognizes the use of which defense mechanism? A. Projection B. Rationalization C. Regression D. Sublimation

ANS: B The nurse should recognize that the client is using rationalization, a common defense mechanism. The client is attempting to make excuses and create logical reasons to justify unacceptable feelings or behaviors.

16. Which nursing statement about the concept of psychoses is most accurate? A. "Individuals experiencing psychoses are aware that their behaviors are maladaptive." B. "Individuals experiencing psychoses experience little distress." C. "Individuals experiencing psychoses are aware of experiencing psychological problems." D. "Individuals experiencing psychoses are based in reality."

ANS: B The nurse should understand that the client with psychoses experiences little distress, because of his or her lack of awareness of reality. The client with psychoses is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.

15. Which nursing statement about the concept of neuroses is most accurate? A. "An individual experiencing neurosis is unaware that he or she is experiencing distress." B. "An individual experiencing neurosis feels helpless to change his or her situation." C. "An individual experiencing neurosis is aware of psychological causes of his or her behavior." D. "An individual experiencing neurosis has a loss of contact with reality."

ANS: B The nurse should understand that the concept of neuroses includes the following characteristics. The client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.

1. A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred? A. These clients do not recognize that their fear is excessive, and they rarely seek treatment. B. These clients have overwhelming symptoms of panic when exposed to the phobic stimulus. C. These clients experience symptoms that mirror a cerebrovascular accident (CVA). D. These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.

ANS: B The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimulus produces an immediate anxiety response.

7. Which phase of the nurseclient relationship begins when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals? A. Preinteraction B. Orientation C. Working D. Termination

ANS: B The orientation phase is when the individuals first meet and is characterized by an agreement to continue to meet and work on setting client-centered goals. There are four phases of relationship development: preinteraction, orientation, working, and termination.

4. What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship? A. Acknowledge the clients actions and generate alternative behaviors. B. Establish rapport and develop treatment goals. C. Attempt to find alternative placement. D. Explore how thoughts and feelings about this client may adversely impact care.

ANS: B The priority nursing action during the orientation phase of the nurseclient relationship should be to establish rapport and develop treatment goals. Rapport implies feelings on the part of both the nurse and the client based on respect, acceptance, a sense of trust, and a nonjudgmental attitude. It is the essential foundation of the nurseclient relationship.

8. Which statement reflects a student nurse's accurate understanding of the concepts of mental health and mental illness? A. "The concepts are rigid and religiously based." B. "The concepts are multidimensional and culturally defined." C. "The concepts are universal and unchanging." D. "The concepts are unidimensional and fixed."

ANS: B The student nurse should understand that mental health and mental illness are multidimensional and culturally defined. It is important for nurses to be aware of cultural norms when evaluating a client's mental state.

23. A client has the following symptoms: preoccupation with imagined defect, verbalizations that are out of proportion to actual physical abnormalities, and numerous visits to plastic surgeons to seek relief. Which nursing diagnosis would best describe the problems evidenced by these symptoms? A. Ineffective coping B. Disturbed body image C. Complicated grieving D. Panic anxiety

ANS: B The symptoms presented describe the DSM-5 diagnosis of body dysmorphic disorder, and the related nursing diagnosis is disturbed body image.

12. A nursing student is observing an electroconvulsive therapy (ECT) procedure. The student notices a blood pressure cuff on the client's lower leg. The student questions the instructor about the cuff placement. Which is the most accurate instructor reply? A. "The cuff has to be placed on the leg because both arms are used for intravenous fluids." B. "The cuff functions to prevent succinylcholine from reaching the foot." C. "The cuff position gives a more accurate blood pressure reading during the treatment." D. "The cuff is placed on the leg so that arms can easily be restrained during seizure."

ANS: B A blood pressure cuff is placed on the lower leg and inflated above systolic pressure before injection of succinylcholine. This is to ensure that seizure activity can be observed and timed in this one limb that is unaffected by the paralytic agent. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client? A. "I'm not going to use heroin ever again. I know I've got the willpower to do it this time." B. "I cannot control my use of heroin. It's stronger than I am." C. "I'm going to get all my children back. They need their mother." D. "Once I deal with my childhood physical abuse, recovery should be easy."

ANS: B A positive prognosis is more likely when a client admits that he or she is addicted to a substance and has a loss of control. One of the first steps in accepting treatment is for the client to admit powerlessness over the substance.

A client states, "I have come to the conclusion that this disease has not paralyzed me." The nurse recognizes that this client is in which stage of the Psychological Recovery Model as described by Andersen and associates? A. Moratorium B. Awareness C. Preparation D. Rebuilding

ANS: B Andresen and associates have conceptualized a five-stage model of recovery called the Psychological Recovery Model. The stages include Stage 1, Moratorium; Stage 2, Awareness; Stage 3, Preparation; Stage 4, Rebuilding; and Stage 5, Growth. In the awareness stage, the individual comes to a realization that a possibility for recovery exists. Andresen and associates state, "It involves an awareness of a possible self other than that of 'sick person': a self that is capable of recovery." KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

During a psychoeducational group on assertiveness training a client asks, "Why do we need to learn about this stuff?" Which is the most appropriate nursing reply? A. "Because your doctor requires you to attend this group." B. "Being assertive is the ability to stand up for yourself while respecting the rights of others." C. "Assertiveness training teaches you how to ask for what you want, when you want it." D. "Assertive people place the needs and rights of others before their own."

ANS: B Assertiveness training assists people to maintain their own self-respect and meet their needs while respecting the rights of others.

An adolescent comes from a dysfunctional family where physical and verbal abuse prevails. At school this adolescent bullies and fights with classmates. According to principles of behavior therapy, what is the probable source of this behavior? A. Shaping B. Modeling C. Premack principle D. Reciprocal inhibition

ANS: B Modeling is the learning of new behaviors by imitating the behaviors of others. This adolescent, witnessing physical and verbal abuse in the home, models this behavior in school. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client Need: Psychosocial Integrity

8. A despondent client who has recently lost her husband of 30 years tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing reply is most appropriate? A. "I'm confident you know what's best for you." B. "This may not be the best time for you to make such an important decision." C. "Your children will be terribly disappointed." D. "Tell me why you want to make this change."

ANS: B During crisis intervention, the nurse should guide the client through a problem-solving process. The nurse should help the individual confront the source of the problem, encourage the individual to discuss changes he or she would like to make, and encourage exploration of feelings about aspects of the crisis that cannot be changed. The nurse should also assist the client in determining whether any changes are realistic and if timing of change is appropriate. PTS: 1 REF: 244 KEY: Cognitive Level: Application | Integrated Process: Implementation

3. A nursing instructor is teaching about electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. "During ECT a state of euphoria is induced." B. "ECT induces a grand mal seizure." C. "During ECT a state of catatonia is induced." D. "ECT induces a petit mal seizure."

ANS: B Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain for the purpose of decreasing depression.

In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention? A. Dextroamphetamine (Dexedrine) B. Diazepam (Valium) C. Morphine (Astramorph) D. Phencyclidine (PCP)

ANS: B If large doses of central nervous system (CNS) depressants (like Valium) are repeatedly administered over a prolonged duration, a period of CNS hyperexcitability occurs on withdrawal of the drug. The response can be quite severe, even leading to convulsions and death.

Parents of a 3-year-old have noticed an improvement in behavior because of using a "time out" behavioral approach. What aspect of "time out" therapy may be responsible for this child's improved behavior? A. "Negative reinforcement discourages maladaptive behavior." B. "Positive reinforcement is removed." C. "Covert sensitization is being applied." D. "Reciprocal inhibition is eliminated."

ANS: B In a "time out," the positive reinforcement of attention is removed from the child during inappropriate behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

A nursing instructor is teaching about components present in the recovery process, as described by Andresen and associates, which led to the development of the Psychological Recovery Model. Which student statement indicates that further teaching is needed? A. "A client has a better chance of recovery if he or she truly believes that recovery can occur." B. "If a client is willing to give the responsibility of treatment to the health-care team, he or she is likely to recover." C. "A client who has a positive sense of self and a positive identity is likely to recover." D. "A client has a better chance of recovery if he or she has purpose and meaning in life."

ANS: B In examining a number of studies, Andresen and associates identified four components that were consistently evident in the recovery process. These components are hope, responsibility, self and identity, and meaning and purpose. Under responsibility, this model tasks the client, not the health-care team, with taking responsibility for his or her life and well-being. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

An adolescent client was recently admitted to the psychiatric unit because of impulsivity and acting-out behavior at school. The nurse should initially implement which nursing action? A. Redirect the client to activities to decrease stress. B. Explain the unit rules and consequences of breaking the rules. C. Place the client on close observation to insure a trusting relationship. D. Administer an anti-anxiety medication.

ANS: B It is important for the nurse to initially explain the unit rules and consequences of breaking the rules. It is imperative that consequences of rule infractions are explained early in treatment to avoid misunderstanding and manipulation. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nursing instructor is teaching about the behavior technique of modeling. When asked to give an example of this behavioral intervention, which student statement meets the learning objective? A. "A child is first rewarded for using a spoon to eat and then rewarded for using a fork, and finally rewarded for cutting food with a knife." B. "An adolescent imitates Dad by using and caring for tools appropriately." C. "A client and therapist agree to conditions of therapy, stating explicitly in writing the behavior change that is desired." D. "A mother tells her child that television can be watched only after homework is completed."

ANS: B Modeling refers to the learning of new behaviors by imitating the behavior of others. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

13. A client states, "My doctor has told me I am a candidate for electroconvulsive therapy (ECT). Where will the treatment take place, and how much time would this entail?" Which is the most accurate nursing reply? A. "Clients typically receive ECT in their hospital room, daily for 1 month." B. "Clients typically undergo 6 to 12 ECT procedures, three times a week in an outpatient setting." C. "Clients typically receive an unlimited number of treatments, in the hospital procedure room." D. "Clients typically receive two to three treatments, in either an outpatient or inpatient setting."

ANS: B Most clients require an average of 6 to 12 ECT procedures, but some may require up to 20 procedures. Treatments are usually administered every other day, three times per week. Treatments are performed on either an inpatient or outpatient basis, depending on the need for client monitoring. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

A client is diagnosed with an anxiety disorder. The nurse counselor recommends intervention with the behavioral technique of reciprocal inhibition. The client asks, "What's that?" Which is the most appropriate nursing reply? A. "At the beginning of this intervention, a contract will be drawn up explicitly stating the behavior change agreed upon." B. "By introducing an adaptive behavior that is mutually exclusive to your maladaptive behavior, we will expect subsequent behavior to improve." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."

ANS: B Reciprocal inhibition decreases or eliminates an undesired behavior by introducing a more adaptive behavior that is incompatible with the undesired behavior. KEY: Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need: Psychosocial Integrity

A client diagnosed with alcohol abuse disorder is referred to a residential care facility after discharge. According to the SAMHSA, which dimension of recovery is supporting this client? A. Health B. Home C. Purpose D. Community

ANS: B SAMHSA describes the dimension of Home as a stable and safe place to live. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nursing instructor is teaching about the guiding principles of the recovery model, as described by the SAMHSA. Which student statement indicates that further teaching is needed? A. "Recovery occurs via many pathways." B. "Recovery emerges from strong religious affiliations." C. "Recovery is supported by peers and allies." D. "Recovery is culturally based and influenced."

ANS: B SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. Recovery emerges from hope, but affiliation with any particular religion would have little bearing on the recovery process. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Which is the priority nursing intervention for a client admitted for acute alcohol intoxication? A. Darken the room to reduce stimuli in order to prevent seizures. B. Assess aggressive behaviors in order to intervene to prevent injury to self or others. C. Administer lorazepam (Ativan) to reduce the rebound effects on the central nervous system. D. Teach the negative effects of alcohol on the body.

ANS: B Symptoms associated with the syndrome of alcohol intoxication include but are not limited to aggressiveness, impaired judgment, impaired attention, and irritability. Safety is a nursing priority in this situation.

A client diagnosed with schizophrenia functions well and is bright, spontaneous, and interactive during hospitalization but then decompensates after discharge. What does the milieu provide that may be missing in the home environment? A. Peer pressure B. Structured programming C. Visitor restrictions D. Mandated activities

ANS: B The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment. The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. In the milieu, time is also devoted to personal problems and focus groups.

A nurse maintains a client's confidentiality, addresses the client appropriately, and does not discriminate on the basis of gender, age, race, or religion. Which guiding principle of recovery has this nurse employed? A. Recovery is culturally based and influenced. B. Recovery is based on respect. C. Recovery involves individual, family, and community strengths and responsibility. D. Recovery is person-driven.

ANS: B The SAMHSA lists the following as guiding principles for the recovery model: recovery emerges from hope; recovery is person-driven; recovery occurs via many pathways; recovery is holistic; recovery is supported by peers and allies; recovery is supported through relationship and social networks; recovery is culturally based and influenced; recovery is supported by addressing trauma; recovery involves individual, family, and community strengths and responsibility; and recovery is based on respect. This nurse accepts and appreciates clients who are affected by mental health and substance use problems. This nurse protects the rights of clients and does not discriminate against them. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

A nursing instructor is teaching about recovery as it applies to mental illness. Which student statement indicates that further teaching is needed? A. "The goal of recovery is improved health and wellness." B. "The goal of recovery is expedient, comprehensive behavioral change." C. "The goal of recovery is the ability to live a self-directed life." D. "The goal of recovery is the ability to reach full potential."

ANS: B The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery from mental health disorders and substance use disorders as a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Change in recovery is not an expedient process. It occurs incrementally over time. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Which is the priority focus of recovery models? A. Empowerment of the health-care team to bring their expertise to decision-making B. Empowerment of the client to make decisions related to individual health care C. Empowerment of the family system to provide supportive care D. Empowerment of the physician to provide appropriate treatments

ANS: B The basic concept of a recovery model is empowerment of the client. The recovery model is designed to allow clients primary control over decisions about their own care. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

14. A client is scheduled for an initial electroconvulsive therapy (ECT) procedure. Which information should a nurse include when teaching about the potential side effects of this procedure? A. "You may experience transient tangential thinking." B. "You may experience some memory deficit surrounding the ECT." C. "You may experience avolution for the remainder of the day." D. "You may experience a higher risk for subsequent seizures."

ANS: B The most common side effect of ECT is temporary amnesia following the ECT procedure. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Safe and Effective Care Environment

9. An inpatient client with a known history of violence suddenly begins to pace. Which client behavior should alert a nurse to escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers.

ANS: B The nurse should assess that tense facial expressions and body language may indicate that a client's anger is escalating. The nurse should conduct a thorough assessment of the client's past and current violent behaviors, and develop interventions for deescalation. PTS: 1 REF: 243 KEY: Cognitive Level: Application | Integrated Process: Assessment

A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence? A. Narcotic pain medication is contraindicated for all clients with active substance-abuse problems. B. Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control. C. There is no need to assess the client for substance dependence. There is an obvious PCA malfunction. D. The client is experiencing symptoms of withdrawal and needs to be accurately assessed for lorazepam (Ativan) dosage.

ANS: B The nurse should assess the client for substance dependence because clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics, and require increased doses to achieve effective pain control. Cross-tolerance occurs when one drug lessened the client's response to another drug.

2. A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis

ANS: B The nurse should determine that the client is experiencing a psychiatric emergency crisis. Psychiatric emergencies occur when crisis situations result in severe impairment, incompetence, or an inability to assume personal responsibility. PTS: 1 REF: 242 KEY: Cognitive Level: Application | Integrated Process: Assessment

A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur? A. 50 mg/dL B. 100 mg/dL C. 250 mg/dL D. 300 mg/dL

ANS: B The nurse should expect that 100 mg/dL is the minimum blood alcohol level at which intoxication occurs. Intoxication usually occurs between 100 and 200 mg/dL. Death has been reported at levels ranging from 400 to 700 mg/dL.

13. A client with a history of cerebrovascular accident (CVA) is brought to an emergency department experiencing memory problems, confusion, and disorientation. On the basis of this clients assessment data, which diagnosis would the nurse expect the physician to assign? A. Medication-induced delirium B. Vascular neurocognitive disorder C. Altered thought processes D. Alzheimers disease

ANS: B The nurse should expect that this client would be diagnosed with vascular neurocognitive disorder (NCD), which is due to significant cerebrovascular disease. Vascular NCD often has an abrupt onset. This disease often occurs in a fluctuating pattern of progression.

A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report to the ED physician? A. Tactile hallucinations B. Blood pressure of 180/100 mm Hg C. Mood rating of 2/10 on numeric scale D. Dehydration

ANS: B The nurse should recognize that high blood pressure is a symptom of alcohol withdrawal and should promptly report this finding to the physician. Complications associated with alcohol withdrawal may progress to alcohol withdrawal delirium and possible seizure activity on about the second or third day following cessation of prolonged alcohol consumption.

A client continually waits more than an hour before being seen at the mental health clinic. The client approaches the nurse and states, "When I have to wait for more than an hour to be seen, I feel like my time is not important." The nurse recognizes this as what type of behavior? A. Aggressive behavior B. Assertive behavior C. Passive-aggressive behavior D. Passive behavior

ANS: B This response is assertive. The client is openly expressing feelings and attempting to correct a stressful situation.

An emergency department nurse, who has worked 10 straight days, is pulled to the psychiatric unit. Which represents a passive-aggressive statement by the emergency department nurse? A. "Get someone else to work 3 to 11! I've been working 10 days straight, and I need a break!" B. "Okay. I'll do it." Then purposefully leaves paperwork undone when leaving the unit at 11 p.m. C. "I have worked 10 days straight, and I cannot work tonight. I will work for you tomorrow if you need me." D. "Yes, I'll do it. Anything to keep peace with the hospital administration is a good thing."

ANS: B This response is passive-aggressive. The staff nurse's anger is expressed indirectly.

A teenager gets a "C" in algebra. The mother angrily states, "All you ever do is listen to music and text your friends." The teenager replies, "What is it that you're really upset about mom?" Which response pattern is the teenager expressing? A. Clouding and fogging B. Shifting from content to process C. Delaying assertively D. Assuming responsibility for one's own statements

ANS: B This response reflects the use of shifting from content to process. The teenager is changing the focus of the communication from discussing the topic at hand to analyzing what is actually going on in the interaction.

1. During a therapeutic group, a client talks about personal accomplishments in an effort to gain attention. Which group role, assumed by this client, should the nurse identify? A. The task role of gatekeeper B. The individual role of recognition seeker C. The maintenance role of dominator D. The task role of elaborator

ANS: B The individual role of recognition seeker The nurse should evaluate that the client is assuming the individual role of the recognition seeker. Other individual roles include the aggressor, the blocker, the dominator, the help seeker, the monopolizer, and the seducer.

4. A client is in the late stage of Alzheimers disease. To address the clients symptoms, which nursing intervention should take priority? A. Improve cognitive status by encouraging involvement in social activities. B. Decrease social isolation by providing group therapies. C. Promote dignity by providing comfort, safety, and self-care measures. D. Facilitate communication by providing assistive devices.

ANS: C

3. How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life

ANS: C Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.

28. A nurse would expect a client diagnosed with schizotypal personality disorder to exhibit which characteristic? A. The client has many friends and associates but prefers to interact in small groups. B. The client has many brief but intense relationships. C. The client experiences incorrect interpretations of external events. D. The client exhibits lack of tender feelings toward others.

ANS: C Clients who are diagnosed with schizotypal personality disorder experience odd beliefs or magical thinking that influences behavior and is inconsistent with cultural norms. This results in incorrect interpretations of external events.

A 2-year-old engages in frequent temper tantrums that usually result in the parents giving in to demands. During family therapy, how should a nurse counsel the parents? A. "You are shaping your child's behavior." B. "Your child has modeled your behavior." C. "You are positively reinforcing your child's behavior." D. "You are negatively reinforcing your child's behavior."

ANS: C KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

23. A husband accuses his wife of infidelity. Which situation would indicate to the nurse the husband's use of the ego defense mechanism of projection? A. The husband cries and stamps his feet, demanding that his wife be true to her marriage vows. B. The husband ignores the wife's continued absence from the home. C. The husband has already admitted to having an affair with a coworker. D. The husband takes out his marital frustrations through employee abuse.

ANS: C Projection is the attribution of feelings or impulses unacceptable to one's self to another person. In this situation, the husband attributes his infidelity to his wife.

22. Warrens college roommate actively resists going out with friends whenever they invite him. He says he cant stand to be around other people and confides to Warren They wouldnt like me anyway. Which disorder is Warrens roommate likely suffering from? A. Agoraphobia B. Mysophobia C. Social anxiety disorder (social phobia) D. Panic disorder

ANS: C Social anxiety disorder is an excessive fear of social situations R/T fear that one might do something embarrassing or be evaluated negatively by others.

21. Which client statement indicates that termination of the therapeutic nurseclient relationship has been handled successfully? A. I know I can count on you for continued support. B. I am looking forward to discharge, but I am surprised that we will no longer work together. C. Reviewing the changes that have happened during our time together has helped me put things in perspective. D. I dont know how comfortable I will feel when talking to someone else.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurseclient relationship ends. Bringing a therapeutic conclusion to the relationship occurs when progress has been made toward attainment of mutually set goals.

14. A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse? A. The client is using manipulation to receive secondary gain. B. The client is using the defense mechanism of denial. C. The client is having trouble terminating the relationship. D. The client is using splitting as a way to remain dependent on the nurse.

ANS: C Termination should begin in the orientation phase to minimize feelings of loss when the nurseclient relationship ends. When a client feels sadness and loss, behaviors to delay termination may become evident.

12. An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee? A. The employee assertively confronts the boss B. The employee leaves the staff meeting to work out in the gym C. The employee criticizes a coworker D. The employee takes the boss out to lunch

ANS: C The client using the defense mechanism of displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less-threatening target.

24. How should a nurse best describe the major maladaptive client response to panic disorder? A. Clients overuse medical care because of physical symptoms. B. Clients use illegal drugs to ease symptoms. C. Clients perceive having no control over life situations. D. Clients develop compulsions to deal with anxiety.

ANS: C The major maladaptive client response to panic disorder is the perception of having no control over life situations, which leads to nonparticipation in decision making and doubts regarding role performance.

12. A client is experiencing a severe panic attack. Which nursing intervention would meet this clients immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar)

ANS: C The nurse can meet this clients immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life, and the presence of a trusted individual provides assurance of personal safety.

7. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." Which is the nurse's best response? A. "It's just a routine part of our assessment. All clients are asked these same questions." B. "Why are you concerned about these types of questions?" C. "Psychological factors, like excessive stress, have been found to affect medical conditions." D. "We can skip these questions, if you like. It isn't imperative that we complete this section."

ANS: C The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip either physiological or psychosocial questions, as this would lead to an inaccurate assessment.

14. A client living on the beachfront seeks help with an extreme fear of crossing bridges, which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge. B. Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response. C. Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety. D. In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate.

ANS: C The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety-provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.

During a hiring interview, which response by a nursing applicant should indicate that the applicant operates from an ethical egoism framework? A. I would want to be treated in a caring manner if I were mentally ill. B. This job will pay the bills, and the workload is light enough for me. C. I will be happy caring for the mentally ill. Working in Med/Surg kills my back. D. It is my duty in life to be a psychiatric nurse. It is the right thing to do.

5. Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)

ANS: C The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.

14. A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified by a nurse as indicative of which defense mechanism? A. Displacement B. Projection C. Reaction formation D. Sublimation

ANS: C The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors. Displacement refers to transferring feelings from one target to another. Rationalization refers to making excuses to justify behavior. Projection refers to the attribution of unacceptable feelings or behaviors to another person. Sublimation refers to channeling unacceptable drives or impulses into more constructive, acceptable activities.

8. Which client statement should a nurse identify as a typical response to stress most often experienced in the working phase of the nurseclient relationship? A. I cant bear the thought of leaving here and failing. B. I might have a hard time working with you. You remind me of my mother. C. I cant tell my husband how I feel; he wouldnt listen anyway. D. Im not sure that I can count on you to protect my confidentiality.

ANS: C The nurse should identify that the client statement I cant tell my husband how I feel; he wouldnt listen anyway reflects resistance to change, which is a common behavior in the working phase of the nurseclient relationship. The working phase includes overcoming resistant behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.

19. A nurse is performing a mental health assessment on an adult client. According to Maslow's hierarchy of needs, which client action would demonstrate the highest achievement in terms of mental health? A. Maintaining a long-term, faithful, intimate relationship B. Achieving a sense of self-confidence C. Possessing a feeling of self-fulfillment and realizing full potential D. Developing a sense of purpose and the ability to direct activities

ANS: C The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs.

18. Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief? A. "If only we could have tried again, things might have worked out." B. "I am so mad that the children and I had to put up with him as long as we did." C. "Yes, it was a difficult relationship, but I think I have learned from the experience." D. "I still don't have any appetite and continue to lose weight."

ANS: C The nurse should recognize that the client is in the acceptance stage of grief. During this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life.

6. What should be the nurses primary goal during the preinteraction phase of the nurseclient relationship? A. To evaluate goal attainment and ensure therapeutic closure B. To establish trust and formulate a contract for intervention C. To explore self-perceptions D. To promote client change

ANS: C The nurses primary goal of the preinteraction phase should be to explore self-perceptions. The nurse should be aware of how any preconceptions may affect his or her ability to care for individual clients. Another goal of the preinteraction phase is to obtain available client information.

13. A college student is unable to take a final examination because of severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear

ANS: C The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the clients healthy coping skills and reduce anxiety.

25. A client diagnosed with generalized anxiety states, I know the best thing for me to do now is to just forget my worries. How should the nurse evaluate this statement? A. The client is developing insight. B. The clients coping skills are improving. C. The client has a distorted perception of problem resolution. D. The client is meeting outcomes and moving toward discharge.

ANS: C This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.

17. As the client and nurse move from the orientation stage to the working stage of the therapeutic relationship, which is the nurses most therapeutic statement? A. I want to assure you that I will maintain your confidentiality. B. A long-term goal for someone your age would be to develop better job skills. C. Which identified problems would you like for us to initially address? D. I think first we need to focus on your relationship issues.

ANS: C When moving on a continuum from the orientation to working phase of the nurseclient relationship, the clients identified goals are addressed through mutual therapeutic work to promote client behavioral change.

A nursing supervisor is scheduling holiday hours. When the supervisor tells the staff nurse that she needs to work Christmas day, the staff nurse calmly repeats, "I worked last Christmas and will not work this Christmas." This is an example of which assertive behavior technique? A. Shifting from content to process B. Standing up for one's basic rights C. Responding as a broken record D. Defusing

ANS: C "Responding as a broken record" is an assertive behavior technique that consists of persistently repeating in a calm voice what is wanted.

16. A client with cognitive deficits is extremely suicidal. The client has not responded to antidepressants and the treatment team is considering electroconvulsive therapy (ECT). What client information would impact the feasibility of this treatment option? A. Because the client is extremely suicidal, ECT is an appropriate option. B. Because antidepressant medications have been ineffective, ECT is a good alternative. C. Because informed consent is required for ECT, cognitive deficits could preclude this option. D. Because of the client's cognitive deficits, a signed consent is waived.

ANS: C A client who is experiencing cognitive deficits cannot give informed consent, which is required prior to ECT. A court proceeding could determine the client's level of competency and, if necessary, the judge would appoint a guardian. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

19. An experienced psychiatric registered nurse has taken a new position leading groups in a day treatment program. Without further education, which group is this nurse most qualified to lead? A. A psychodrama group B. A psychotherapy group C. A parenting group D. A family therapy group

ANS: C A psychiatric registered nurse is qualified to lead a parenting group. A parenting group can be classified as either a teaching group or therapeutic group. Psychodrama, psychotherapy, and family therapy are forms of group therapy that must be facilitated by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine. PTS: 1 REF: 190 KEY: Cognitive Level: Application | Integrated Process: Implementation

A nurse on an inpatient unit helps a client understand the significance of treatments and provides the client with copies of all documents related to the plan of care. This nurse is employing which commitment in the "Tidal Model of Recovery?" A. Know that Change Is Constant B. Reveal Personal Wisdom C. Be Transparent D. Give the Gift of Time

ANS: C Barker & Buchanan-Barker developed a set of essential values termed The 10 Tidal Commitments, upon which the Tidal Model is based. They include Value the Voice, Respect the Language, Develop Genuine Curiosity, Become the Apprentice, Use the Available Toolkit, Craft the Step Beyond, Give the Gift of Time, Reveal Personal Wisdom, Know that Change Is Constant, and Be Transparent. This nurse is employing the Be Transparent commitment. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

10. A client who is learning about electroconvulsive therapy (ECT) asks a nurse, "Isn't this treatment dangerous?" Which is the most appropriate nursing reply? A. "No, this treatment is side-effect free." B. "There can be temporary paralysis, but full functioning returns within 3 hours of treatment." C. "There are some risks, but a thorough examination will determine your candidacy for ECT." D. "Transient ischemic attacks (TIAs) can occur but are rare."

ANS: C Clients are given medical clearance for ECT. This decreases the risk of injury from the treatment. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Physiological Integrity: Reduction of Risk Potential

A mother tells her teenager that in order for college tuition to be paid, the teenager must quit smoking. They develop a written agreement stipulating time frames and consequences. This is an example of which technique of behavior modification? A. Shaping B. Modeling C. Contracting D. Premack principle

ANS: C Contracting occurs when the mother and teenager together develop a written agreement related to desired behavior (smoking cessation) and positive reinforcement (paid college tuition). KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A nurse should assign which nursing diagnosis to a client needing assistance with assertiveness? A. Disturbed personal identity B. Disturbed thought processes C. Defensive coping D. Impaired verbal communication

ANS: C Defensive coping reflects a self-protective pattern that defends against underlying perceived threats to positive self-regard. Clients who are utilizing defensive coping lack assertiveness skills.

During hospitalization, an attention-seeking client has repeatedly cut herself. After threatening to cut herself again, the nurse states, "Here are some Band-Aids so you won't bleed on the sheets." Which is the underlying reason for this nurse's response? A. The nurse is using an aversive stimulus in response to the client's manipulative cutting behavior. B. The nurse is using negative reinforcement in response to the client's behavior. C. The nurse is minimizing reinforcement of the client's manipulative behavior with the goal of extinction. D. The nurse lacks empathy for the client's recurring self-injurious behavior.

ANS: C Extinction is the gradual decrease in frequency or disappearance of a response when a positive reinforcement is withheld. The nurse is withholding attention to the client who is exhibiting manipulative, attention-seeking behavior. The lack of positive response (attention) should cause extinction of the undesired behavior. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

8. A nursing instructor is teaching about the medications given prior to and during electroconvulsive therapy (ECT). Which student statement indicates that learning has occurred? A. "Atropine (Atro-Pen) is administered to paralyze skeletal muscles during ECT." B. "Succinylcholine chloride (Anectine) decreases secretions to prevent aspiration." C. "Thiopental sodium (Pentothal) is a short-acting anesthesia to render the client unconscious." D. "Glycopyrrolate (Robinul) is given to prevent severe muscle contractions during seizure."

ANS: C In order to render a client unconscious during the ECT procedure, an anesthesiologist administers intravenously a short-acting anesthetic such as thiopental sodium (Pentothal).

A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse? A. Alcohol poisoning B. Cardiovascular accident (CVA) C. A reaction to disulfiram (Antabuse) D. A reaction to tannins in the red wine

ANS: C Ingestion of alcohol while disulfiram is in the body results in a syndrome of symptoms that can produce a good deal of discomfort for the individual. Symptoms may include but are not limited to flushed skin, throbbing in the head and neck, respiratory difficulty, dizziness, nausea and vomiting, confusion, hypotension, and tachycardia.

A client reports, "My friend panicked at the site of spiders. Her therapist used gradual exposure to spiders that initially made her increasingly more anxious." Which technique was the friend's therapist most likely using? A. Extinction B. Covert sensitization C. Systematic desensitization D. Reciprocal inhibition

ANS: C Systematic desensitization is a treatment for phobias in which a phobic individual is gradually exposed to increasing amounts of the phobic stimulus while practicing relaxation techniques. Eventually, the phobic stimulus causes little or no anxiety. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility? A. By asking directly if the client has ever had a problem with alcohol B. By holistically assessing the client using the CIWA scale C. By using a screening tool such as the CAGE questionnaire D. By referring the client for physician evaluation

ANS: C The CAGE questionnaire is a screening tool used to determine the diagnosis of alcoholism. This questionnaire is composed of four simple questions. Scoring two or three "yes" answers strongly suggests a problem with alcohol.

A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response? A. "Why do you assume responsibility for his behaviors?" B. "Codependency is a typical behavior of spouses of alcoholics." C. "Your husband needs to deal with the consequences of his drinking." D. "Do you understand what the term 'enabler' means?"

ANS: C The appropriate nursing response is to use confrontation with caring. The nurse should understand that the client's wife may be in denial and enabling the husband's behavior. Partners of clients with substance abuse must come to realize that the only behavior they can control is their own.

5. After undergoing two of nine electroconvulsive therapy (ECT) procedures, a client states, "I can't even remember eating breakfast, so I want to stop the ECT." Which is the most appropriate nursing reply? A. "After you begin the course of treatments, you must complete all of them." B. "You'll need to talk with your doctor about what you're thinking." C. "It is within your right to discontinue the treatments, but let's talk about your concerns." D. "Memory loss is a rare side effect of the treatment. I don't think it should be a concern."

ANS: C The client has the right to terminate treatment. This nursing reply acknowledges this right but focuses on the client's concerns so that the nurse can provide needed information.

A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement? A. The client is using minimization as an ego defense. B. The client is ready to sign an Alcoholics Anonymous contract for sobriety. C. The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous. D. The client has met the requirements to be designated as an Alcoholics Anonymous sponsor.

ANS: C The first step of the 12-step program advocated by Alcoholics Anonymous is that clients must admit powerlessness over alcohol and that their lives have become unmanageable.

12. A client diagnosed with a neurocognitive disorder is exhibiting behavioral problems on a daily basis. At change of shift, the clients behavior escalates from pacing to screaming and flailing. Initially, which action should a nurse implement in this situation? A. Consult the psychologist regarding behavior-modification techniques. B. Medicate the client with prn antianxiety medications. C. Assess environmental triggers and potential unmet needs. D. Anticipate the behavior and restrain when pacing begins.

ANS: C The initial nursing action is to assess environmental triggers and potential unmet needs. Due to the cognitive decline experienced in a client diagnosed with neurocognitive disorder, communication skills may be limited. The client may become disoriented and frustrated

1. A nurse administers pure oxygen to a client during and after electroconvulsive therapy. What is the nurse's rationale for this procedure? A. To prevent increased intracranial pressure resulting from anoxia B. To prevent hypotension, bradycardia, and bradypnea due to electrical stimulation C. To prevent anoxia due to medication-induced paralysis of respiratory muscles D. To prevent blocked airway resulting from seizure activity

ANS: C The nurse administers 100% oxygen during and after electroconvulsive therapy to prevent anoxia due to medication-induced paralysis of respiratory muscles. Electroconvulsive therapy is the induction of a grand mal seizure through the application of electrical current to the brain.

Upon admission for symptoms of alcohol withdrawal a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis? A. Knowledge deficit B. Fluid volume excess C. Imbalanced nutrition: less than body requirements D. Ineffective individual coping

ANS: C The nurse should assess that the priority nursing diagnosis is imbalanced nutrition: less than body requirements. The client is exhibiting signs and symptoms of malnutrition as well as alcohol withdrawal. The nurse should consult a dietitian, restrict sodium intake to minimize fluid retention, and provide small, frequent feedings of nonirritating foods.

8. At what time during a 24-hour period should a nurse expect clients with Alzheimers disease to exhibit more pronounced symptoms? A. When they first awaken B. In the middle of the night C. At twilight D. After taking medications

ANS: C The nurse should determine that clients with Alzheimers disease exhibit more pronounced symptoms at twilight. Sundowning is the term used to describe the worsening of symptoms in the late afternoon and evening.

10. What is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken-down" after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger

ANS: C The nurse should determine that the purpose for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken-down" after a violent outburst is to process feelings and concerns related to the witnessed intervention. PTS: 1 REF: 244 KEY: Cognitive Level: Application | Integrated Process: Implementation

7. Which symptom should a nurse identify that would differentiate clients diagnosed with neurocognitive disorders from clients with pseudodementia (depression)? A. Altered sleep B. Impaired attention and concentration C. Altered task performance D. Impaired psychomotor activity

ANS: C The nurse should identify that attention and concentration are impaired in neurocognitive disorder and not in pseudodementia (depression).

16. When planning group therapy, a nurse should identify which configuration as most optimal for a therapeutic group? A. Open-ended membership; circle of chairs; group size of 5 to 10 members B. Open-ended membership; chairs around a table; group size of 10 to 15 members C. Closed membership; circle of chairs; group size of 5 to 10 members D. Closed membership; chairs around a table; group size of 10 to 15 members

ANS: C The nurse should identify that the most optimal conditions for a therapeutic group are when the membership is closed and the group size is between 5 and 10 members who are arranged in a circle of chairs. The focus of therapeutic groups is on relationships within the group and the interactions among group members. PTS: 1 REF: 191-192 KEY: Cognitive Level: Application | Integrated Process: Planning

During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement? A. The client is using denial by avoiding responsibility. B. The client is using displacement by blaming his wife. C. The client is using rationalization to excuse his alcohol dependence. D. The client is using reaction formation by appealing to the group for sympathy.

ANS: C The nurse should interpret that the client is using rationalization to excuse his alcohol dependence. Rationalization is the defense mechanism by which people avoid taking responsibility for their actions by making excuses for the behavior.

10. After 1 week of continuous mental confusion, an elderly African American client is admitted with a preliminary diagnosis of major neurocognitive disorder due to Alzheimers disease. What should cause the nurse to question this diagnosis? A. Neurocognitive disorder does not typically occur in African American clients. B. The symptoms presented are more indicative of Parkinsonism. C. Neurocognitive disorder does not develop suddenly. D. There has been no T3 or T4 level evaluation ordered.

ANS: C The nurse should know that neurocognitive disorder (NCD) does not develop suddenly and should question this diagnosis. The onset of NCD symptoms is slow and insidious and is unrelated to race, culture, or creed. The disease is generally progressive and debilitating.

5. A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. A nurse should recognize these as classic signs of which condition? A. Mania B. Delirium C. Neurocognitive disorder D. Parkinsonism

ANS: C The nurse should recognize that the client is exhibiting signs of neurocognitive disorder (NCD). In NCD, impairment is evident in abstract thinking, judgment, and impulse control. Behavior may be uninhibited and inappropriate.

An angry client on an inpatient unit approaches a nurse stating, "Someone took my lunch! People need to respect others, and you need to do something about this now!" The nurse's response should be guided by which basic assumption of milieu therapy? A. Conflict should be avoided at all costs on inpatient psychiatric units. B. Conflict should be resolved by the nursing staff. C. Every interaction is an opportunity for therapeutic intervention. D. Conflict resolution should only be addressed during group therapy.

ANS: C The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. The nurse can utilize milieu therapy to effect behavioral change and improve psychological health and functioning.

15. A client diagnosed with neurocognitive disorder due to Alzheimers disease is disoriented and ataxic, and he wanders. Which is the priority nursing diagnosis? A. Disturbed thought processes B. Self-care deficit C. Risk for injury D. Altered health-care maintenance

ANS: C The priority nursing diagnosis for this client is risk for injury. Both ataxia (muscular incoordination) and purposeless wandering place the client at an increased risk for injury.

4. A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to also attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations

ANS: C The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client and/or others. Nursing diagnoses should be correctly written to include evidence if actual and no evidence if the diagnosis is determined to be potential. PTS: 1 REF: 244 KEY: Cognitive Level: Analysis | Integrated Process: Diagnosis

On the first day of a client's alcohol detoxification, which nursing intervention should take priority? A. Strongly encourage the client to attend 90 Alcoholics Anonymous meetings in 90 days. B. Educate the client about the biopsychosocial consequences of alcohol abuse. C. Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. D. Administer vitamin B1 to prevent Wernicke-Korsakoff syndrome.

ANS: C The priority nursing intervention for this client should be to administer ordered chlordiazepoxide (Librium) in a dosage according to protocol. Chlordiazepoxide (Librium) is a benzodiazepine and is often used for substitution therapy in alcohol withdrawal. Substitution therapy may be required to reduce life-threatening effects of the rebound stimulation of the central nervous system that occurs during withdrawal.

A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem? A. Ineffective coping R/T unresolved anxiety AEB substance abuse B. Anxiety R/T poor sleep AEB difficulty falling asleep C. Disturbed sleep pattern R/T Librium tolerance AEB difficulty falling asleep D. Risk for injury R/T addiction to Librium

ANS: C Tolerance is defined as the need for increasingly larger or more frequent doses of a substance in order to obtain the desired effects originally produced by a lower dose.

A nurse has identified the following nursing diagnosis: "ineffective communication R/T lack of assertiveness skills AEB inability to state needs." Which statement encourages the client to acknowledge the priority of this problem? A. "Are you having thoughts of harming yourself or others?" B. "With whom are you least assertive?" C. "On a scale of 1 to 10, rank the importance of being assertive." D. "When are you available to attend the assertiveness training class?"

ANS: C This nursing statement encourages the client to objectively evaluate the priority of being assertive.

While trying to control aggressive behavior, a client asks an assertiveness training nurse to give an example of an "I statement." Which is an example of this assertive communication technique? A. "I would like to know why you came home late without calling me." B. "I hate it when you think you can just come home late without calling anyone to let them know where you are." C. "I feel angry when you come home late without calling." D. "I think you don't care about me, because if you did, you'd call me if you were planning on coming home late."

ANS: C This response clearly states feelings about a situation without blaming another.

The dean of nursing criticizes a faculty member about views on academic freedom. The faculty member states, "Are you upset because I believe in academic freedom or because you don't?" The faculty member is using which technique to promote assertive behavior? A. Standing up for one's basic human rights B. Delaying assertively C. Inquiring assertively D. Responding assertively with irony

ANS: C This response reflects the use of inquiring assertively. Inquiring assertively is an attempt to seek additional information about critical statements.

11. A client experienced bradycardia during electroconvulsive therapy (ECT). A nurse assigns a nursing diagnosis of decreased cardiac output R/T vagal stimulation occurring during ECT. Which outcome would the nurse expect the client to achieve? A. The client will verbalize an understanding of the need for moving slowly after treatment. B. The client will maintain an oxygen saturation level of 88% 1 hour after treatment. C. The client will continue adequate tissue perfusion 1 hour after treatment. D. The client will verbalize an understanding of common side effects of ECT.

ANS: C Vagal stimulation induced by ECT may cause a client to experience bradycardia. Adequate tissue perfusion would be a realistic expectation when normal cardiac output is restored. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client Need: Physiological Integrity

A client is in therapy with a nurse practitioner for the treatment of arachnophobia. The nurse practitioner decides to use the technique of "flooding." Which intervention best exemplifies this technique? A. Giving rewards for demonstrating a decrease in fear of spiders B. Encouraging the client to sit through the movie "Spiderman" C. Accompanying the client to a 1-hour visit to the local zoo's spider room D. Offering a computer program that progressively presents anxiety-producing spider scenarios

ANS: C Visiting the spider room would flood the client with the phobic stimuli of real spiders. This would continue until the stimulus no longer creates anxiety. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

15. According to Peplau, which nursing action demonstrates the nurses role as a resource person? A. The nurse balances a safe therapeutic environment to increase the clients sense of belonging. B. The nurse holds a group meeting with the clients on the unit to discuss common feelings about mental illness. C. The nurse monitors the administration of medications and watches for signs of cheeking. D. The nurse explains, in language the client can understand, information related to the clients health care.

ANS: D According to Peplau, a resource person provides specific answers to questions usually formulated with relation to a larger problem.

22. Which is the most significant consequence of the excessive use of defense mechanisms? A. The superego will be suppressed. B. Emotions will be experienced intensely. C. Learning and the ability to grow will be enhanced. D. Problem-solving will be limited.

ANS: D Defense mechanisms become maladaptive when they are used by an individual to such a degree that there is interference with the ability to deal with reality, effective interpersonal relations, or occupational performance.

31. A client exhibits dependency on staff and peers and expresses fear of abandonment. Using Mahlers theory of object relations, which should the nurse expect to note in this clients childhood? A. Lack of fulfillment of basic needs by parental figures B. Absence of the clients maternal figure during symbiosis C. Difficulty establishing trust with the maternal figure D. Inconsistency by the maternal figure during individuation

ANS: D During phase 3 (5 to 36 months) of Margaret Mahlers individuation theory, there should be a strengthening of the ego and an acceptance of self with independent ego boundaries. Inconsistency by the maternal figure during individuation may in later years result in feelings of helplessness when the client is alone because of exaggerated fears of being unable to care for self.

21. Which is an example of the ego defense mechanism of regression? A. A mother blames the teacher for her child's failure in school. B. A teenager becomes hysterical after seeing a friend killed in a car accident. C. A woman wants to marry a man exactly like her beloved father. D. An adult throws a temper tantrum when he does not get his own way.

ANS: D Regression is the retreating to an earlier level of development and the comfort measures associated with that level of functioning.

27. Which should the nurse recognize as an example of the defense mechanism of repression? A. A student aware of the need to study for tomorrow's test goes to a movie instead. B. A woman whose son was killed in Iraq does not believe the military report. C. A man who is unhappily married goes to school to become a marriage counselor. D. A woman was raped when she was 12 and no longer remembers the incident.

ANS: D Repression is the involuntary blocking of unpleasant feelings and experiences from one's awareness.

22. When is self-disclosure by the nurse appropriate in a therapeutic nurseclient relationship? A. When it is judged that the information may benefit the nurse and client B. When the nurse has a duty to warn C. When the nurse feels emotionally indebted toward the client D. When it is judged that the information may benefit the client

ANS: D Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurses needs.

1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the recent death of a beloved pet. The client's appetite, sleep patterns, and daily routine have not changed. How should the nurse interpret the client's behaviors? A. The client's behaviors demonstrate mental illness in the form of depression. B. The client's behaviors are extensive, which indicates the presence of mental illness. C. The client's behaviors are not congruent with cultural norms. D. The client's behaviors demonstrate no functional impairment, indicating no mental illness.

ANS: D The nurse should assess that the client's daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the client's distress does not indicate a mental illness.

17. When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial? A. Hiding liquor bottles in a closet B. Yelling at their son for slouching in his chair C. Burning dinner on purpose D. Saying to the spouse, "I don't drink too much!"

ANS: D The nurse should associate the client statement "I don't drink too much!" with the use of the defense mechanism of denial. The client who refuses to acknowledge the existence of a real situation and the feelings associated with it is using the defense mechanism of denial.

18. A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this clients problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.

ANS: D The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the clients room are not appropriate interventions because they do not help the client recognize anxiety triggers.

17. A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization

ANS: D The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.

12. On which task should a nurse place priority during the working phase of relationship development? A. Establishing a contract for intervention B. Examining feelings about working with a particular client C. Establishing a plan for continuing aftercare D. Promoting the clients insight and perception of reality

ANS: D The nurse should place priority on promoting the clients insight and perception of reality during the working phase of relationship development. Establishing a contract for intervention would occur in the orientation phase. Examining feelings about working with a client should occur in the preinteraction phase. Establishing a plan for aftercare would occur in the termination phase.

4. How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.

ANS: D The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.

3. Which is the best nursing action when a client demonstrates transference toward a nurse? A. Promoting safety and immediately terminating the relationship with the client B. Encouraging the client to ignore these thoughts and feelings C. Immediately reassigning the client to another staff member D. Helping the client to clarify the meaning of the current nurseclient relationship

ANS: D The nurse should respond to a clients transference by clarifying the meaning of the nurseclient relationship, based on the current situation. Transference occurs when the client unconsciously displaces feelings toward the nurse about a person from the past. The nurse should assist the client in separating the past from the present.

8. A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of panic anxiety

ANS: D The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be panic anxiety. Panic disorder is characterized by recurrent, sudden-onset panic attacks in which the person feels intense fear, apprehension, or terror.

10. A mother who has learned that her child was killed in a tragic car accident states, I cant bear to go on with my life. Which nursing statement conveys empathy? A. This situation is very sad, but time is a great healer. B. You are sad, but you must be strong for your other children. C. Once you cry it all out, things will seem so much better. D. It must be horrible to lose a child; Ill stay with you until your husband arrives.

ANS: D The nurses response, It must be horrible to lose a child; Ill stay with you until your husband arrives, conveys empathy to the client. Empathy is the ability to see the situation from the clients point of view. Empathy is considered to be one of the most important characteristics of the therapeutic relationship.

Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal? A. Antagonist therapy B. Deterrent therapy C. Codependency therapy D. Substitution therapy

ANS: D A CNS depressant such as Ativan is used during alcohol withdrawal as substitution therapy to prevent life-threatening symptoms that occur because of the rebound reaction of the central nervous system.

Which client statement demonstrates positive progress toward recovery from substance abuse? A. "I have completed detox and therefore am in control of my drug use." B. "I will faithfully attend Narcotic Anonymous (NA) when I can't control my carvings." C. "As a church deacon, my focus will now be on spiritual renewal." D. "Taking those pills got out of control. It cost me my job, marriage, and children."

ANS: D A client who takes responsibility for the consequences of substance abuse/dependence is making positive progress toward recovery. This client would most likely be in the working phase of the counseling process in which acceptance of the fact that substance abuse causes problems occurs.

Parents decide to try the nurse practitioner's suggestion of time out when their child misbehaves. What teaching should the nurse practitioner provide the parents? A. "Correct your child's behavior by spanking for a specified time period." B. "Ignore the child's negative behavior." C. "Add positive reinforcement for acceptable behavior." D. "Temporarily move your child to an area where behavior is not being reinforced."

ANS: D A time out is an aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is occurring. Usually during a time out, the person is temporarily isolated so there is no reinforcing attention. This discourages a reoccurrence of the undesired behavior. KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need: Health Promotion and Maintenance

Which is the most appropriate nursing reply when a client asks what is the goal and benefit of assertive skills training? A. "It protects the client from others who express aggressive feelings." B. "It gives reliable, expert information so that clients may correct faulty behaviors." C. "It clarifies misperceptions that have caused clients to distort reality." D. "It improves communication skills in order to improve interpersonal relationships."

ANS: D Assertiveness training helps to develop satisfying interpersonal relationships by teaching people how to communicate in a manner to meet their own needs while respecting the rights and needs of others.

When asked to identify principles that define the term "maladaptive behavior," which nursing student statement indicates that further teaching is needed? A. "Behavior is maladaptive when it is age inappropriate." B. "Behavior is maladaptive when it interferes with adaptive functioning." C. "Behavior is maladaptive when it is identified as inappropriate in the context of one's culture." D. "Behavior is maladaptive when it results in change within an otherwise stable subsystem."

ANS: D Behaviors that result in change within a subsystem, even when it is stable, could be either adaptive or maladaptive behaviors. This statement, therefore, is incorrect. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

2. A client diagnosed with vascular dementia is discharged to home under the care of his wife. Which information should cause the nurse to question the clients safety? A. His wife works from home in telecommunication. B. The client has worked the night shift his entire career. C. His wife has minimal family support. D. The client smokes one pack of cigarettes per day.

ANS: D Forgetfulness is an early symptom of dementia that would alert the nurse to question the clients safety at home if the client smokes cigarettes. Vascular dementia is a clinical syndrome of dementia due to significant cerebrovascular disease. The cause of vascular dementia is related to an interruption of blood flow to the brain. High blood pressure and hypertension are significant factors in the etiology.

7. A nurse administers ordered preoperative glycopyrrolate (Robinul) 30 minutes prior to a client's electroconvulsive therapy (ECT) procedure. What is the rationale for administering this medication? A. Robinul decreases anxiety during the ECT procedure. B. Robinul induces an unconscious state to prevent pain during the ECT procedure. C. Robinul prevents severe muscle contractions during the ECT procedure. D. Robinul decreases secretions to prevent aspiration during the ECT procedure.

ANS: D Glycopyrrolate (Robinul) is the standard preoperative medication given prior to ECT procedures to decrease secretions and prevent aspiration.

A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication? A. "Only oral ingestion of alcohol will cause a reaction when taking this drug." B. "It is safe to drink beverages that have only 12% alcohol content." C. "This medication will decrease your cravings for alcohol." D. "Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."

ANS: D If Antabuse is discontinued, it is important for the client to understand that the sensitivity to alcohol may last for as long as 2 weeks.

A kindergarten rule states that if unacceptable behavior occurs, a child's personalized fish will be moved to the sea grass. Children who behave keep their fish out of the sea grass. The school nurse should identify this intervention as based on which principle of behavior therapy? A. Classical conditioning B. Conditioned response C. Positive reinforcement D. Negative reinforcement

ANS: D Negative reinforcement is increasing the probability that behavior (appropriate classroom behavior) will recur by removal of an undesirable reinforcing stimulus (personalized fish in sea grass). KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

Which assumption is most reflective of a behavioral theory model? A. Mental illness is characterized by structural and biochemical alterations. B. Thought processes influence behaviors. C. All personality development has a social context. D. There is a basic relationship between stimulus and response.

ANS: D That there is a basic relationship between stimulus and response is an assumption of a behavioral theory model. The connection between a stimulus and a response is strengthened or weakened by the consequences of the response. KEY: Cognitive Level: Comprehension | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

A client experiences an exacerbation of psychiatric symptoms to the point of threatening self-harm. Which action step of the Wellness Recovery Action Plan (WRAP) model should be employed, and what action reflects this step? A. Step 3: Triggers that cause distress or discomfort are listed. B. Step 4: Signs indicating relapse are identified and plans for responding are developed. C. Step 5: A specific plan to help with symptoms is formulated. D. Step 6: Following client-designed plan, caregivers now become decision-makers.

ANS: D The WRAP recovery model is a step-wise process through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include Step 1, Develop a Wellness Toolbox; Step 2, Daily Maintenance List; Step 3, Triggers; Step 4, Early Warning Signs; Step 5, Things Are Breaking Down or Getting Worse; and Step 6, Crisis Planning. In Step 6 (Crisis Planning), clients can no longer care for themselves, make independent decisions, or keep themselves safe. Caregivers take an active role in this step on behalf of the client and implement the plan that the client has previously developed. All other actions presented require the client to be functionally capable. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Safe and Effective Care Environment

A client is experiencing high stress. The client states, "My boss treats me like a doormat and thinks nothing of demanding frequent overtime." Which nursing intervention would be appropriate? A. To incorporate the family support system into the clients plan of care B. To teach thought reframing techniques C. To encourage the client to seek other employment D. To hold a group in which clients are encouraged to use "I" statements

ANS: D The ability to use "I" statements is essential in assertive communication. The situation presented indicates that the client needs assertiveness training.

6. An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which intervention should a nurse prioritize to address this behavior? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. With staff support and a show of solidarity, set firm limits on the behavior.

ANS: D The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor does not warrant forced medication because the behavior is not a direct safety concern. Exploring the source of anger may be appropriate after the client has gained emotional control. Ignoring the act may further upset the client and does not reinforce appropriate behavior. PTS: 1 REF: 244 KEY: Cognitive Level: Analysis | Integrated Process: Planning

A client on an inpatient unit angrily states to a nurse, "Peter is not cleaning up after himself in the community bathroom. You need to address this problem." Which is the appropriate nursing response? A. "I'll talk to Peter and present your concerns." B. "Why are you overreacting to this issue?" C. "You should bring this to the attention of your treatment team." D. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

ANS: D The most appropriate nursing response involves restating the client's feeling and developing a plan with the client to solve the problem. According to Skinner, every interaction in the therapeutic milieu is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention? A. To assess for emotional strength B. To assess for Wernicke-Korsakoff syndrome C. To assess for tachycardia D. To assess for fine tremors

ANS: D The nurse is most likely assessing the client for fine tremors secondary to alcohol withdrawal. Withdrawal from alcohol can also cause headache, insomnia, transient hallucinations, depression, irritability, anxiety, elevated blood pressure, sweating, tachycardia, malaise, coarse tremors, and seizure activity.

Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines? A. Haloperidol (Haldol) and fluoxetine (Prozac) B. Carbamazepine (Tegretol) and donepezil (Aricept) C. Disulfiram (Antabuse) and lorazepan (Ativan) D. Chlordiazepoxide (Librium) and phenytoin (Dilantin)

ANS: D The nurse should anticipate that a physician would order chlordiazepoxide (Librium) and phenytoin (Dilantin) for a client who has a history of complicated withdrawal from benzodiazepines. It is common for long-lasting benzodiazepines to be prescribed for substitution therapy. Phenytoin (Dilantin) is an anticonvulsant that would be indicated for a client who has experienced a complicated withdrawal. Complicated withdrawals may progress to seizure activity.

Which client statement indicates a knowledge deficit related to substance abuse? A. "Although it's legal, alcohol is one of the most widely abused drugs in our society." B. "Tolerance to heroin develops quickly." C. "Flashbacks from LSD use may reoccur spontaneously." D. "Marijuana is like smoking cigarettes. Everyone does it. It's essentially harmless."

ANS: D The nurse should determine that the client has a knowledge deficit related to substance abuse when the client compares marijuana to smoking cigarettes and claims it to be harmless. Cannabis is the second most widely abused drug in the United States.

7. A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. At the final session, which client statement most clearly suggests that the goals of crisis intervention have been met? A. "You've really been helpful. Can I count on you for continued support?" B. "I work out in the college gym rather than jogging outdoors." C. "I'm really glad I didn't go home. It would have been hard to come back." D. "I carry mace when I jog. It makes me feel safe and secure."

ANS: D The nurse should evaluate that the client who has developed adaptive coping strategies has achieved the goals of crisis intervention. PTS: 1 REF: 244-245 KEY: Cognitive Level: Analysis | Integrated Process: Evaluation

14. An older client has recently moved to a nursing home. The client has trouble concentrating and socially isolates. A physician believes the client would benefit from medication therapy. Which medication should the nurse expect the physician to prescribe? A. Haloperidol (Haldol) B. Donepezil (Aricept) C. Diazepam (Valium) D. Sertraline (Zoloft)

ANS: D The nurse should expect the physician to prescribe sertraline (Zoloft) to improve the clients social functioning and concentration levels. Sertraline (Zoloft) is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Depression is the most common mental illness in older adults and is often misdiagnosed as neurocognitive disorder.

3. A client comes to a psychiatric clinic experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. What correctly written long-term outcome is realistic in addressing this client's crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6.

ANS: D The nurse should identify that a realistic long-term outcome for this client would be to return to previous adaptive levels of functioning. The nurse should work with the client to develop attainable outcomes that reflect the immediacy of the situation. To be correctly written, an outcome must be client-centered, specific, measurable, realistic, and contain a time frame. PTS: 1 REF: 242 KEY: Cognitive Level: Application | Integrated Process: Planning

A nurse working on an inpatient psychiatric unit is assigned to conduct a 45-minute education group. What should the nurse identify as an appropriate group topic? A. Dream analysis B. Creative cooking C. Paint by number D. Stress management

ANS: D The nurse should identify that teaching clients about stress management is an appropriate education group topic. Nurses should be able to perform the role of client teacher in the psychiatric area. Nurses need to be able to assess a client's learning readiness. Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication compliance.

3. A client diagnosed with neurocognitive disorder due to Alzheimers disease can no longer ambulate, does not recognize family members, and communicates with agitated behaviors and incoherent verbalizations. The nurse recognizes these symptoms as indicative of which stage of the illness? A. Confabulation stage B. Early stage C. Middle stage D. Late stage

ANS: D The nurse should recognize that this client is in the late stage of Alzheimers disease. The late stage is characterized by a severe cognitive decline.

1. A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.

ANS: D The nurse should understand that this type of crisis is precipitated by normal life-cycle transitions that overwhelm the client. Reassurance and guidance should be provided as needed, and the client should be referred to services that can provide assistance. PTS: 1 REF: 240 KEY: Cognitive Level: Application | Integrated Process: Planning

11. A client diagnosed with neurocognitive disorder due to Alzheimers disease has impairments of memory and judgment and is incapable of performing activities of daily living. Which nursing intervention should take priority? A. Present evidence of objective reality to improve cognition B. Design a bulletin board to represent the current season C. Label the clients room with name and number D. Assist with bathing and toileting

ANS: D The priority nursing intervention for this client is to assist with bathing and toileting. A client who is incapable of performing activities of daily living requires assistance in these areas to ensure health and safety.

17. During the sixth week of a 10-week parenting skills group, a nurse observes as several members get into a heated dispute about spanking. As a group, they decide to create a pros-and-cons poster on the use of physical discipline. At this time, what is the role of the group leader? A. To referee the debate B. To adamantly oppose physical discipline measures C. To redirect the group to a less controversial topic D. To encourage the group to solve the problem collectively

ANS: D The role of the group leader is to encourage the group to solve the problem collectively. A democratic leadership style supports members in their participation and problem solving. Members are encouraged to cooperatively solve issues that relate to the group. PTS: 1 REF: 194 KEY: Cognitive Level: Application | Integrated Process: Implementation

During a smoking cessation group, the community health nurse explains that in their effort to quit smoking, a reciprocal inhibition approach will be used. The nurse should give the group which example of this technique? A. "Before you can smoke, you must first take a half-hour walk." B. "When you have the urge to smoke, imagine being short of breath." C. "You'll receive $1 for each cigarette not smoked and forfeit $2 for each cigarette smoked." D. "When you have the urge to smoke, hold your breath and then rhythmically breathe."

ANS: D These breathing exercises cannot be done while the client smokes. Therefore, they decrease or eliminate the undesired behavior (smoking) that is incompatible with the desired behavior (smoking cessation). This is an example of the behavior therapy of reciprocal inhibition. KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation | Client Need: Psychosocial Integrity

During an assertiveness training group, a client admits to aggressive behaviors. The client asks for suggestions for how to become more assertive and less aggressive. Which is the most appropriate nursing reply? A. "Several techniques, including meditation and progressive muscle relaxation, appear helpful." B. "There's not much that can be done about aggressive behavior because of biological responses." C. "Certain types of medications have been proven effective in promoting assertive communication." D. "There are several techniques, including 'I statements,' role playing, and thought stopping, that can help promote assertive and decrease aggressive behaviors."

ANS: D These techniques promote assertive behaviors and would help diminish aggressive responses.

A child always chooses to ask mother over father when seeking special privileges. The father is more apt to disagree than agree with the child's requests, whereas the mother usually consents. The child's choice is the result of which component of operant conditioning? A. Conditioned stimuli B. Unconditioned stimuli C. Aversive stimuli D. Discriminative stimuli

ANS: D This child is able to discriminate between stimuli. This child can predict with assurance that asking mother (not father) will result in a desired response. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

Which best describes a nurse's use of assertive behavior? A. When a nurse attempts to please others and apologizes for awkwardness in a new role B. When a nurse becomes defensive and angry when peers offer suggestions for improvement C. When a nurse has problems making decisions and has a tendency to procrastinate D. When a nurse is open and direct when asked by the nurse manager to complete assignments

ANS: D This is an assertive response. There is clear expression of needs and feelings.

An instructor is teaching about assertive rights. Which student statement indicates a need for further instruction? A. "The right to be treated with respect is an assertive right." B. "The right to say "no" without feeling guilty is an assertive right." C. "The right to change your mind is an assertive right." D. "The right to always put oneself first is an assertive right."

ANS: D This is not an assertive right. An assertive right is "to consider others as well as yourself." This student statement indicates a need for further instruction.

A client on an inpatient unit is angry with a peer. During lunch, when the peer is not looking, the client spits into his soup. How would the nurse document this interaction? A. "Client is displaying assertive behaviors." B. "Client is displaying aggressive behaviors." C. "Client is displaying passive behaviors." D. "Client is displaying passive-aggressive behaviors."

ANS: D This response is passive-aggressive. The client's anger is expressed indirectly by spitting in the soup when the peer is not looking.

After vying for a nurse management position, nurse "A" is chosen over nurse "B." When nurse manager "A" calls for staff meetings, nurse "B" is chronically late or absent. Nurse "B" is exhibiting which type of behavior? A. Passive B. Assertive C. Aggressive D. Passive-aggressive

ANS: D This response is passive-aggressive. The colleague's anger is expressed indirectly by being late or absent from the meetings.

An aggressive nurse manager tells a staff nurse she has no business rallying staff to change the schedule. What would be an example of a technique that the staff nurse could use to stand up for her basic human rights? A. "What is the real reason that you don't want the schedule changed?" B. "Sounds to me like you're threatened by this change." C. "Are you upset because you don't want to redo the schedule?" D. "I have the right to express my opinion about the schedule."

ANS: D This response reflects the use of standing up for one's basic human rights.

A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish? A. The client will identify one person to turn to for support. B. The client will give up all old drinking buddies. C. The client will be able to verbalize the effects of alcohol on the body. D. The client will correlate life problems with alcohol use.

ANS: D To promote the recovery process the nurse should expect that the client would initially correlate life problems with alcohol use. Acceptance of the problem is the first step of the recovery process.

Which situation presents an example of the basic concept of a recovery model? A. The client's family is encouraged to make decisions in order to facilitate discharge. B. A social worker, discovering the client's income, changes the client's discharge placement. C. A psychiatrist prescribes an antipsychotic drug on the basis of observed symptoms. D. A client diagnosed with schizophrenia schedules follow-up appointments and group therapy.

ANS: D The basic concept of a recovery model is empowerment of the consumer. The recovery model is designed to allow consumers primary control over decisions about their own care. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Evaluation | Client Need: Psychosocial Integrity

4. During a community meeting, a nurse encourages clients to present unit problems and discuss possible solutions. Which type of leadership style is the nurse demonstrating?

ANS: Democratic The nurse who encourages clients to present problems and discuss solutions is demonstrating a democratic leadership style. Democratic leaders share information with group members and promote decision making by the members of the group. The leader provides guidance and expertise as needed.

_________________________ from mental health disorders and substance use disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

ANS: Recovery Recovery from mental health disorders and substance use disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. Recovery is the restoration to a former or better state or condition. KEY: Cognitive Level: Knowledge | Integrated Processes: Nursing Process: Assessment | Client Need: Health Promotion and Maintenance

Order the six steps of The Wellness Recovery Action Plan (WRAP) Model as described by Copeland et al. A.________ Daily Maintenance List B.________ Things Are Breaking Down or Getting Worse C. ________Crisis Planning D.________ Develop a Wellness Toolbox E._________Early Warning Signs F. ________ Triggers

ANS: The correct order is 2, 5, 6, 1, 4, 3. The WRAP model is a step-wise process, through which an individual is able to monitor and manage distressing symptoms that occur in daily life. The six steps include Step 1, Develop a Wellness Toolbox; Step 2, Daily Maintenance List; Step 3, Triggers; Step 4, Early Warning Signs; Step 5, Things Are Breaking Down or Getting Worse; and Step 6, Crisis Planning. KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Assessment | Client Need: Psychosocial Integrity

5. Which situation should a nurse identify as an example of an autocratic leadership style?

ANS: Without faculty input, the dean mandates that all course content be delivered via the Internet. The nurse should identify that mandating decisions without consulting the group is considered an autocratic leadership style. Autocratic leadership increases productivity but often reduces morale and motivation due to lack of member input and creativity.

The parent of a 20-year-old client recently diagnosed with paranoid schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia? Select all that apply. 1. Prostaglandins 2. Glutamate 3. Thyroxine 4. Dopamine 5. Erythropoietin

ANSWER 1. Prostaglandins 2. Glutamate 4. Dopamine

7. The treatment team is making a discharge decision regarding a previously suicidal client. Which client assessment information should a nurse recognize as contributing to the team's decision? No previous admissions for major depressive disorder Vital signs stable; no psychosis noted Able to comply with medication regimen; able to problem-solve life issues Able to participate in a plan for safety; family agrees to constant observation

Able to participate in a plan for safety; family agrees to constant observation

The triage nurse notes a client with a history of alcohol use disorder has an elevated heart rate, palpitations, shortness of breath, and a dry cough. Which best explains the client's symptoms?

Alcoholic cardiomyopathy

A nurse notices a client clenching fists periodically and pacing the hallway. Which nursing interventions should the nurse implement? Select all that apply.

Acknowledge the client's behavior. Assist the client to a quiet area. Speak with a soft and calming voice

Aisha has just experienced the unexpected death of a parent. Which criteria may the nurse use for measurement of outcomes in Aisha's grief care? Select all that apply

Acknowledges awareness of the loss Expresses feelings about the loss Expresses personal satisfaction and support from spiritual practices

Which is determined by the degree to which thoughts, feelings, and behaviors interfere with an individual's functioning?

Adaptation

The nurse is caring for an older adult client with an NCD who becomes agitated. Which intervention by the nurse is appropriate? Select all that apply

Administer an antipsychotic medication as prescribed. Encourage doll therapy Perform relaxation techniques.

A nurse in the ED assesses a 17-year-old client exhibiting symptoms of opioid intoxication. Which should be the nurse's first action?

Administer naloxone (Narcan).

A teenager has recently lost a parent. Which grieving behavior would the school nurse expect when assessing this client?

Aggressive and defiant behaviors

The nurse understands psychotic postpartum depression is characterized by which symptoms? Select all that apply

Agitation Fear the infant will be harmed Guilt

11. A nursing instructor is teaching about suicide in the elderly population. Which information should the instructor include? Elderly people use less lethal means to commit suicide. Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides. Suicide is the second leading cause of death among the elderly. It is normal for elderly individuals to express a desire to die, because they have come to terms with their mortality.

Although the elderly comprise less than 13 percent of the population, they account for 15 percent of all suicides.

Based on epidemiological factors, who is at the greatest risk for suicide?

An 82-year old Caucasian male

. ___________ ____________ is a personal signal of threat or injustice against the self. The signal elicits coping responses to deal with the distress.

Anger arousal

Which of the following statements about anger are true? Select all that apply

Anger is not a primary emotion Anger is a physiological arousal. Anger, when not expressed appropriately, can result in depression and low selfesteem.

. _______________ is the inability to feel pleasure

Anhedonia

The nurse understands that abnormal levels of growth hormone may play a role in which disorder?

Anorexia nervosa

18. A nurse is working with a client who has recently been under a great deal of stress. Which nursing recommendations would be most helpful when assisting the client in coping with stress? Select all that apply. A. Enjoy a pet. B. Spend time with a loved one. C. Listen to music. D. Focus on the stressors. E. Journal your feelings.

Answer: A, B, C, E Rationale: Focusing on the stressors is more likely to increase stress in the clients life. However, pets, music, journaling feelings, and healthy relationships have all been shown to decrease amounts of stress.

17. A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the clients appraisal of the situation? Select all that apply. A. What resources have you used previously in stressful situations? B. Have you ever experienced a similar stressful situation? C. Who do you think is to blame for this situation? D. Why do you think you were fired from your job? E. What skills do you possess that might lead to gainful employment?

Answer: A, B, E Rationale: These questions specifically address the clients coping resources and encourage the client to apply learning from past experiences. These questions also encourage the client to consider alternative methods for dealing with stress. Asking who is to blame does not assess coping abilities but, rather, encourages maladaptive behavior. Requesting an explanation is a nontherapeutic block to communication.

13. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this clients plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision making D. A schedule that includes mandatory activities to decrease social isolation

Answer: A. A simple, structured daily schedule with limited choices of activities Rationale: A client with depression has difficulty concentrating and may be overwhelmed by activity overload or the expectation of independent decision making. A simple, structured daily schedule with limited choices of activities is more appropriate.

24. A client diagnosed with bipolar disorder states, I hate oatmeal. Lets get everybody together to do exercises. Im thirsty and Im burning up. Get out of my way; I have to see that guy. What should be the priority nursing action? A. Assess the clients vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away.

Answer: A. Assess the clients vital signs. Rationale: When assessing a client diagnosed with bipolar disorder, the nurse should not lose sight of the fact that cooccurring physical problems could be masked by hyperactive, manic, or both behaviors. The clients statement of Im thirsty and Im burning up could be a symptom of either infection or dehydration and must be assessed.

24. A client diagnosed with major depressive disorder was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention would be most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system in order to improve coping skills.

Answer: A. Encourage the client to bring into awareness underlying sources of guilt. Rationale: A client raised in an environment that reinforces ones inadequacy may be at risk for experiencing guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting the client to bring these feelings into awareness allows the client to realistically appraise distorted responsibility and dysfunctional guilt.

23. A client is admitted with a diagnosis of persistent depressive disorder. Which client statement would describe a symptom consistent with this diagnosis? A. I am sad most of the time and Ive felt this way for the last several years. B. I find myself preoccupied with death. C. Sometimes I hear voices telling me to kill myself. D. Im afraid to leave the house.

Answer: A. I am sad most of the time and Ive felt this way for the last several years. Rationale: Persistent depressive disorder is characterized by depressed mood for most of day, for more days than not, for at least 2 years. Thoughts of death would be more consistent with major depressive disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the house is more consistent with a phobia.

20. A client who has been diagnosed with bipolar I disorder states, God has taught me how to decode the Bible. A nurse should anticipate that which combination of medications would be ordered to address this clients symptoms? A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal)

Answer: A. Lithium carbonate (Lithobid) and risperidone (Risperdal) Rationale: The patient who is experiencing psychosis (in this case, delusions of grandeur) may be benefited by the addition of an antipsychotic medication (risperidone) to the mood stabilizer (lithium). In addition, since lithium does not immediately reach therapeutic levels, the sedative properties of an antipsychotic may be useful in reducing agitation, hyperactivity, and/or insomnia.

11. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola

Answer: A. Pepperoni pizza and red wine Rationale: The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

13. A client is diagnosed with bipolar I disorder: manic episode. Which nursing intervention would be implemented to achieve the outcome of Client will gain 2 pounds by the end of the week? A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.

Answer: A. Provide client with high-calorie finger foods throughout the day. Rationale: The nurse should provide the client with high-calorie finger foods throughout the day to help the client achieve the outcome of gaining 2 pounds by the end of the week. Because of hyperactivity, the client will have difficulty sitting still to consume large meals.

4. A client diagnosed with bipolar disorder: depressive episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. What should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment

Answer: A. Risk for suicide R/T hopelessness Rationale: The priority nursing diagnosis for this client should be risk for suicide R/T hopelessness. The nurse should prioritize diagnoses on the basis of physical and safety needs. This client continues to be at risk for suicide related to an intentional Zoloft overdose.

4. A nurse reviews the laboratory data of a 29-year-old client suspected of having major depressive disorder. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+ ) level of 4.2 mEq/L C. Sodium (Na+ ) level of 140 mEq/L D. Calcium (Ca 2+ ) level of 9.5 mg/dL

Answer: A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL Rationale: According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of major depressive disorder may be ruled out if the clients laboratory results indicate a high TSH level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to depressive symptoms

15. A nurse begins the intake assessment of a client diagnosed with bipolar I disorder. The client shouts, You cant do this to me. Do you know who I am? Which is the priority nursing action in this situation? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation

Answer: A. To provide self and client with a safe environment Rationale: During a manic episode the clients mood is elevated, expansive, and irritable. Providing a safe environment should be prioritized to protect the client and staff from potential injury.

28. A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention should be most therapeutic for this client? A. Using a calm, unemotional approach during client interactions B. Focusing primarily on enforcing limits C. Limiting interactions to decrease external stimuli D. Encouraging the client to establish social relationships with peers

Answer: A. Using a calm, unemotional approach during client interactions Rationale: Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain a calm, unemotional approach during client interactions.

18. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. The nurse should correlate these symptoms with which lithium level? A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L

Answer: B. 1.7 mEq/L Rationale: The therapeutic level of lithium carbonate is 1.0 to 1.5 mEq/L for acute mania and 0.6 to 1.2 mEq/L for maintenance therapy. There is a narrow margin between the therapeutic and toxic levels. The symptoms presented in the question can be correlated with a lithium level of 1.7 mEq/L. Levels of 2.3 mEq/L and 3.7 mEq/L would produce more extreme symptoms of intensified toxicity, eventually leading to death.

10. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a nurse, I heard about something called a monoamine oxidase inhibitor (MAOI). Cant my doctor add that to my medications? Which is an appropriate nursing reply? A. This combination of drugs can lead to delirium tremens. B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis. C. Thats a good idea. There have been good results with the combination of these two drugs. D. The only disadvantage would be the exorbitant cost of the MAOI.

Answer: B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Rationale: The nurse should explain to the client that combining an MAOI and Luvox can lead to a life-threatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional photophobia, sensations of choking, palpitations, and a feeling of dread.

2. A client diagnosed with bipolar I disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this clients priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights

Answer: B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss Rationale: The nurse should identify that the priority nursing diagnosis for this client is altered nutrition: less than body requirements R/T hyperactivity AEB weight loss. Due to the clients rapid weight loss, the nurse should prioritize interventions to ensure proper nutrition and health.

18. A nurse is implementing a one-on-one suicide observation level with a client diagnosed with major depressive disorder. The client states, I'm feeling a lot better, so you can stop watching me. I have taken up too much of your time already. Which is the best nursing reply? A. I really appreciate your concern but I have been ordered to continue to watch you. B. Because we are concerned about your safety, we will continue to observe you. C. I am glad you are feeling better. The treatment team will consider your request. D. I will forward you request to your psychiatrist because it is his decision.

Answer: B. Because we are concerned about your safety, we will continue to observe you. Rationale: Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide plan. A nurse should continually observe a client when risk for suicide is suspected

27. A newly admitted client diagnosed with major depressive disorder states, I have never considered suicide. Later the client confides to the nurse about plans to end it all by medication overdose. What is the most helpful nursing reply? A. There is nothing to worry about. We will handle it together. B. Bringing this up is a very positive action on your part. C. We need to talk about the things you have to live for. D. I think you should consider all your options prior to taking this action.

Answer: B. Bringing this up is a very positive action on your part. Rationale: By admitting to the staff a suicide plan, this client has taken responsibility for possible personal actions and expresses trust in the nurse. Therefore, the client may be receptive to continuing a safety plan. Recognition of this achievement reinforces this adaptive behavior.

19. A newly admitted client is diagnosed with major depressive disorder with suicidal ideations. Which would be the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.

Answer: B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around the clock. Rationale: The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the basis of assessed data at varied intervals around the clock. If a nurse observes behavior that indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.

6. What is the priority reason for a nurse to perform a full physical health assessment on a client admitted with a diagnosis of major depressive disorder? A. The attention during the assessment is beneficial in decreasing social isolation. B. Depression is a symptom of several medical conditions. C. Physical health complications are likely to arise from antidepressant therapy. D. Depressed clients avoid addressing physical health and ignore medical problems.

Answer: B. Depression is a symptom of several medical conditions. Rationale: Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional deficiencies may produce symptoms of depression. These are a priority to identify and treat, since they may be the cause of the depressive symptoms and represent physiological needs.

10. What tool should a nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. Risky Activity tool B. FIND tool C. Consensus Committee tool D. Monotherapy tool ANS: B The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

Answer: B. FIND tool Rationale: The Consensus Group recommends that clinicians use the FIND tool to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder. FIND is an acronym that stands for frequency, intensity, number, and duration and is used to assess behaviors in children.

25. A newly admitted client is diagnosed with bipolar disorder: manic episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability

Answer: B. Flight of ideas Rationale: Clients diagnosed with bipolar disorder: manic episode experience cognition and perception fragmentation often with psychosis during acute mania. Rapid thinking proceeds to racing and disjointed thinking (flight of ideas) and may be manifested by a continuous flow of accelerated, pressured speak with abrupt changes from topic to topic.

For select clients, physical restraint is considered to be a beneficial intervention. This is based on which premise? A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting. B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C. Clients with antisocial tendencies need to submit to authority. D. Clients with behavioral dysfunction need behavioral interventions.

27. A clients spouse asks, What evidence supports the possibility of genetic transmission of bipolar disorder? Which is the best nursing reply? A. Clients diagnosed with bipolar disorders have alterations in neurochemicals that affect behaviors. B. Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder. C. Higher rates of relatives of clients diagnosed with bipolar disorder respond in an exaggerated way to daily stress. D. More individuals diagnosed with bipolar disorder come from higher socioeconomic and educational backgrounds.

Answer: B. Higher rates of relatives diagnosed with bipolar disorder are found in families of clients diagnosed with this disorder. Rationale: Family studies have shown that if one parent is diagnosed with bipolar disorder, the risk that a child will have the disorder is around 28%. If both parents are diagnosed with the disorder, the risk is two to three times as great

22. Which client statement would the nurse recognize as indicating that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. I will limit my intake of fluids daily. B. I will maintain normal salt intake. C. I will take Lithobid on an empty stomach. D. I will increase my caloric intake to prevent weight loss.

Answer: B. I will maintain normal salt intake. Rationale: A client taking Lithobid should be taught not to skimp on dietary sodium intake. He or she should take Lithobid on a full stomach to avoid gastrointestinal upset and choose lower-calorie foods to prevent weight gain.

17. After teaching a client about lithium carbonate (Lithane), a nurse would consider the teaching successful on the basis of which client statement? A. I should expect to feel better in a couple of days. B. I'll call my doctor immediately if I experience any diarrhea or ringing in my ears. C. If I forget a dose, I can double the dose the next time I take this drug. D. I need to restrict my intake of any food containing salt.

Answer: B. I'll call my doctor immediately if I experience any diarrhea or ringing in my ears. Rationale: The initial signs of lithium toxicity include ataxia, blurred vision, severe diarrhea, persistent nausea and vomiting, and tinnitus.

14. An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. Well go to the day room when you are ready for group. B. I'll walk with you to the day room. Group is about to start. C. It must be difficult for you to attend group when you feel so bad. D. Let me tell you about the benefits of attending this group.

Answer: B. I'll walk with you to the day room. Group is about to start. Rationale: A client diagnosed with major depressive disorder exhibits little to no motivation and must be actively directed by staff to participate in therapy. It is difficult for a severely depressed client to make decisions, and this function must be temporarily assumed by the staff.

21. A nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement would provide supportive evidence of this symptom? A. I cant stop my sexual urges. They have led me to numerous affairs. B. I'm the worlds most perceptive attorney. C. My wife is distraught about my overspending. D. The FBI is out to get me.

Answer: B. I'm the worlds most perceptive attorney. Rationale: Grandiosity is defined as a belief that personal abilities are better than anyone elses. This client is experiencing delusions of grandeur, which are commonly experienced in mania.

12. A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to discharge. Which statement indicates to the nurse that the client has an understanding of important discharge teaching? A. I cannot drink any alcohol with this medication. B. It is going to take 2 to 3 weeks in order for me to begin to feel better. C. This drug causes physical dependence, and I need to strictly follow doctors orders. D. I cant take this medication with food. It needs to be taken on an empty stomach.

Answer: B. It is going to take 2 to 3 weeks in order for me to begin to feel better. Rationale: BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is important to teach clients in order to prevent potential noncompliance due to the perception that the medication is ineffective.

26. A client admitted to the psychiatric unit following a suicide attempt is diagnosed with major depressive disorder. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem

Answer: B. Lack of attention to grooming and hygiene Rationale: Lack of attention to grooming and hygiene is the only behavioral symptom presented. Lack of energy, low self-esteem, and feelings of helplessness and hopelessness (all common symptoms of depression) contribute to lack of attention to activities of daily living, including grooming and hygiene.

2. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse assign to this client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

Answer: B. Social isolation R/T poor self-esteem AEB secluding self in room Rationale: A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, maintaining a fetal position, and no personal hygiene and/or grooming.

15. A client who is diagnosed with major depressive disorder asks the nurse what causes depression. Which of these is the most accurate response? A. Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine. B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. C. Depression is a learned state of helplessness cause by ineffective parenting. D. Depression is caused by intrapersonal conflict between the id and the ego.

Answer: B. The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role. Rationale: Depression is likely an illness that has varied and multiple causative factors, but at present the exact cause of depressive disorders is not entirely understood.

8. A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates that learning has occurred? A. This disorder is more prevalent in the lower socioeconomic groups. B. This disorder is more prevalent in the higher socioeconomic groups. C. This disorder is equally prevalent in all socioeconomic groups. D. This disorders prevalence cannot be evaluated on the basis of socioeconomic groups.

Answer: B. This disorder is more prevalent in the higher socioeconomic groups. Rationale: The nursing student is accurate when stating that bipolar disorder is more prevalent in higher socioeconomic groups. Theories consider both hereditary and environmental factors in the etiology of bipolar disorder.

5. A client diagnosed with bipolar I disorder: manic episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)

Answer: B. Valproic acid (Depakote) Rationale: Although lithium is a prototype drug in the treatment of bipolar disorders, anticonvulsants such as valproic acid also have demonstrated efficacy for mood stabilization.

3. A nurse is planning care for a client diagnosed with bipolar disorder: manic episode. In which order should the nurse prioritize the listed client outcomes? Client Outcomes: 1. Maintains nutritional status. 2. Interacts appropriately with peers. 3. Remains free from injury. 4. Sleeps 6 to 8 hours a night. A. 2, 1, 3, 4 B. 4, 1, 2, 3 C. 3, 1, 4, 2 D. 1, 4, 2, 3

Answer: C. 3, 1, 4, 2 Rationale: The nurse should order client outcomes based on priority in the following order: Remains free of injury, maintains nutritional status, sleeps 6 to 8 hours a night, and interacts appropriately with peers. The nurse should prioritize the clients physical and safety needs.

23. A client on an inpatient unit is diagnosed with bipolar disorder: manic episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. What should be the nurses initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems.

Answer: C. Assist the client to move to a calmer location. Rationale: During a manic episode, the client experiences increased agitation and extreme hyperactivity that can lead to a risk for injury. Overstimulation can exacerbate these symptoms. Therefore, the nurses initial action should focus on removing the client from the stimulating environment to a calmer location.

20. The nurse is providing counseling to clients diagnosed with major depressive disorder. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory

Answer: C. Cognitive theory Rationale: Cognitive theory suggests that depression is a product of negative thinking. Helping the individual change the way they think is believed to have a positive impact on mood and self-esteem.

5. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, what is the cause of this clients symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.

Answer: C. Depression is a result of repeated failures. Rationale: Learning theory describes a model of learned helplessness in which multiple life failures cause the client to abandon future attempts to succeed.

22. A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count

Answer: C. Risk for injury R/T orthostatic hypotension Rationale: A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.

19. A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night

Answer: C. Risk for violence: directed toward others R/T agitation and hyperactivity Rationale: Some signs and symptoms of mania include manic excitement, delusional thinking, and hallucinations, which may predispose the client to aggressive behavior. Nurses should be alert to the risk for self or other directed violence and intervene immediately at the first signs of agitation or aggression.

14. A client is diagnosed with bipolar disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge.

Answer: C. The client will remain safe throughout hospitalization. Rationale: A client diagnosed with bipolar disorder is at risk for injury in either pole of this disorder. In the manic phase the client is hyperactive and can injure self inadvertently, and in the depressive phase the client can be at risk for suicide.

19. A nurse is conducting education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety? A. Diagnostic blood tests. B. Awareness of factors creating stress. C. Relaxation exercises. D. Identifying support systems.

Answer: b. Awareness of factors creating stress. Rationale: Although all of the above answers may be useful in the comprehensive management of stress, the initial step is awareness that stress is being experienced and awareness of factors that create stress.

16. What client information does a nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The clients understanding of the need for regular bloodwork B. The clients mood and affect score, according to the facilitys mood scale C. The clients cognitive ability to understand information about the medication D. The clients access to a support network willing to participate in treatment

Answer: C. The clients cognitive ability to understand information about the medication Rationale: There are many dietary and medication restrictions when taking Nardil. A client must have the cognitive ability to understand information about the medication and which foods, beverages, and medications to eliminate when taking Nardil.

11. An adult client diagnosed with bipolar I disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which is a true statement about this medication order? A. This dosage is within the recommended dosage range. B. This dosage is lower than the recommended dosage range. C. This dosage is more than twice the recommended dosage range. D. This dosage is four times higher than the recommended dosage range.

Answer: C. This dosage is more than twice the recommended dosage range. Rationale: The recommended dose of lamotrigine for treatment of bipolar disorder in adult clients should not exceed 400 mg daily.

8. A nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status exam? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder D. To rule out a personality disorder

Answer: C. To rule out neurocognitive disorder Rationale: A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly are often misdiagnosed with neurocognitive disorder such as Alzheimers disease, when depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common symptoms of depression in the elderly.

7. A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply? A. That's strange. Weight loss is the typical pattern. B. What have you been eating? Weight gain is not usually associated with lithium. C. Weight gain is a common but troubling side effect. D. Weight gain occurs only during the first month of treatment with this drug.

Answer: C. Weight gain is a common but troubling side effect. Rationale: The nurse should explain to the client that weight gain is a common side effect of lithium carbonate. The nurse should educate the client on the importance of medication compliance and discuss concerns with the prescribing physician if the client does not wish to continue taking the medication.

1. A highly agitated client paces the unit and states, I could buy and sell this place. The clients mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this clients behavior? A. Rates mood 8/10. Exhibiting looseness of association. Euphoric. B. Mood euthymic. Exhibiting magical thinking. Restless. C. Mood labile. Exhibiting delusions of reference. Hyperactive. D. Agitated and pacing. Exhibiting grandiosity. Mood labile.

Answer: D. Agitated and pacing. Exhibiting grandiosity. Mood labile. Rationale: The nurse should document that this clients behavior is Agitated and pacing. Exhibiting grandiosity. Mood labile. The client is exhibiting signs of irritation accompanied by aggressive behavior. Grandiosity refers to an exaggerated sense of power, importance, knowledge, or identity.

7. A nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)

Answer: D. Fluoxetine (Prozac) Rationale: Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents. Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression. All antidepressants carry an FDA warning for increased risk of suicide in children and adolescents.

1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life

Answer: D. Gloomy and pessimistic outlook on life Rationale: The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of dysthymia. Symptoms of depression can be described as alterations in four areas of human functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that relate to the mood.

17. A client diagnosed with major depressive disorder states, Ive been feeling down for 3 months. Will I ever feel like myself again? Which reply by the nurse will best assess this clients affective symptoms? A. Have you been diagnosed with any physical disorder within the last 3 months? B. Have you ever felt this way before? C. People who have mood changes often feel better when spring comes. D. Help me understand what you mean when you say, feeling down?

Answer: D. Help me understand what you mean when you say, feeling down? Rationale: The nurse is using a clarifying statement in order to gather more details related to this clients mood.

21. Which client statement expresses a typical underlying feeling of clients diagnosed with major depressive disorder? A. Its just a matter of time and I will be well. B. If I ignore these feelings, they will go away. C. I can fight these feelings and overcome this disorder. D. Nothing will help me feel better.

Answer: D. Nothing will help me feel better. Rationale: Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive disorder

25. A nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Tofranil B. Senequan C. Geodon D. Parnate ANS: D Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.

Answer: D. Parnate Rationale: Hypertensive crisis occurs in clients receiving a monoamine oxidase inhibitor (MAOI) who consume foods or drugs with a high tyramine content.

26. The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom dcor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? A. Rooms should contain extra-large windows with views of the street. B. Rooms should contain brightly colored walls with printed drapes. C. Rooms should be painted deep colors and located close to the nurses station. D. Rooms should be painted with neutral colors and contain pale-colored accessories.

Answer: D. Rooms should be painted with neutral colors and contain pale-colored accessories. Rationale: Clients experiencing mania are subject to frequent mood variations, easily changing from irritability and anger to sadness and crying. Therefore, it is necessary to maintain low levels of stimuli in the clients environment (low lighting, few people, simple dcor, low noise levels). Anxiety levels rise in a stimulating environment. Neutral colors and pale accessories are most appropriate for a client experiencing mania.

9. A confused client has recently been prescribed sertraline (Zoloft). The clients spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. What complication does a nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake inhibitors (SSRIs) B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI D. Serotonin syndrome caused by ingestion of two different SSRIs

Answer: D. Serotonin syndrome caused by ingestion of two different SSRIs Rationale: The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include confusion, agitation, tachycardia, hypertension, nausea, abdominal pain, myoclonus, muscle rigidity, fever, sweating, and tremor

9. A client diagnosed with bipolar disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. How should the nurse interpret these symptoms? A. Symptoms indicate consumption of foods high in tyramine. B. Symptoms indicate lithium carbonate discontinuation syndrome. C. Symptoms indicate the development of lithium carbonate tolerance. D. Symptoms indicate lithium carbonate toxicity.

Answer: D. Symptoms indicate lithium carbonate toxicity. Rationale: The nurse should interpret that the clients symptoms indicate lithium carbonate toxicity. The initial signs of toxicity include ataxia, blurred vision, severe diarrhea, nausea and vomiting, and tinnitus. Lithium levels should be monitored monthly during maintenance therapy to ensure proper dosage.

3. A nurse assesses a client suspected of having major depressive disorder. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.

Answer: D. The client has maxed-out charge cards and exhibits promiscuous behaviors. Rationale: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would rule out the diagnosis of major depressive disorder.

12. A nursing instructor is discussing various challenges in the treatment of clients diagnosed with bipolar disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. Treatment is compromised when clients cant sleep. B. Treatment is compromised when irritability interferes with social interactions. C. Treatment is compromised when clients have no insight into their problems. D. Treatment is compromised when clients choose not to take their medications.

Answer: D. Treatment is compromised when clients choose not to take their medications. Rationale: The nursing student should understand that the most critical challenge in the care of clients diagnosed with bipolar disorder is that treatment is often compromised when clients choose to not take their medications. Symptoms of bipolar disorder will reemerge if medication is stopped.

6. A client diagnosed with bipolar I disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The clients spouse questions the Zyprexa order. Which is the appropriate nursing reply? A. Zyprexa in combination with Eskalith cures manic symptoms. B. Zyprexa prevents extrapyramidal side effects. C. Zyprexa ensures a good nights sleep. D. Zyprexa calms hyperactivity until the Eskalith takes effect.

Answer: D. Zyprexa calms hyperactivity until the Eskalith takes effect. Rationale: The nurse should explain to the clients spouse that Zyprexa can calm hyperactivity until the Eskalith takes effect. Eskalith may take 1 to 3 weeks to begin to decrease hyperactivity. Zyprexa is classified as an antipsychotic and can be used to immediately to reduce hyperactive symptoms in acute manic episodes.

9. Meditation has been shown to be an effective stress management technique. When meditation is effective, what should a nurse expect to assess? A. An achieved state of relaxation. B. An achieved insight into ones feelings. C. A demonstration of appropriate role behaviors. D. An enhanced ability to problem-solve.

Answer: a. An achieved state of relaxation. Rationale: Meditation produces relaxation by creating a special state of consciousness through focused concentration.

12. When an individuals stress response is sustained over a long period of time, which physiological effect of the endocrine system should a nurse anticipate? A. Decreased resistance to disease. B. Increased libido. C. Decreased blood pressure. D. Increased inflammatory response.

Answer: a. Decreased resistance to disease. Rationale: In a general adaptation syndrome, prolonged exposure to stress leads to the stage of exhaustion at which time the body's compensatory mechanisms no longer function effectively and diseases of adaptation occur. A decreased immune response is seen at this stage.

3. Which client statement should alert a nurse that a client may be responding maladaptively to stress? A. I've found that avoiding contact with others helps me cope. B. I really enjoy journaling; its my private time. C. I signed up for a yoga class this week. D. I made an appointment to meet with a therapist.

Answer: a. I've found that avoiding contact with others helps me cope. Rationale: Reliance on social isolation as a coping mechanism is a maladaptive method to relieve stress. It can prevent learning appropriate coping skills and can prevent access to needed support systems.

16. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response? A. Genetics have nothing to do with your temperament. B. How you reacted to past experiences influences how you feel now. C. If youre in good physical health, your stress level will be low. D. Stress can always be avoided if appropriate coping mechanisms are employed

Answer: b. How you reacted to past experiences influences how you feel now. Rationale: Past experiences are occurrences that result in learned patterns that can influence an individuals current adaptation response. They include previous exposure to the stressor or other stressors in general, learned coping responses, and degree of adaptation to previous stressors.

13. Which symptom should a nurse identify as typical of the fight-or-flight response? A. Pupil constriction. B. Increased heart rate. C. Increased salivation. D. Increased peristalsis.

Answer: b. Increased heart rate. Rationale: During the fight-or-flight response, the heart rate increases in response to the release of epinephrine. Pupils dilate to enhance vision. Salivation and peristalsis decrease as the body slows unessential functions.

6. A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time? A. Meditation B. Problem-solving training C. Relaxation D. Journaling

Answer: b. Problem-solving training Rationale: The student must assess his or her situation and determine the best course of action. Problem-solving training, by providing structure and objectivity, can assist in decision making.

8. A school nurse is assessing a distraught female high school student who is overly concerned because her parents cant afford horseback riding lessons. How should the nurse interpret the students reaction to her perceived problem? A. The problem is endangering her well-being. B. The problem is personally relevant to her. C. The problem is based on immaturity. D. The problem is exceeding her capacity to cope.

Answer: b. The problem is personally relevant to her. Rationale: Psychological stressors to self-esteem and self-image are related to how the individual perceives the situation or event. Self-image is of particular importance to adolescents, who feel entitled to have all the advantages that other adolescents experience.

4. A nursing student finds that she comes down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing? A. Alarm reaction stage. B. Stage of resistance. C. Stage of exhaustion. D. Fight-or-flight stage.

Answer: c. Stage of exhaustion. Rationale: At the stage of exhaustion, the students exposure to stress has been prolonged and adaptive energy has been depleted. Diseases of adaptation occur more frequently in this stage.

1. A client has experienced the death of a close family member and at the same time becomes unemployed. This situation has resulted in a 6-month score of 110 on the Recent Life Changes Questionnaire. How should the nurse evaluate this client data? A. The client is experiencing severe distress and is at risk for physical and psychological illness. B. A score of 110 on the Miller and Rahe Recent Life Changes Questionnaire indicates no significant threat of stress-related illness. C. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports. D. The client may view these losses as challenges and perceive them as opportunities.

Answer: c. Susceptibility to stress-related physical or psychological illness cannot be estimated without knowledge of coping resources and available supports. Rationale: The Recent Life Changes Questionnaire is an expanded version of the Schedule of Recent Experiences and the Rahe-Holmes Social Readjustment Rating Scale. A 6-month score of 300 or more, or a year-score total of 500 or more, indicates high stress in a clients life. However, positive coping mechanisms and strong social support can limit susceptibility to stress-related illnesses

14. A nurse is evaluating a clients response to stress. What would indicate to the nurse that the client is experiencing a secondary appraisal of the stressful event? A. When the individual judges the event to be benign. B. When the individual judges the event to be irrelevant. C. When the individual judges the resources and skills needed to deal with the event. D. When the individual judges the event to be pleasurable.

Answer: c. When the individual judges the resources and skills needed to deal with the event. Rationale: When the individual judges the resources and skills needed to deal with the event, the individual is conducting a secondary appraisal. There are three types of primary appraisals: irrelevant, benign-positive, and stressful.

7. An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention? A. Encourage the student to use the alternative coping mechanism of relaxation exercises. B. Complete the problem-solving process for the client. C. Work through the problem-solving process with the client. D. Encourage the client to keep a journal.

Answer: c. Work through the problem-solving process with the client. Rationale: During times of high anxiety and stress, clients will need more assistance in problem-solving and decision making.

10. A distraught, single, first-time mother cries and asks a nurse, How can I go to work if I cant afford childcare? What is the nurses initial action in assisting the client with the problem-solving process? A. Determine the risks and benefits for each alternative. B. Formulate goals for resolution of the problem. C. Evaluate the outcome of the implemented alternative. D. Assess the facts of the situation.

Answer: d. Assess the facts of the situation. Rationale: Before any other steps can be taken, accurate information about the situation must be gathered and assessed.

2. A physically and emotionally healthy client has just been fired. During a routine office visit he states to a nurse: Perhaps this was the best thing to happen. Maybe Ill look into pursuing an art degree. How should the nurse characterize the clients appraisal of the job loss stressor? A. Irrelevant B. Harm/loss C. Threatening D. Challenging

Answer: d. Challenging Rationale: The client perceives the situation of job loss as a challenge and an opportunity for growth.

15. Research undertaken by Miller and Rahe in 1997 demonstrated a correlation between the effects of life change and illness. This research led to the development of the Recent Life Changes Questionnaire (RLCQ). Which principle most limits the effectiveness of this tool? A. Specific illnesses are not identified. B. The numerical values associated with specific life events are randomly assigned. C. Stress is viewed as only a physiological response. D. Personal perception of the event is excluded.

Answer: d. Personal perception of the event is excluded. Rationale: Individuals differ in response to life events. The RLCQ uses a scale that does not take these differences into consideration.

5. A school nurse is assessing a female high school student who is overly concerned about her appearance. The clients mother states, Thats not something to be stressed about! Which is the most appropriate nursing response? A. Teenagers! They don't know a thing about real stress. B. Stress occurs only when there is a loss. C. When you are in poor physical condition, you can;t experience psychological well-being. D. Stress can be psychological. A threat to self-esteem may result in high stress levels.

Answer: d. Stress can be psychological. A threat to self-esteem may result in high stress levels. Rationale: Stress can be physical or psychological in nature. A perceived threat to self-esteem can be as stressful as a physiological change.

11. A nursing instructor is asking students about diseases of adaptation and when they are likely to occur. Which student response indicates that learning has occurred? A. When an individual has limited experience dealing with stress. B. When an individual inherits maladaptive genes. C. When an individual experiences existing conditions that exacerbate stress. D. When an individuals physiological and psychological resources have become depleted.

Answer: d. When an individuals physiological and psychological resources have become depleted. Rationale: During the stage of exhaustion of the general adaptation syndrome, the individual loses the capacity to adapt effectively because physiological and psychological resources have become depleted. This is the time when diseases of adaptation may occur.

16. A client is diagnosed with cyclothymic disorder. What client behaviors should the nurse expect to assess? A. The client expresses feeling blue most of the time. B. The client has endured periods of elation and dysphoria lasting for more than 2 years. C. The client fixates on hopelessness and thoughts of suicide continually. D. The client has labile moods with periods of acute mania.

Answwer: B. The client has endured periods of elation and dysphoria lasting for more than 2 years. Rationale: The essential feature of cyclothymic disorder is a chronic mood disturbance of at least 2 years duration, involving numerous episodes of hypomania and depressed mood of insufficient severity or duration to meet the criteria for bipolar I or II disorder

The nurse is caring for a client admitted to the palliative care unit. The client's spouse has been at the client's bedside since the client was admitted. One week ago, the spouse began to visit 2 or 3 hours a day. Which is the spouse experiencing?

Anticipatory grief

A client whose child is diagnosed with terminal breast cancer is constantly crying and depressed. Which type of grieving is she experiencing?

Anticipatory grieving

Which carries a warning label stating that the use of the medication increases risk for suicidal thoughts and behaviors?

Antiepileptics

____________________ is the subjective emotional response to a stressor or fear

Anxiety

In which way can anxiety be distinguished from fear?

Anxiety is an emotional process while fear is a cognitive one

____________________ is the inability to perform motor activities despite intact motor function.

Apraxia

Which dining arrangement would the nurse use to best promote a sense of community?

Arrange tables seating 5 or 6 clients around the dining room

19. Which nursing intervention strategy is most important to implement initially with a suicidal client? Ask a direct question such as, "Do you ever think about killing yourself?" Ask client, "Please rate your mood on a scale from 1 to 10." Establish a trusting nurse-client relationship. Apply the nursing process to the planning of client care.

Ask a direct question such as, "Do you ever think about killing yourself?"

15. A nursing student is developing a plan of care for a suicidal client. Which documented intervention should the student implement first? Communicate therapeutically. Observe the client. Provide a hazard-free environment. Assess suicide risk.

Assess suicide risk.

18. A nurse is caring for four clients diagnosed with major depressive disorder. When considering each client's belief system, the nurse should conclude which client would potentially be at highest risk for suicide? Roman Catholic Protestant Atheist Muslim

Atheist

Which disorder is genetically inherited?

Autism

2. During a therapeutic group, two clients engage in an angry verbal exchange. The nurse leader interrupts the exchange and excuses both of the clients from the group. The nurse has demonstrated which leadership style?

Autocratic The nurse who excuses clients from the group has demonstrated an autocratic leadership style. An autocratic leadership style may be useful in certain situations that require structure and limit setting. Democratic leaders focus on the members of the group and group-selected goals. Laissez-faire leaders provide no direction to group members.

Which concepts are included in Hobfoll's Conservation of Resources theory? Select all that apply.

Availability of resources Genetics Past experiences

Which of the following instructions regarding lithium therapy should be included in the nurse's discharge teaching? Select all that apply.

Avoid excessive use of beverages containing caffeine. Maintain a consistent sodium intake. Consume at least 2500 to 3000 mL of fluid per day

15. A mother rescues two of her four children from a house fire. In the emergency department, she cries, "I should have gone back in to get them. I should have died, not them." What is the nurse's best response? A. "The smoke was too thick. You couldn't have gone back in." B. "You're feeling guilty because you weren't able to save your children." C. "Focus on the fact that you could have lost all four of your children." D. "It's best if you try not to think about what happened. Try to move on."

23. A student nurse tells the instructor, "I'm concerned that when a client asks me for advice I won't have a good solution." Which should be the nursing instructor's best response? A. "It's scary to feel put on the spot by a client. Nurses don't always have the answer." B. "Remember, clients, not nurses, are responsible for their own choices and decisions." C. "Just keep the client's best interests in mind and do the best that you can." D. "Set a goal to continue to work on this aspect of your practice."

26. After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, "You are incompetent!" Which is the nurse's best response? A. "Do you believe that I was the cause of your blood test being canceled?" B. "I see that you are upset, but I feel uncomfortable when you swear at me." C. "Have you ever thought about ways to express anger appropriately?" D. "I'll give you some space. Let me know if you need anything."

31. Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations? A. "My sister has the same diagnosis as you and she also hears voices." B. "I understand that the voices seem real to you, but I do not hear any voices." C. "Why not turn up the radio so that the voices are muted." D. "I wouldn't worry about these voices. The medication will make them disappear."

32. Which nursing statement is a good example of the therapeutic communication technique of offering self? A. "I think it would be great if you talked about that problem during our next group session." B. "Would you like me to accompany you to your electroconvulsive therapy treatment?" C. "I notice that you are offering help to other peers in the milieu." D. "After discharge, would you like to meet me for lunch to review your outpatient progress?"

6. A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening? A. "What occurred prior to the rape, and when did you go to the emergency department?" B. "What would you like to talk about?" C. "I notice you seem uncomfortable discussing this." D. "How can we help you feel safe during your stay here?"

8. A nurse maintains an uncrossed arm and leg posture. This nonverbal behavior is reflective of which letter of the SOLER acronym for active listening? A. S B. O C. L D. E E. R

Group therapy is strongly encouraged, but not mandatory, on an inpatient psychiatric unit. The unit managers policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit managers policy preserve? A. Justice B. Autonomy C. Veracity D. Beneficence

A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. Anger is physiological arousal. B. Anger and aggression are essentially the same. C. Anger expression is a learned response. D. Anger is not a primary emotion

A nursing instructor is teaching about violence-intervention protocols. Which student statement would indicate the need for further instruction? A. Administering psychotropic medications can be a part of violence-intervention protocols. B. Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols. C. Applying leather restraints can be a part of violence-intervention protocols. D. Calling for assistance is a part of violence-intervention protocols

A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, How will we know if someone may get violent? Which is the most appropriate reply by the nursing instructor? A. You cant really say for sure. There are limited indicators of potential violence. B. Certain behaviors indicate a potential for violence. They are labeled as a prodromal syndrome and include rigid posture, clenched fists, and raised voice. C. Any client can become violent, so it is best to be aware of your surroundings at all times. D. When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence.

An adult client assaults another client and is placed in restraints. Which statement from the client while in restraints should alert a nurse that further assessment is necessary? A. I hate all of you! B. My fingers are tingly. C. You wait until I tell my lawyer. D. I have a sinus headache

At 3 a.m., when less restrictive methods fail, a physician orders restraints for an angry, aggressive client. To meet Joint Commission standards, at what time and by whom should a nurse expect an in-person client evaluation? A. No later than 8 a.m., by a licensed independent practitioner or a clinical nurse specialist B. No later than 4 a.m., by a physician or a licensed independent practitioner (LIP) C. No later than 3:30 a.m., by a physician or the clients case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist

In the situation presented, which nursing intervention constitutes false imprisonment? A. The client is combative and will not redirect, stating, No one can stop me from leaving. The nurse seeks the physicians order after the client is restrained. B. The client has been consistently seeking the attention of the nurses much of the day. The nurse institutes seclusion. C. A psychotic client, admitted in an involuntary status, runs off the psychiatric unit. The nurse runs after the client and the client agrees to return. D. A client hospitalized as an involuntary admission attempts to leave the unit. The nurse calls the security team and they prevent the client from leaving.

On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released. To meet Joint Commission standards, at what time should a nurse expect the physician to renew the clients restraint order? A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order

Once the nurse initiates restraint for an out-of-control 45-year-old patient, what must occur within 1 hour, according to JCAHO standards? A. The patient must be let out of restraint. B. A physician or other licensed independent practitioner must conduct an in-person evaluation. C. The patient must be bathed and fed. D. The patient must be included in debriefing.

The experience of being physically restrained can be traumatic. Which nursing intervention would best help the client deal with this experience? A. Administering a tranquilizing medication before applying the restraints B. Talking to the client at brief but regular intervals while the client is restrained C. Decreasing stimuli by leaving the client alone most of the time D. Checking on the client infrequently, in order to meet documentation requirements

The nurse observes a clients escalating anger. The client begins to pace the hall and shouts, You all better watch out. Im going to hurt anyone who gets in my way. Which should be the priority nursing intervention? A. Calmly tell the client, Staff will help you to control your impulse to hurt others. B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, You will need to be medicated and secluded.

Which client should a nurse identify as a potential candidate for involuntarily commitment? A. A client living under a bridge in a cardboard box B. A client threatening to commit suicide C. A client who never bathes and wears a wool hat in the summer D. A client who eats waste out of a garbage can

Which is an example of an intentional tort? A. A nurse fails to assess a clients obvious symptoms of neuroleptic malignant syndrome. B. A nurse physically places an irritating client in four-point restraints. C. A nurse makes a medication error and does not report the incident. D. A nurse gives patient information to an unauthorized person.

Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? A. Place a hand on the clients shoulder and state, I will help you to your room. B. Slowly and matter-of-factly state, I am your nurse and I will show you to your room. C. Firmly set limits by stating, If your behavior does not improve you will be secluded. D. Smile and state, I am your nurse. When do you want to go to your room?

Which situation exemplifies both assault and battery? A. The nurse becomes angry, calls the client offensive names, and withholds treatment. B. The nurse threatens to tie down the client and then does so against the clients wishes. C. The nurse hides the clients clothes and medicates the client to prevent elopement. D. The nurse restrains the client without just cause and communicates this to family.

The nurse is assessing a client newly admitted to the eating disorders unit. Which findings indicate the client may have a diagnosis of bulimia nervosa? Select all that apply

BMI of 24 kg/m^2 Erosion of tooth enamel Russell's sign

8. The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide? Address only serious suicide threats to avoid the possibility of secondary gain. Promote trust by verbalizing a promise to keep suicide attempt information within the family. Offer a private environment to provide needed time alone at least once a day. Be available to actively listen, support, and accept feelings.

Be available to actively listen, support, and accept feelings.

Which concepts are considered part of the grief response? Select all that apply.

Bereavement Mourning

Bob Taylor's home was recently destroyed in a fire. Margaret Smith is 35 years old and has just learned that she must have a hysterectomy. Which scenario will most likely trigger a grief response?

Both scenarios could trigger individual grief responses

Which elements must be proven for a plaintiff to prevail in a nursing malpractice suit? Select all that apply.

Breach of duty Injury to client Duty to client existed

13. A client diagnosed with dependant personality disorder states, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate? A. "It would be best to do that in order to increase independence." B. "Why would you want to leave a secure home?" C. "Let's discuss and explore all of your options." D. "I'm afraid you would feel very guilty leaving your parents."

14. When interviewing a client, which nonverbal behavior should a nurse employ? A. Maintaining indirect eye contact with the client B. Providing space by leaning back away from the client C. Sitting squarely, facing the client D. Maintaining open posture with arms and legs crossed

19. A client's younger daughter is ignoring curfew. The client states, "I'm afraid she will get pregnant." The nurse responds, "Hang in there. Don't you think she has a lot to learn about life?" This is an example of which communication block? A. Requesting an explanation B. Belittling the client C. Making stereotyped comments D. Probing

20. Which nursing statement is a good example of the therapeutic communication technique of giving recognition? A. "You did not attend group today. Can we talk about that?" B. "I'll sit with you until it is time for your family session." C. "I notice you are wearing a new dress and you have washed your hair." D. "I'm happy that you are now taking your medications. They will really help."

22. The nurse asks a newly admitted client, "What can we do to help you?" What is the purpose of this therapeutic communication technique? A. To reframe the client's thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation

28. A client on an inpatient psychiatric unit tells the nurse, "I should have died because I am totally worthless." In order to encourage the client to continue talking about feelings, which should be the nurse's initial response? A. "How would your family feel if you died?" B. "You feel worthless now, but that can change with time." C. "You've been feeling sad and alone for some time now?" D. "It is great that you have come in for help."

3. Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition

4. The nurse is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a "general lead"? A. "Do you know why you are here?" B. "Are you feeling depressed or anxious?" C. "Yes, I see. Go on." D. "Can you chronologically order the events that led to your admission?"

9. An instructor is correcting a nursing student's clinical worksheet. Which instructor statement is the best example of effective feedback? A. "Why did you use the client's name on your clinical worksheet?" B. "You were very careless to refer to your client by name on your clinical worksheet." C. "Surely you didn't do this deliberately, but you breeched confidentiality by using the client's name." D. "It is disappointing that after being told, you're still using client names on your worksheet."

A brother calls to speak to his sister who has been admitted to the psychiatric unit. The nurse connects him to the community phone and the sister is summoned. Later the nurse realizes that the brother was not on the clients approved call list. What law has the nurse broken? A. The National Alliance for the Mentally Ill Act B. The Tarasoff Ruling C. The Health Insurance Portability and Accountability Act D. The Good Samaritan Law

A client diagnosed with paranoid schizophrenia has a history of aggravated assault. A nurse assigns Risk for other-directed violence as the clients priority nursing diagnosis. Based on this diagnosis, which would be an appropriate, correctly written outcome for this client? A. The client will not verbalize anger or hit anyone. B. The client will verbalize anger rather than hit others. C. The client will not inflict harm on others during this shift. D. The client will be restrained if verbal or physical abuse is observed during this shift.

A client diagnosed with schizophrenia refuses to take medication, citing the right of autonomy. Under which circumstance would a nurse have the right to medicate the client against the clients wishes? A. When the client makes inappropriate sexual innuendos to a staff member B. When the client constantly demands inappropriate attention from the nurse C. When the client physically attacks another client after being confronted in group therapy D. When the client refuses to bathe or perform hygienic activities

A client is concerned that information given to the nurse remains confidential. Which is the nurses best response? A. Your information is confidential. It will be kept just between you and me. B. I will share the information with staff members only with your approval. C. If the information impacts your care, I will need to share it with the treatment team. D. You can make the decision whether your physician needs this information or not.

A client who will be receiving electroconvulsive therapy (ECT) must provide informed consent. Which situation should cause a nurse to question the validity of the informed consent? A. The client is paranoid. B. The client is 87 years old. C. The client incorrectly reports his or her spouses name, the date, and the time of day. D. The client relies on his or her spouse to interpret the information.

A nursing instructor is presenting content on the provisions of the Nurse Practice Act as it relates to their state. Which student statement indicates a need for further instruction? A. The Nurse Practice Act provides a list of definitions of important terms, including the definition of nursing. B. The Nurse Practice Act lists education requirements for licensure and reciprocity. C. The Nurse Practice Act contains detailed statements that describe the scope of practice for registered nurses (RNs). D. The Nurse Practice Act lists the general authority and powers of the state board of nursing.

The client states, I get into trouble because I respond violently without thinking. That usually gets me into a mess. Which nursing reply would be most therapeutic to address this clients problem? A. Everybody loses their temper. Its good that you know that about yourself. B. Ill bet you have some interesting stories to share about overreacting. C. Lets explore methods to help you stop and think before taking action. D. Its good that you are showing readiness for behavioral change.

The nursing staff is discussing the concept of competency. Which information about competency should a nurse recognize as true? A. Competency is determined with a clients compliance with treatment. B. Refusal of medication can initiate an incompetency hearing leading to forced medications. C. A competent client has the ability to make reasonable judgments and decisions. D. Competency is a medical determination made by the clients physician.

There is one bed available on an inpatient psychiatric unit. For which client should a nurse advocate emergency commitment? A. An individual who is persistently mentally ill and evicted from an apartment B. An individual treated in the emergency department (ED) for generalized anxiety disorder C. An individual who is delusional and has a plan to kill his wife D. An individual who rates mood 4/10 and is participating in a no-harm safety plan

Which initial nursing approach makes limit-setting better accepted by clients who are aggressively acting out? A. Confronting clients with their needs for secondary gains B. Teaching relaxation techniques C. Reflecting back to the client empathy about the clients distress D. Presenting appropriate values that need to be modified

Which situation contradicts the ethical principle of veracity? A. A nurse provides a client with outpatient resources to benefit recovery. B. A nurse refuses to give information to a physician who is not responsible for the clients care. C. A nurse tricks a client into seclusion by asking the client to carry linen to the seclusion room. D. A nurse treats all of the clients equally regardless of illness severity.

18. A client tells the nurse, "I feel bad because my mother does not want me to return home after I leave the hospital." Which nursing response is therapeutic? A. "It's quite common for clients to feel that way after a lengthy hospitalization." B. "Why don't you talk to your mother? You may find out she doesn't feel that way." C. "Your mother seems like an understanding person. I'll help you approach her." D. "You feel that your mother does not want you to come back home?"

25. Which nursing statement is a good example of the therapeutic communication technique of focusing? A. "Describe one of the best things that happened to you this week." B. "I'm having a difficult time understanding what you mean." C. "Your counseling session is in 30 minutes. I'll stay with you until then." D. "You mentioned your relationship with your father. Let's discuss that further."

Neuroimaging studies of individuals with a hoarding disorder have indicated less activity in the:

Cingulate cortex

A client diagnosed with Lewy body dementia has been prescribed an antipsychotic medication to manage a decline in mental capacities. Why would the nurse question this prescription?

Clients with Lewy body dementia are highly sensitive to the extrapyramidal effects of antipsychotic medications

30. A client states, "You won't believe what my husband said to me during visiting hours. He has no right treating me that way." Which nursing response would best assess the situation that occurred? A. "Does your husband treat you like this very often?" B. "What do you think is your role in this relationship?" C. "Why do you think he behaved like that?" D. "Describe what happened during your time with your husband."

Kimberly is diagnosed with antisocial behavior disorder. Kimberly's grandiosity, denial of obvious weaknesses, and projection of blame onto others is an example of a _________ coping strategy

defensive

12. A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst? A. "Why do you continue to alienate your peers by your angry outbursts?" B. "You accomplish nothing when you lose your temper like that." C. "Showing your anger in that manner is very childish and insensitive." D. "During group, you raised your voice, yelled at a peer, left, and slammed the door."

16. A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation? A. "Everyone diagnosed with OCD needs to control their ritualistic behaviors." B. "It is important for you to discontinue these ritualistic behaviors." C. "Why are you asking for help if you won't participate in unit therapy?" D. "Let's figure out a way for you to attend unit activities and still wash your hands."

5. A nurse states to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique? A. The therapeutic technique of "giving advice" B. The therapeutic technique of "defending" C. The nontherapeutic technique of "presenting reality" D. The nontherapeutic technique of "giving false reassurance"

1. Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get into a fistfight with my wife or I take it out on the kids." Nurse: "I notice that you are smiling as you talk about this physical violence." A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations

11. What is the purpose of a nurse providing appropriate feedback? A. To give the client good advice B. To advise the client on appropriate behaviors C. To evaluate the client's behavior D. To give the client critical information

A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal.C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client.

A client is served divorce papers while on the inpatient psychiatric unit. When a nurse tells the client the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism has the client exhibited? A. The defense mechanism of projection B. The defense mechanism of reaction formation C. The defense mechanism of sublimation D. The defense mechanism of displacement

A geriatric client is confused and wandering in and out of every door. Which scenario reflects the least restrictive alternative for this client? A. The client is placed in seclusion. B. The client is placed in a geriatric chair with tray. C. The client is placed in soft Posey restraints. D. The client is monitored by an ankle bracelet.

A nurse is caring for four clients. Which client should the nurse identify as least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents

After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30- year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? A. 1 hour B. 2 hours C. 3 hours D. 4 hours

After restraints are removed from a client, the staff discusses the incident and establishes guidelines for the clients return to the therapeutic milieu. Which unit procedure is the staff implementing? A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing

An inpatient psychiatric physician refuses to treat clients without insurance and prematurely discharges those whose insurance benefits have expired. Which violation of an ethical principle should a nurse recognize in this situation? A. Autonomy B. Beneficence C. Nonmaleficence D. Justice

An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit? A. Verbally redirect the client, and then limit one-on-one interaction. B. Involve the hospitals security division as soon as possible. C. Notify the client that documenting personal staff information is against hospital policy. D. Continue professional attempts to establish a positive working relationship with the client.

Which is an accurate description of a common law? A. A common law would be invoked to deal with a nurse who, without justification, threatens a client with restraints. B. A common law would be invoked to deal with a nurse who touches a client without the clients consent. C. A common law would be invoked to deal with a hospital employee who steals drugs, hospital equipment, or both. D. A common law would be invoked to deal with a nurses refusal to provide care for a specific client.

Which statement should a nurse identify as correct regarding a clients right to refuse treatment? A. Clients can refuse pharmacological but not psychological treatment. B. Clients can refuse any treatment at any time. C. Clients can refuse only electroconvulsive therapy (ECT). D. Professionals can override treatment refusal if the client is actively suicidal or homicidal.

A 32-year-old person is speaking to the office nurse at an initial visit. The nurse asked, "What brings you in today?" The client replied, "I have been having headaches three to four times a week for the past month or so. I'm not sleeping well and feel tired most of the time. I work 60 hours per week and am going through a divorce." The nurse determines the client's symptoms represent which of the following? Adaptive coping Maladaptive coping Problem-solving Self-awareness

Maladaptive coping

A client arrives at the primary care physician with complaints of increased symptoms of colitis. During the intake interview, the patient mentions having two migraines in the past 3 weeks and asks for a new medication, stating, "It doesn't seem like the current medication is working as well as I expected." In reviewing the client's medical record, it is noted that the client was prescribed medication for depression and a referral to a marriage counselor at her last visit 2 months ago. Which of the following might the nurse suspect?

Maladaptive expression of anger

Which alteration in brain chemistry would the nurse correlate with a client presenting with decreased motor function and memory deficit?

Decreased levels of acetylcholine

A client experiencing sleep apnea underwent a sleep study. During stage 3 of sleep, a delta rhythm was recorded. The nurse recognizes that a delta rhythm is characterized by which sleep activity?

Deep and restful sleep

Place Kübler-Ross' stages of grief in the correct order

Denial Anger Bargaining Depression Acceptance

Place in order Elizabeth Kübler-Ross's stages of grief.

Denial Anger Bargaining Depression Acceptance

The nurse anticipates the client with an increased thyroid-stimulating hormone (TSH) level will exhibit which symptoms? Select all that apply.

Depression Fatigue

Which responsibilities describe those of the psychiatric-mental health nurse on the interdisciplinary treatment team? Select all that apply.

Develop one-to-one relationships with clients. Manage the therapeutic milieu on a 24-hour basis. Provide input during the development of the treatment plan

A client is diagnosed with anxiety disorder. Which medication is prescribed for anxiety? 1. Chlorpromazine (Thorazine) 2. Clozapine (Clozaril) 3. Diazepam (Valium) 4. Methylphenidate (Ritalin)

Diazepam (Valium)

Which datum indicates a suicidal client is participating in a safety plan?

Disclosing a plan for suicide to staff

Which neurotransmitters would the nurse expect to be elevated in a client with a diagnosis of catatonic schizophrenia?

Dopamine

Who believed mental illness was curable? 1. Benjamin Rush 2. Dorothea Dix 3. Florence Nightingale 4. Linda Richards

Dorothea Dix

An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should the nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply.

Drastic temperature and barometric pressure changes Increased levels of melatonin Variations in serotonergic functioning

Which symptoms would the nurse expect to assess in a client experiencing decreased levels of thyroid hormone? Select all that apply.

Emotional lability Insomnia Restlessness

Which action would the nurse take to promote safety in the client with an NCD?

Encourage the client to call for assistance when getting out of bed.

Which of the following behavioral skills should a nurse implement when leading a group that is functioning in the orientation phase of group development? Select all that apply.

Ensuring that rules established by the group do not interfere with goal fulfillment Working with group members to establish rules that will govern the group Emphasizing the need for and importance of confidentiality within the group

The nurse-client therapeutic relationship includes which of the following characteristics? Select all that apply.

Ensuring therapeutic termination Promoting client insight into problematic behavior Collaborating to set appropriate goals Meeting the holistic needs of the client

Which of the following are included in Jahoda's six indicators of mental health? Select all that apply.

Environmental mastery Integration

The nursing supervisor reassigned the psychiatric-mental health nurse to the surgical intensive care unit (SICU) 4 hours into his shift. The nurse is observing an actively suicidal client who requires one-to-one observation. The charge nurse informs the nurse there is no other staff member available to take over the one-to-one observation. The nurse does not feel qualified to care for clients in the SICU. Which of the following represents the nurse's situation?

Ethical dilemma

Which of the following are symptoms of inhalant intoxication? Select all that apply

Euphoria Ataxia Nystagmus

Therapeutic community is based on which of Skinner's assumptions? Select all that apply

Every interaction is an opportunity for therapeutic intervention. Peer pressure is a useful and powerful tool. Inappropriate behaviors are dealt with as they occur.

Which concepts are essential to psychiatric-mental health nursing practice? Select all that apply.

Evidence-based outcomes Integration of biological knowledge Psychosocial adaptation and physical functioning

The nurse in the intensive care unit (ICU) is giving report to the nurse on the cardiac step-down unit. The nurse states, "The client is a 48-year-old admitted 3 days ago for chest pain and a stent placement. Vital signs are stable, but I am worried about her stress level. She said she just moved here due to a job transfer, and her spouse stayed behind to sell the house. She told me they have a high insurance deductible, and she is worried about the hospital bill." Which factor has the most significant influence on the client's health?

Existing conditions

A college student has been diagnosed with GAD. Which of the following symptoms should a campus nurse expect this client to exhibit? Select all that apply

Fatigue Insomnia Irritability

. Nursing students were provided serum blood levels of 30 different clients and were asked to identify those most at risk for a future suicide attempt based on the laboratory levels alone. Which two of the following factors should the students focus on for statistically significant biological factors? Select two choices.

Fish oil nutrients Cytokines

Place the selected steps of the problem-solving process in the correct order.

Formulate goals to resolve the stressful situation Study the alternatives for dealing with the situation. Determine risks and benefits of each option. Implement a second alternative

Which behaviors indicate a client is experiencing moderate anxiety? Select all that apply.

Gastric discomfort Focus on self

Which preexisting conditions influence the outcome of communication? Select all that apply.

Gender Distance Values

The nurse observes a client sitting alone and crying after a group therapy session. The nurse sits in the chair nearest to the client and states, "I see you are crying. I'd like to sit with you for a few minutes." Which communication technique is the nurse using?

Making an observation

6. During a one-to-one session with a client, the client states, "Nothing will ever get better," and "Nobody can help me." Which nursing diagnosis is most appropriate for a nurse to assign to this client at this time? Powerlessness R/T altered mood AEB client statements Risk for injury R/T altered mood AEB client statements Risk for suicide R/T altered mood AEB client statements Hopelessness R/T altered mood AEB client statements

Hopelessness R/T altered mood AEB client statements The client's statements indicate the problem of hopelessness. Prior to assigning either risk for injury or risk for suicide, a further evaluation of the client's suicidal ideations and intent would be necessary.

On which teaching topics would the nurse focus for a caregiver of a client with stage 5 Alzheimer's disease? Select all that apply.

How to assist with some ADLs, such as hygiene, dressing, and grooming Tools to help reorientate the client to time and place

The psychiatric-mental health nurse is providing discharge teaching for a client diagnosed with bipolar disorder. Which statement indicates that the nurse's teaching is effective?

I'll be the designated driver since I shouldn't have alcohol with lamotrigine."

Which nursing diagnosis is appropriate for a client who is unable to identify objects, confabulating, screaming, and demanding verbalizations?

Impaired verbal communication

A nursing student is developing a study guide related to historical facts about suicide. Which of the following facts should the student include? Select all that apply

In the Middle Ages, suicide was viewed as a selfish and criminal act. Suicide was an offense in ancient Greece, and a common-site burial was denied. During the Renaissance, suicide was discussed and viewed more philosophically

When the general population cannot understand the motivation behind one's behavior, which would be the appropriate term to use?

Incomprehensibility

4. A client with a history of three suicide attempts has been taking fluoxetine (Prozac) for 1 month. The client suddenly presents with a bright affect, rates mood at 9/10, and is much more communicative. Which action should be the nurse's priority at this time? Give the client off-unit privileges as positive reinforcement. Encourage the client to share mood improvement in group. Increase frequency of client observation. Request that the psychiatrist reevaluate the current medication protocol.

Increase frequency of client observation. The nurse should be aware that a sudden increase in mood rating and change in affect could indicate that the client is at risk for suicide and client observation should be more frequent. Suicide risk may occur early during treatment with antidepressants. The return of energy may bring about an increased ability to act out self-destructive behaviors prior to attaining the full therapeutic effect of the antidepressant medication.

Which statement reflects the model of transactional communication?

Individuals simultaneously perceive each other

Yelling, name-calling, hitting others, and temper tantrums as expressions of anger are all evidence supporting which nursing diagnosis?

Ineffective coping related to negative role modeling and dysfunctional family systems

7. A man diagnosed with alcohol dependence experiences his first relapse. During his AA meeting, another group member states, "I relapsed three times, but now have been sober for 15 years." Which of Yalom's curative group factors does this illustrate?

Instillation of hope This scenario is an example of the curative group factor of instillation of hope. This occurs when members observe the progress of others in the group with similar problems and begin to believe that personal problems can also be resolved.

As clients are leaving the dayroom following a group therapy session, the nurse notices that a client admitted for acute mania is clenching and unclenching both fists, swearing, and glaring at a staff member. Which action should the nurse take first?

Instruct clients to return to the dayroom

A person who demonstrates the ability to exert _________ __________ over feelings of anger would demonstrate a successful nursing outcome in the care of the client needing assistance with anger management.

Internal control

When a person is at risk for spiritual distress, for which reasons is it an appropriate nursing intervention to stay with the client and accepting and nonjudgmental when the client expresses anger and bitterness (e.g., toward God, the universe)? Select all that apply.

It increases the client's feelings of self-worth. It promotes trust in the nurse-client relationship

For which reasons is the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) useful in the practice of psychiatric-mental health nursing? Select all that apply.

It informs the nurse of accurate and reliable psychiatric diagnoses. It represents progress toward a more holistic view of mind and body. It provides a framework for interdisciplinary communication.

According to the Three-Step Theory, when strong, active suicide ideation is present:

It leads to an attempt only if the individual has the capacity to make an attempt.

A woman returns home after delivering a stillborn infant to find that neighbors have dismantled the nursery that she and her spouse planned. According to Worden, which indicates the effect the neighbors' action may have on the woman's grieving task completion?

It may hamper the woman from accepting the reality of the loss

A client in stage 3 Alzheimer's disease frequently wanders. Which interventions can the nurse implement to reduce the incidence of wandering and promote safety? Select all that apply.

Keep the client on a strict toileting schedule Walk with the individual and redirect them back to the unit. Keep the client on a structured schedule of activities.

. The psychiatric-mental health nurse is obtaining informed consent for a client who is scheduled for ECT the following morning. Which major elements must be addressed when obtaining informed consent? Select all that apply.

Lack of coercion Unimpaired cognition Client knowledge of the procedure

Teaching is effective if the students identify which cerebral structure as the "emotional brain?"

Limbic system

A(n) ____________________________________ is a written document made by a competent individual that provides instructions that should be used when that individual is no longer able to express their wishes for health care treatment

Living will

A client and a nurse therapist are developing a treatment plan that includes strategies to manage bipolar disorder. Which should be included? Select all that apply

Maintain a consistent sleep schedule. Become an expert on the disorder. Create a daily medication schedule. Develop an emergency plan

A decrease in norepinephrine levels plays a significant role in which disorder?

Major depressive disorder

Which of the following occupational groups are at highest risk of suicide?

Mechanics

Learning has occurred when the student identifies that the neurotransmitter serotonin is catabolized by which enzyme?

Monoamine oxidase

Which of the following is indicative of serious critical thinking about how individuals should treat others?

Morals

Which of the following is considered a fact about suicide?

Most suicidal people have ambivalent feelings regarding living or dying

Which of the following best represents a patient-centered approach that promotes a change in behavior?

Motivational interviewing

Psychotropic medications improve symptoms of mental disorders by acting on which component of the brain?

Neural synapse

A client who is diagnosed with schizophrenia expresses little emotion and refuses to attend group therapy is influenced by which component of the nervous system?

Neurotransmitters

Nina is an artist who dresses in long, colorful kaftans and wears sequin and rhinestone hats. Her makeup is dramatic, and her long, false fingernails are always painted a bright color. Every time Nina attends a social event, she waltzes into the room and shouts "Hello people! I have arrived." Which behavior is congruent with Nina's diagnosis? Select all that apply.

Nina flirts with someone significantly younger who tells her that she doesn't look or act her age Nina becomes anxious when the hostess of a party excuses herself from speaking with Nina to greet other guests

20. A client is newly committed to an inpatient psychiatric unit. Which nursing intervention best lowers this client's risk for suicide? Encouraging participation in the milieu to promote hope Developing a strong personal relationship with the client Observing the client at intervals determined by assessed data Encouraging and redirecting the client to concentrate on happier times

Observing the client at intervals determined by assessed data The nurse should observe the actively suicidal client continuously for the first hour after admission. After a full assessment the treatment team will determine the observation status of the client. Observation of the client allows the nurse to interrupt any observed suicidal behaviors.

. A nurse attends an interdisciplinary team meeting on an inpatient unit. Which of the following individuals are typically included as members of the interdisciplinary treatment team in psychiatry? Select all that apply.

Occupational therapist Recreational therapist Psychiatric social worker Mental health technician

A client was diagnosed with OCPD several years ago and visits the outpatient mental health clinic for medication evaluation. As the nurse updates her health record with new assessment data, she reviews the client's family history. The nurse knows that the client most likely grew up in which family environment? Select all that apply.

One where punishment for undesirable behaviors was frequent One where positive achievements were taken for granted and seldom acknowledged One where following rigid restrictions and rules was required

The clinic nurse is reviewing the medication list of a client diagnosed with medication-induced bipolar disorder. The nurse recognizes which may have precipitated the client's mood disturbance? Select all that apply.

Oral contraceptives Antihypertensives Corticosteroids

Which are associated with codependent behaviors among nurses? Select all that apply

Overspending Perfectionism Denial

Which hormone is used experimentally to increase socialization?

Oxytocin

Which client diagnosis would the nurse associate with a decrease in gammaaminobutyric acid (GABA) levels?

Panic disorder

5. A nurse admitted a client to an inpatient unit after a suicide attempt. A health-care provider orders amitriptyline (Elavil) for the client. Which intervention related to this medication should be initiated to maintain this client's safety upon discharge? Provide a 6-month supply of Elavil to ensure long-term compliance. Provide a 3-day supply of Elavil with refills contingent on follow-up appointments. Provide a pill dispenser as a memory aid. Provide education regarding the avoidance of foods containing tyramine

Provide a 3-day supply of Elavil with refills contingent on follow-up appointments. The health-care provider should provide no more than a 3-day supply of Elavil with refills contingent on follow-up appointments as an appropriate intervention to maintain the client's safety. Tricyclic antidepressants have a narrow therapeutic range and can be used in overdose to commit suicide. Distributing limited amounts of the medication decreases this potential. In addition, clients may gain energy to carry out a suicide once they begin to have more energy from taking the antidepressants.

The master's-prepared nurse with specialized training is serving as a group leader, where the client becomes an "actor" in a life-situation scenario. This scenario provides the client a safe atmosphere to work through unresolved conflicts. What is this type of therapeutic group?

Psychodrama

Six months after a client's spouse and children were killed in a car accident, the client is diagnosed with ulcerative colitis. The nurse should recognize that this situation validates which study perspective?

Psychoneuroimmunology

Elevated levels of adrenocorticotropic hormone (ACTH) are associated with which symptom?

Psychosis

Rebecca expresses to the nurse that she feels like she didn't do enough to prevent the loss of her father. Which interventions would the nurse use to address Rebecca's feelings?

Review the circumstances of the loss and the reality that it could not be prevented

The nurse notices that Martha, the primary caregiver for her spouse with Alzheimer's disease, seems distracted, and she asks how Martha is doing. "I'm doing OK," said Martha. "I'm just so overwhelmed. I can't seem to get anything done. Just when I think I'm handling everything, something else comes up. Hopefully things will settle down soon, and I can get a break." Which intervention would most help Martha cope with the caregiver strain she's expressing?

Referrals to support services for Alzheimer's disease

The nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? Select all that apply

Systematic desensitization Imploding (flooding)

Which of the following indicate that the integrity of the nurse-client relationship may be in jeopardy? Select all that apply

Requesting to be reassigned to a particular client Contacting the client after discharge

. Which mental illness would a nurse identify as being associated with a decrease in prolactin levels?

Schizophrenia

An increase in dopamine activity might play a significant role in the development of which disorder?

Schizophrenia

. The nurse assesses a woman whose spouse died 13 months ago. She isolates herself, screams at her deceased spouse, and is increasingly restless and aimless. According to Bowlby, this widow is in which stage of the grieving process?

Stage III: disorganization and despair

The psychiatric-mental health nurse is teaching a client about the side effects of amlodipine besylate (Norvasc). The nurse's action is within the nurse's scope of practice in the state. Which type of law defines nursing scope of practice?

Statutory law

Which nursing interventions would be used for a client with a nursing diagnosis of risk of trauma related to impairments in cognitive and psychomotor functioning? Select all that apply.

Store frequently used items within easy access. Keep cigarettes and lighters out of reach of the client. Keep a dim light on at night.

Which adoption studies about the influence of genetics on the development of psychiatric disorders were described by Knowles? Select all that apply

Studies in which children whose biological parents had a psychiatric disorder were raised by adoptive parents who did not have a psychiatric disorder Studies in which children whose biological parents did not have a psychiatric disorder were raised by adoptive parents who had a psychiatric disorder

The predisposing factor, anger turned inward, is a psychological theory of Freud's proposing which of the following?

Suicide occurs because of an earlier repressed desire to kill someone else.

A client was diagnosed with depression resulting from the loss of her twin sister in a skiing accident. Her parents reported that all the client has done since the accident was lay in her bed and cry, asking why she survived the accident. The physician prescribed Prozac to treat the depression and suggested that the parents "keep a close eye on her." After a week, the client began to show some signs of improvement, even coming out of her room to eat with the family. After 2 months, the client committed suicide despite seeming to come out of the depression. What is the likeliest reason?

Suicide risk can increase early in treatment with antidepressants.

Mental illness was attributed to which of the following factors prior to the influence of Middle Eastern countries? Select all that apply

Supernatural forces Disequilibrium of humors Demons

Which part of the nervous system would the nurse identify as playing a major role during stressful situations?

Sympathetic nervous system

A 20-year-old female has a diagnosis of PMDD. Which of the following should the nurse identify as consistent with this diagnosis? Select all that apply.

Symptoms are causing significant interference with daily activities. Mood swings occur the week before onset of menses. Client reports subjective difficulty concentrating

Which of the following explanations should the nurse include when teaching parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply

Symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. Children are naturally active, energetic, and spontaneous.

After disturbing the peace, an aggressive, disoriented, unkempt, homeless individual is escorted to an emergency department by police. The client threatens suicide. Which criteria enable a physician to consider involuntary commitment? Select all that apply

The client is a danger to others. . The client is gravely disabled and unable to meet basic needs. The client is suicidal

A client is diagnosed with terminal cancer. Which situation would the nurse assess as reflecting Kübler-Ross's grief stage of anger?

The client is a devoted Catholic but refuses to attend church and states that his faith has failed him

A client was admitted to the hospital after being treated in the emergency department for seizures following a head trauma. Within a few minutes of arriving on the floor, the admitting nurse noticed that the client had a difficult time sustaining attention and did not know where she was. Which statement describes the rationale for the abnormal behavior?

The client is experiencing delirium

A client's spouse of 34 years dies unexpectedly. The client cries often and becomes socially isolated. The client's therapist stresses the importance of proper sleep, nutrition, and exercise. Which statement is true regarding the rationale for the therapist's advice?

The client is susceptible to illness due to effects of stress on the immune system.

The nurse assesses a client as experiencing maladaptive grieving. Which factor confirms the nurse's assessment?

The client reports feelings of worthlessness

Which is the most accurate description of the nursing diagnosis of spiritual distress?

The client struggles to identify meaning and purpose in life

16. Which is a correctly written, appropriate outcome for a client with a history of suicide attempts who is currently exhibiting symptoms of low self-esteem by isolating self? The client will not physically harm self. The client will express three positive self-attributes by day four. The client will reveal a suicide plan. The client will establish a trusting relationship.

The client will express three positive self-attributes by day four. Although the client has a history of suicide attempts, the current problem is isolative behaviors based on low self-esteem. Outcomes should be client-centered, specific, realistic, and measurable and contain a time frame.

2. During the planning of care for a suicidal client, which correctly written outcome should be a nurse's first priority? The client will not physically harm self. The client will express hope for the future by day three. The client will establish a trusting relationship with the nurse. The client will remain safe during the hospital stay.

The client will remain safe during the hospital stay. The nurse's priority should be that the client will remain safe during the hospital stay. Client safety should always be the nurse's priority.

A client is newly admitted to an inpatient psychiatric unit. Which of the following is the most critical assessment when determining risk for suicide?

The client's history of suicide attempts

Thomas Joiner's interpersonal theory of suicide proposes which of the following?

The concept of suicide ideation and suicide attempts are distinct processes.

13. Which group leader activity should a nurse identify as being most effective in the final, or termination, phase of group development?

The group leader helps the members to process feelings of loss. The most effective intervention in the final, or termination, phase of group development would be for the group leader to help the members to process feelings of loss. The leader should encourage the members to review the goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress.

12. A nurse is caring for a client who has threatened to commit suicide by hanging. The client states, "I'm going to use a knotted shower curtain when no one is around." Which information would determine the nurse's plan of care for this client? The more specific the plan is, the more likely the client will attempt suicide. Clients who talk about suicide never actually commit it. Clients who threaten suicide should be observed every 15 minutes. After a brief assessment, the nurse should avoid the topic of suicide.

The more specific the plan is, the more likely the client will attempt suicide

Which epidemiological factor related to suicide makes it difficult to determine the number of attempts that happen each year?

The number of suicide attempts reflects only those who enter treatment.

A nurse believes that the members of a parenting group are in the initial, or orientation, phase of group development. Which group behaviors would support this assumption?

The nurse should anticipate that members in the initial, or orientation, phase of group development often compliment the leader and compete for the role of recorder. Members in this phase have not yet established trust and have a fear of not being accepted. Power struggles may occur as members compete for their position in the group.

10. During an inpatient educational group, a client shouts out, "This information is worthless. Nothing you have said can help me." These statements indicate to the nurse leader that the client is assuming which group role?

The nurse should identify that the client is assuming the group role of the aggressor. The aggressor expresses negativism and hostility toward others in the group or to the group leader and may use sarcasm in an effort to degrade the status of others.

The nurse should utilize which group function to help an extremely withdrawn, paranoid client increase feelings of security?

The nurse should identify that the group function of support would help an extremely withdrawn, paranoid client increase feelings of security. Support assists group members in gaining a feeling of security from group involvement.

During a therapeutic group, which nursing action demonstrates a laissez-faire leadership style?

The nurse sits silently as the group members stray from the assigned topic. The nurse leader who sits silently and allows group members to stray from the assigned topic is demonstrating a laissez-faire leadership style. This style allows group members to do as they please with no direction from the leader. Group members often become frustrated and confused in reaction to a laissez-faire leadership style.

Which information would the nurse include when teaching a client about the causes of anorexia nervosa? Select all that apply.

There is a possible correlation between abnormal secretion of growth hormone and anorexia nervosa There is a possible correlation between low levels of gonadotropin and anorexia nervosa.

Which statements regarding defense mechanisms are true? Select all that apply.

They are employed when there is a threat to biological or psychological integrity. They are used to relieve mild to moderate anxiety. They are mechanisms that are characteristically self-deceptive

The nurse is caring for an Irish client who has recently lost a spouse. The client states to the nurse, "I'm planning an elaborate wake and funeral." According to George Engel, which purpose do these rituals serve?

To facilitate the acceptance of the loss of the client's spouse

Which descriptors are true regarding a therapeutic community? Select all that apply.

Unit responsibilities are assigned according to client capabilities. . A democratic form of government exists.

6. A single, pregnant teenager in a parenting class discloses her ambivalence toward the pregnancy and the subsequent guilt that these thoughts generate. A mother of three admits to having felt that way herself. Which of Yalom's curative group factors does this illustrate?

Universality The scenario is an example of the curative group factor of universality. Universality occurs when individuals realize that they are not alone in the problems, thoughts, and feelings they are experiencing. This realization reduces anxiety by the support and understanding of others.

The nurse is providing care to the client during the detoxification process and does so without emotion. The nurse does not recognize the client's perception of the care as cold and judgmental. Which quadrant of the Johari window would this be considered?

Unknowing self

The nurse is assisting the social worker and therapist in leading a presentation on life skills to the clients on a psychiatric unit. The client, who has been diagnosed with BPD, begins to threaten another client who constantly interrupts the presentation by asking questions. As the client's behavior escalates, which actions should the nurse take first? Select all that apply.

Use a calm voice to ask the other clients to leave the room Ask the social worker and therapist to alert the other staff nurses to the situation

A client tells the nurse, "I have nothing left to enjoy in life. My children are grown and married." The nurse replies, "I'm sure you are looking forward to having grandchildren." Which communication technique is this considered?

Using denial

Which of the following can the psychiatric-mental health nurse utilize to best increase self-awareness? Select all that apply.

Values clarification The Johari window

Prior to anxiety being clearly defined as a separate entity, which of the following diagnostic terms were used to identify symptoms? Select all that apply

Vasomotor neurosis Vasoregulatory asthenia

A client presents in the emergency department immediately following a shooting incident in a school where she has been teaching. Which are common initial biological responses to stress the teacher might demonstrate? Select all that apply.

Watery eyes Increased heart rate Increased respirations

The mother of a 6-month-old child was diagnosed with a terminal illness and died just 4 days after her child's first birthday. At the 1-year well-child visit, the spouse shares some concerns with the pediatrician regarding changes in the child's normal behavior. Which are common changes in children from birth to age 2 years when they are separated from their mothers? Select all that apply.

Weight loss Sleeplessness

A client is diagnosed with BPD. One of the client's current defensive mechanisms is to engage in suicidal ideation when he feels threatened. The type of therapy that will most benefit the client is ______________ ______________ therapy.

dialectical behavior

Dissociative disorders are defined by a disturbance of or alteration in the usually integrated functions of consciousness, memory, and ____________________.

identity

____________________ is defined as an inability to remember or recall bits of information or behavioral skills.

impaired memory

A client displays emotional dysregulation, impulsive behavior, and aggressive symptoms. The client is diagnosed with BPD. The most effective pharmacotherapy for the client is ____________________ agents.

mood-stabilizing

Which interventions would the nurse anticipate implementing when planning care for children diagnosed with ADHD? Select all that apply.

Behavior modification Group therapy Family therapy

A pregnant client is being treated for uncontrolled diabetes and reports to the nurse, "I have two other children, and my diabetes hasn't affected them. I'm sure this baby will be fine too." What percentage of ID cases result in early alterations in embryonic development?

30%

Which risk factors noted during a family history assessment would the nurse associate with the potential development of ID? Select all that apply.

A family history of Tay-Sachs disease Childhood meningococcal infection Deprivation of nurturance and social contact

Which individuals are at highest risk for exhibiting aggressive behavior? Select all that apply.

A parent who has been struggling to find work A person who suffers from epilepsy . An adult whose father would abuse his mother

3. Which statement made by an emergency department nurse indicates accurate knowledge of domestic violence? A. Power and control are central to the dynamic of domestic violence. B. Poor communication and social isolation are central to the dynamic of domestic violence. C. Erratic relationships and vulnerability are central to the dynamic of domestic violence. D. Emotional injury and learned helplessness are central to the dynamic of domestic violence.

ANS: A The nurse accurately states that power and control are central to the dynamic of domestic violence. Battering is defined as a pattern of coercive control founded on physical and/or sexual violence or threat of violence. The typical abuser is very possessive and perceives the victim as a possession.

When planning care for women in abusive relationships, which information is important for the nurse to understand? Select all that apply.

It often takes several attempts before a woman leaves an abusive situation. Substance abuse is a common factor in abusive relationships. Women in abusive relationships usually feel isolated and unsupported.

Which nursing diagnoses would be expected for an adult survivor of incest? Select all that apply

Low self-esteem Powerlessness

Which medications could be used to reduce aggression by dampening excessive nonadrenergic activity?

Propranolol

15. A child diagnosed with autism spectrum disorder has the nursing diagnosis of disturbed personal identity. Which outcome would best address this client's diagnosis? A. The client will name own body parts as separate from others by day 5. B. The client will establish a means of communicating personal needs by discharge. C. The client will initiate social interactions with caregivers by day 4. D. The client will not harm self or others by discharge.

ANS: A An appropriate outcome for this client is to name own body parts as separate from others. The nurse should assist the client in the recognition of separateness during self-care activities such as dressing and feeding. The long-term goal for disturbed personal identity is for the client to develop an ego identity.

6. Which nursing approach should be used to maintain a therapeutic relationship with a client diagnosed with borderline personality disorder? A. Being firm, consistent, and empathetic, while addressing specific client behaviors B. Promoting client self-expression by implementing laissez-faire leadership C. Using authoritative leadership to help clients learn to conform to societal norms D. Overlooking inappropriate behaviors to avoid promoting secondary gains

ANS: A The best nursing approach when working with a client diagnosed with borderline personality disorder is to be firm, consistent, and empathetic while addressing specific client behaviors. Individuals diagnosed with borderline personality disorder always seem to be in a state of crisis and can often have negative patterns of interaction, such as manipulation and splitting.

6. An adolescent client who was diagnosed with conduct disorder at the age of 8 is sentenced to juvenile detention after bringing a gun to school. How should the nurse apply knowledge of conduct disorder to this client's situation? A. Childhood-onset conduct disorder is more severe than the adolescent-onset type, and these individuals likely develop antisocial personality disorder in adulthood. B. Childhood-onset conduct disorder is caused by a difficult temperament, and the child is likely to outgrow these behaviors by adulthood. C. Childhood-onset conduct disorder is diagnosed only when behaviors emerge before the age of 5, and therefore improvement is likely. D. Childhood-onset conduct disorder has no treatment or cure, and children diagnosed with this disorder are likely to develop progressive oppositional defiant disorder.

ANS: A The nurse should apply knowledge of conduct disorder to determine that childhood-onset conduct disorder is more severe than adolescent-onset type. These individuals are likely to develop antisocial personality disorder in adulthood. Individuals with this subtype are usually boys and frequently display physical aggression and have disturbed peer relationships.

9. Family members of a client ask a nurse to explain the difference between schizoid and avoidant personality disorders. Which is the appropriate nursing reply? A. Clients diagnosed with avoidant personality disorder desire intimacy but fear it, and clients diagnosed with schizoid personality disorder prefer to be alone. B. Clients diagnosed with schizoid personality disorder exhibit odd, bizarre, and eccentric behavior, whereas clients diagnosed with avoidant personality disorder do not. C. Clients diagnosed with avoidant personality disorder are eccentric, and clients diagnosed with schizoid personality disorder are dull and vacant. D. Clients diagnosed with schizoid personality disorder have a history of psychotic thought processes, whereas clients diagnosed with avoidant personality disorder remain based in reality.

ANS: A The nurse should educate the family that clients diagnosed with avoidant personality disorder desire intimacy but fear it, whereas clients diagnosed with schizoid personality disorder prefer to be alone. Avoidant personality disorder is characterized by an extreme sensitivity to rejection, which leads to social isolation. Schizoid personality disorder is characterized by a profound deficit in the ability to form personal relationships.

13. When planning care for a client, which medication classification should a nurse recognize as effective in the treatment of Tourette's disorder? A. Antipsychotic medications B. Antimanic medications C. Tricyclic antidepressant medications D. Monoamine oxidase inhibitor medications

ANS: A The nurse should recognize that antipsychotic medications are effective in the treatment of Tourette's disorder. These medications are used to reduce the severity of tics and are most effective when combined with psychosocial therapy. Risperidone (Risperdal) has been shown to reduce symptoms by 21% to 61%.

5. After an adolescent diagnosed with attention deficit-hyperactivity disorder (ADHD) begins methylphenidate (Ritalin) therapy, a nurse notes that the adolescent loses 10 pounds in a 2-month period. What is the best explanation for this weight loss? A. The pharmacological action of Ritalin causes a decrease in appetite. B. Hyperactivity seen in ADHD causes increased caloric expenditure. C. Side effects of Ritalin cause nausea; therefore, caloric intake is decreased. D. Increased ability to concentrate allows the client to focus on activities rather than food.

ANS: A The pharmacological action of Ritalin causes a decrease in appetite that often leads to weight loss. Methylphenidate (Ritalin) is a central nervous symptom stimulant that serves to increase attention span, control hyperactive behaviors, and improve learning ability for clients diagnosed with ADHD.

15. Which nursing diagnosis should be prioritized when providing care to a client diagnosed with paranoid personality disorder? A. Risk for violence: directed toward others R/T suspicious thoughts B. Risk for suicide R/T altered thought C. Altered sensory perception R/T increased levels of anxiety D. Social isolation R/T inability to relate to others

ANS: A The priority nursing diagnosis for a client diagnosed with paranoid personality disorder should be risk for violence: directed toward others R/T suspicious thoughts. Clients diagnosed with paranoid personality disorder have a pervasive distrust and suspiciousness of others that may result in hostile actions to protect self. They are often tense and irritable, which increases the likelihood of violent behavior.

16. A nursing instructor presents a case study in which a 3-year-old child is in constant motion and is unable to sit still during story time. The instructor asks a student to evaluate this child's behavior. Which student response indicates an appropriate evaluation of the situation? A. "This child's behavior must be evaluated according to developmental norms." B. "This child has symptoms of attention deficit hyperactivity disorder." C. "This child has symptoms of the early stages of autistic disorder." D. "This child's behavior indicates possible symptoms of oppositional defiant disorder."

ANS: A The student's evaluation of the situation is appropriate when indicating a need for the client to be evaluated according to developmental norms. Guidelines for determining whether emotional problems exist in a child should consider if the behavioral manifestations are not age-appropriate, deviate from cultural norms, or create deficits or impairments in adaptive functioning.

2. Paula's husband returned from active duty 1 month ago, and Paula is now seeing a counselor for relational conflict in her marriage. She tells the counselor she thinks her husband "can't love anything as much as he loves the military" and that "he acts like he can't wait to be redeployed." Which of these common aspects about military culture might be contributing to her husband's behavior? A. Military mission is advanced as the highest priority. B. Marriage is discouraged in the military. C. Redeployment is considered the highest honor. D. People who choose a military lifestyle often have asocial personality traits.

ANS: A One aspect of military culture is advancing the idea that the military mission takes precedence over other concerns, which could be perceived to include family and marital relationships.

8. A college student was sexually assaulted when out on a date. After several weeks of crisis intervention therapy, which client statement should indicate to a nurse that the student is handling this situation in a healthy manner? A. I know that it was not my fault. B. My boyfriend has trouble controlling his sexual urges. C. If I dont put myself in a dating situation, I wont be at risk. D. Next time I will think twice about wearing a sexy dress.

ANS: A The client who realizes that sexual assault was not her fault is handling the situation in a healthy manner. The nurse should provide nonjudgmental listening and communicate statements that instill trust and validate self-worth.

1. A kindergarten student is frequently violent toward other children. A school nurse notices bruises and burns on the childs face and arms. What other symptom should indicate to the nurse that the child might have been physically abused? A. The child shrinks at the approach of adults. B. The child begs or steals food or money. C. The child is frequently absent from school. D. The child is delayed in physical and emotional development.

ANS: A The nurse should determine that a child who shrinks at the approach of adults in addition to having bruises and burns might be a victim of abuse. Whether or not the adult intended to harm the child, maltreatment should be considered.

13. Which assessment data should a school nurse recognize as signs of physical neglect? A. The child is often absent from school and seems apathetic and tired. B. The child is very insecure and has poor self-esteem. C. The child has multiple bruises on various body parts. D. The child has sophisticated knowledge of sexual behaviors.

ANS: A The nurse should recognize that a child who is often absent from school and seems apathetic and tired might be a victim of neglect. Other indicators of neglect are stealing food or money, lacking medical or dental care, being consistently dirty, lacking sufficient clothing, or stating that there is no one home to provide care.

6. Mary is seeing her family physician for a routine checkup and mentions to the nurse that her husband just returned from active duty in the military. He was deployed to Iraq for the last 18 months, and Mary says she is very excited that they will finally be able to "pick up" where they left off. The nurse decides to ask more questions about their marital relationship in this post-deployment period. What is the best rationale for including these assessment questions? A. The post-deployment period is often the most difficult time period for veterans and spouses to negotiate. B. All veterans experience some PTSD and are unable to return to previous relationship patterns. C. Denial about the impact of combat experiences is common in military spouses. D. Mary is most likely being abused by her husband and is covering this up.

ANS: A There is no evidence that denial is common in military spouses, and although physical aggression is a common symptom of PTSD, there is no report of PTSD symptoms in this case. Furthermore, not all veterans experience PTSD. However, knowing that the post-deployment period has been identified as the most difficult period for couples to negotiate, the nurse may find it beneficial to assess their relationship and provide an opportunity for education and resources as needed.

10. John is being treated for PTSD symptoms, which began shortly after his retirement from the military. He has had nightmares, flashbacks of traumatic events from combat, and episodes of acute anxiety. His wife is asking the nurse how he could be developing PTSD at this time when he hasn't been in a combat situation for over 10 years. Which of these teaching points are evidence-based pieces of information to share with John's wife? Select all that apply. A. Retirement has been identified as a common precipitating factor for PTSD. B. PTSD symptoms may develop at any time after a trauma. C. PTSD is not the appropriate diagnosis, according to DSM-5, unless the trauma occurred greater than 5 years ago. D. This is probably not PTSD but rather a brief adjustment reaction to retirement.

ANS: A, B Retirement has been identified as a common precipitating factor for PTSD, but symptoms may develop at any time. The DSM-5 establishes symptoms occurring and/or persisting beyond 3 months following a trauma as indicative of PTSD.

11. Les has been referred to the VA clinic because he was recently fired from his job. His former employer reported that he was drinking on the job and had become physically aggressive with one of his coworkers. Which of the following statements during the intake assessment are consistent with common symptoms of PTSD? Select all that apply. A. "I've been drinking and smoking pot more frequently in the past few months." B. "I've always thought I was too good for that job anyway." C. "Sometimes I get so angry I just want to punch someone's lights out." D. "I haven't been getting enough sleep because the nightmares keep waking me up." E. "I don't like authority figures."

ANS: A, C, D Substance abuse, aggression, insomnia, and nightmares are all symptoms commonly associated with PTSD.

12. Jane has begun treatment for PTSD with symptoms of depression. The nurse is reviewing the physician's orders. Which of these are evidence-based modalities for initial treatment of Jane's illnesses? Select all that apply. A. Acupuncture B. Electroconvulsive therapy (ECT) C. Sertraline (Zoloft) D. Cognitive behavior therapy (CBT) E. Propranolol (Inderal)

ANS: A, C, D, E Acupuncture, SSRIs, CBT, and antihypertensives such as propranolol have been shown to be effective in treating symptoms of PTSD. ECT has not been identified as an effective treatment of symptoms of PTSD and would not be a first-line treatment for depression.

21. A nurse has taken report for the evening shift on an adolescent inpatient unit. Which client should the nurse address first? A. A client diagnosed with oppositional defiant disorder being sexually inappropriate with staff B. A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu C. A client diagnosed with conduct disorder who is demanding special attention from staff D. A client diagnosed with attention deficit disorder who has a history of self-mutilation

ANS: B A client diagnosed with conduct disorder who is verbally abusing a peer in the milieu presents a potential safety concern that would need to be addressed by the nurse immediately.

22. A 6-year-old client is prescribed methylphenidate (Ritalin) for a diagnosis of attention deficit-hyperactivity disorder (ADHD). When teaching the parents about this medication, which nursing statement explains how Ritalin works? A. "Ritalin's sedation side effect assists children by decreasing their energy level." B. "How Ritalin works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD." C. "Ritalin helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapse." D. "Ritalin decreases hyperactivity by increasing serotonin levels."

ANS: B It is unknown how Ritalin works, but even though it is a stimulant, it does decrease hyperactivity in individuals diagnosed with ADHD.

24. The nurse should recognize which factors that distinguish personality disorders from psychosis? A. Functioning is more limited in personality disorders than in psychosis. B. Major disturbances of thought are absent in personality disorders. C. Personality disordered clients require hospitalization more frequently. D. Personality disorders do not affect family relationships as much as psychosis.

ANS: B Major disturbances of thought are absent in personality disorders and are a classic symptom of psychosis.

8. A pessimistic client expresses low self-worth, has much difficulty making decisions, avoids positions of responsibility, and has a behavioral pattern of suffering in silence. Which underlying cause of this clients personality disorder should a nurse recognize? A. Nurturance was provided from many sources, and independent behaviors were encouraged. B. Nurturance was provided exclusively from one source, and independent behaviors were discouraged. C. Nurturance was provided exclusively from one source, and independent behaviors were encouraged. D. Nurturance was provided from many sources, and independent behaviors were discouraged.

ANS: B Nurturance provided from one source and discouragement of independent behaviors can attribute to the etiology of dependent personality disorder. Dependent behaviors may be rewarded by a parent who is overprotective and discourages autonomy.

2. Which nursing intervention related to self-care would be most appropriate for a teenager diagnosed with moderate intellectual disability? A. Meeting all of the client's self-care needs to avoid injury B. Providing simple directions and praising client's independent self-care efforts C. Avoiding interference with the client's self-care efforts in order to promote autonomy D. Encouraging family to meet the client's self-care needs to promote bonding

ANS: B Providing simple directions and praise is an appropriate intervention for a teenager diagnosed with moderate intellectual disability. Individuals with moderate intellectual disability can perform some activities independently and may be capable of academic skill to a second-grade level.

17. A client has an IQ of 47. Which nursing diagnosis best addresses a client problem associated with this degree of intellectual disability? A. Risk for injury R/T self-mutilation B. Altered social interaction R/T nonadherence to social convention C. Altered verbal communication R/T delusional thinking D. Social isolation R/T severely decreased gross motor skills

ANS: B The appropriate nursing diagnosis associated with this degree of intellectual disability is altered social interaction R/T nonadherence to social convention. A client with an IQ of 47 would be diagnosed with moderate intellectual disability and may also experience some limitations in speech communications.

1. During an assessment interview, a client diagnosed with antisocial personality disorder spits, curses, and refuses to answer questions. Which is the most appropriate nursing statement to address this behavior? A. You are very disrespectful. You need to learn to control yourself. B. I understand that you are angry, but this behavior will not be tolerated. C. What behaviors could you modify to improve this situation? D. What anti-personality-disorder medications have helped you in the past?

ANS: B The appropriate nursing statement is to reflect the clients feeling while setting firm limits on behavior. Clients diagnosed with antisocial personality disorder have a low tolerance for frustration, see themselves as victims, and use projection as a primary ego defense mechanism. Antidepressants and anxiolytics are used for symptom relief; however, there are no specific medications targeted for the treatment of a personality disorder.

11. A nursing instructor is teaching students about clients diagnosed with histrionic personality disorder and the quality of their relationships. Which student statement indicates that learning has occurred? A. Their dramatic style tends to make their interpersonal relationships quite interesting and fulfilling. B. Their interpersonal relationships tend to be shallow and fleeting, serving their dependency needs. C. They tend to develop few relationships because they are strongly independent but generally maintain deep affection. D. They pay particular attention to details, which can frustrate the development of relationships.

ANS: B The instructor should evaluate that learning has occurred when the student describes clients diagnosed with histrionic personality disorder as having shallow, fleeting interpersonal relationships that serve their dependency needs. Histrionic personality disorder is characterized by colorful, dramatic, and extroverted behavior. These individuals also have difficulty maintaining long-lasting relationships.

16. Using a behavioral approach, which nursing intervention is most appropriate when caring for a client diagnosed with borderline personality disorder? A. Seclude the client when inappropriate behaviors are exhibited. B. Contract with the client to reinforce positive behaviors with unit privileges. C. Teach the purpose of antianxiety medications to improve medication compliance. D. Encourage the client to journal feelings to improve awareness of abandonment issues.

ANS: B The most appropriate nursing intervention from a behavioral perspective is to contract with the client to reinforce positive behaviors with unit privileges. Behavioral strategies offer reinforcement for positive change.

3. A child has been diagnosed with autism spectrum disorder. The distraught mother cries out, "I'm such a terrible mother. What did I do to cause this?" Which nursing reply is most appropriate? A. "Researchers really don't know what causes autistic disorder, but the relationship between autistic disorder and fetal alcohol syndrome is being explored." B. "Poor parenting doesn't cause autism. Research has shown that abnormalities in brain structure and/or function are to blame. This is beyond your control." C. "Research has shown that the mother appears to play a greater role in the development of this disorder than the father." D. "Lack of early infant bonding with the mother has shown to be a cause of autistic disorder. Did you breastfeed or bottle-feed?"

ANS: B The most appropriate reply by the nurse is to explain to the parent that autism spectrum disorder is believed to be caused by abnormalities in brain structure and/or function, not poor parenting. Autism spectrum disorder occurs in approximately 6 per 1,000 children and is about four times more likely to occur in boys.

13. When planning care for a client diagnosed with borderline personality disorder, which self-harm behavior should a nurse expect the client to exhibit? A. The use of highly lethal methods to commit suicide B. The use of suicidal gestures to evoke a rescue response from others C. The use of isolation and starvation as suicidal methods D. The use of self-mutilation to decrease endorphins in the body

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder might use suicidal gestures to evoke a rescue response from others. Repetitive, self-mutilative behaviors are common in clients diagnosed with borderline personality disorders. These behaviors are generated by feelings of abandonment following separation from significant others.

21. Which client is a nurse most likely to admit to an inpatient facility for self-destructive behaviors? A. A client diagnosed with antisocial personality disorder B. A client diagnosed with borderline personality disorder C. A client diagnosed with schizoid personality disorder D. A client diagnosed with paranoid personality disorder

ANS: B The nurse should expect that a client diagnosed with borderline personality disorder would be most likely to be admitted to an inpatient facility for self-destructive behaviors. Clients diagnosed with this disorder often exhibit repetitive, self-mutilative behaviors. Most gestures are designed to evoke a rescue response.

7. Which finding would be most likely in a child diagnosed with separation anxiety disorder? A. The child has a history of antisocial behaviors. B. The child's mother is diagnosed with an anxiety disorder. C. The child previously had an extroverted temperament. D. The child's mother and father have an inconsistent parenting style.

ANS: B The nurse should expect to find a mother diagnosed with an anxiety disorder when assessing a child diagnosed with separation anxiety. Some parents instill anxiety in their children by being overprotective or by exaggerating dangers. Research studies speculate that there is a hereditary influence in the development of separation anxiety disorder.

8. A child has been recently diagnosed with mild intellectual disability (ID). What information about this diagnosis should the nurse include when teaching the child's mother? A. Children with mild ID need constant supervision. B. Children with mild ID develop academic skills up to a sixth-grade level. C. Children with mild ID appear different from their peers. D. Children with mild ID have significant sensory-motor impairment.

ANS: B The nurse should inform the child's mother that children with mild ID develop academic skills up to a sixth-grade level. Individuals with mild ID are capable of independent living, capable of developing social skills, and have normal psychomotor skills.

18. A physician orders methylphenidate (Ritalin) for a child diagnosed with attention deficit-hyperactivity disorder (ADHD). Which information about this medication should the nurse provide to the parents? A. If one dose of Ritalin is missed, double the next dose. B. Administer Ritalin to the child after breakfast. C. Administer Ritalin to the child just prior to bedtime. D. A side effect of Ritalin is decreased ability to learn.

ANS: B The nurse should instruct the parents to administer Ritalin to the child after breakfast. Ritalin is a central nervous system stimulant and can cause decreased appetite. Central nervous system stimulants can also temporarily interrupt growth and development.

10. Which nursing intervention should be prioritized when caring for a child diagnosed with intellectual disability? A. Encourage the parents to always prioritize the needs of the child. B. Modify the child's environment to promote independence and encourage impulse control. C. Delay extensive diagnostic studies until the child is developmentally mature. D. Provide one-on-one tutorial education in a private setting to decrease overstimulation.

ANS: B The nurse should prioritize modifying the child's environment to promote independence and encourage impulse control. This intervention is related to the nursing diagnosis self-care deficit. Positive reinforcement can serve to increase self-esteem and encourage repetition of behaviors.

11. A preschool child is admitted to a psychiatric unit with a diagnosis of autism spectrum disorder. To help the child feel more secure on the unit, which intervention should a nurse include in this client's plan of care? A. Encourage and reward peer contact. B. Provide consistent caregivers. C. Provide a variety of safe daily activities. D. Maintain close physical contact throughout the day.

ANS: B The nurse should provide consistent caregivers as part of the plan of care for a child diagnosed with autism spectrum disorder. Children diagnosed with autism spectrum disorder have an inability to trust. Providing consistent caregivers allows the client to develop trust and a sense of security.

14. Which behavioral approach should a nurse utilize when caring for children diagnosed with disruptive behavior disorders? A. Involving parents in designing and implementing the treatment process B. Reinforcing positive actions to encourage repetition of desired behaviors C. Providing opportunities to learn appropriate peer interactions D. Administering psychotropic medications to improve quality of life

ANS: B The nurse should reinforce positive actions to encourage repetition of desired behaviors when caring for children diagnosed with a disruptive behavior disorder. Behavior therapy is based on the concepts of classical conditioning and operant conditioning.

5. A client diagnosed with borderline personality disorder brings up a conflict with the staff in a community meeting and develops a following of clients who unreasonably demand modification of unit rules. How can the nursing staff best handle this situation? A. Allow the clients to apply the democratic process when developing unit rules. B. Maintain consistency of care by open communication to avoid staff manipulation. C. Allow the client spokesperson to verbalize concerns during a unit staff meeting. D. Maintain unit order by the application of autocratic leadership.

ANS: B The nursing staff can best handle this situation by maintaining consistency of care by open communication to avoid staff manipulation. Clients diagnosed with borderline personality disorder can exhibit negative patterns of interaction, such as clinging and distancing, splitting, manipulation, and self-destructive behaviors.

4. A client is brought to an emergency department after being violently raped. Which nursing action is appropriate? A. Discourage the client from discussing the event, as this may lead to further emotional trauma. B. Remain nonjudgmental and actively listen to the clients description of the event. C. Meet the clients self-care needs by assisting with showering and perineal care. D. Provide cues, based on police information, to encourage further description of the event.

ANS: B The most appropriate nursing action is to remain nonjudgmental and actively listen to the clients description of the event. It is important to also communicate to the victim that he or she is safe and that it is not his or her fault. Nonjudgmental listening provides an avenue for client catharsis needed in order to begin the process of healing.

14. An anorexic client states to a nurse, My father has recently moved back to town. Since that time the client has experienced insomnia, nightmares, and panic attacks that occur nightly. She has never married or dated and lives alone. What should the nurse suspect? A. Possible major depressive disorder B. Possible history of childhood incest C. Possible histrionic personality disorder D. Possible history of childhood bulimia

ANS: B The nurse should suspect that this client might have a history of childhood incest. Adult survivors of incest are at risk for developing posttraumatic stress disorder, sexual dysfunction, somatization disorders, compulsive sexual behavior disorders, depression, anxiety, eating disorders, and substance abuse disorders.

7. Which adult client should a nurse identify as exhibiting the characteristics of a dependent personality disorder? A. A physically healthy client who is dependent on meeting social needs by contact with 15 cats B. A physically healthy client who has a history of depending on intense relationships to meet basic needs C. A physically healthy client who lives with parents and relies on public transportation D. A physically healthy client who is serious, inflexible, perfectionistic, and depends on rules to provide security

ANS: C A physically healthy adult client who lives with parents and relies on public transportation exhibits signs of dependent personality disorder. Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior.

24. A child diagnosed with attention deficit-hyperactivity disorder (ADHD) is having difficulty completing homework assignments. What information should the nurse include when teaching the parents about task performance improvement? A. The parents should isolate the child when completing homework to improve focus. B. The parents should withhold privileges if homework is not completed within a 2-hour period. C. The parents should divide the homework task into smaller steps and provide an activity break. D. The parents should administer an extra dose of methylphenidate (Ritalin) prior to homework.

ANS: C By dividing the homework task into smaller steps, the child can remain more focused within a limited about of time. Physical activity can release pent-up energy that would distract from task completion.

12. A preschool child diagnosed with autism spectrum disorder has been engaging in constant head-banging behavior. Which nursing intervention is appropriate? A. Place client in restraints until the aggression subsides. B. Sedate the client with neuroleptic medications. C. Hold client's head steady and apply a helmet. D. Distract the client with a variety of games and puzzles.

ANS: C The most appropriate intervention for head banging is to hold the client's head steady and apply a helmet. The helmet is the least restrictive intervention and will serve to protect the client's head from injury.

3. A client diagnosed with paranoid personality disorder becomes violent on a unit. Which nursing intervention is most appropriate? A. Provide objective evidence that violence is unwarranted. B. Initially restrain the client to maintain safety. C. Use clear, calm statements and a confident physical stance. D. Empathize with the clients paranoid perceptions.

ANS: C The most appropriate nursing intervention is to use clear, calm statements and to assume a confident physical stance. A calm attitude avoids escalating the aggressive behavior and provides the client with a feeling of safety and security. It may also be beneficial to have sufficient staff on hand to present a show of strength.

2. A client diagnosed with antisocial personality disorder comes to a nurses station at 11:00 p.m., requesting to phone a lawyer to discuss filing for a divorce. The unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing reply is most appropriate? A. Go ahead and use the phone. I know this pending divorce is stressful. B. You know better than to break the rules. Im surprised at you. C. It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow. D. The decision to divorce should not be considered until you have had a good nights sleep.

ANS: C The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. Because of the probability of manipulative behavior in this client population, it is imperative to maintain consistent application of rules.

4. In planning care for a child diagnosed with autistic spectrum disorder, which would be a realistic client outcome? A. The client will communicate all needs verbally by discharge. B. The client will participate with peers in a team sport by day 4. C. The client will establish trust with at least one caregiver by day 5. D. The client will perform most self-care tasks independently.

ANS: C The most realistic client outcome for a child diagnosed with autism spectrum disorder is for the client to establish trust with at least one caregiver. Trust should be evidenced by facial responsiveness and eye contact. This outcome relates to the nursing diagnosis impaired social interaction.

4. A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should a nurse associate with this assessment data? A. Compulsive personality disorder B. Schizotypal personality disorder C. Histrionic personality disorder D. Manic personality disorder

ANS: C The nurse should associate histrionic personality disorder with this assessment data. Individuals diagnosed with histrionic personality disorder tend to be self-dramatizing, attention seeking, overly gregarious, and seductive. They often use manipulation and exhibitionism as a means of gaining attention.

20. A mother questions the decreased effectiveness of methylphenidate (Ritalin), prescribed for her child's attention deficit-hyperactivity disorder (ADHD). Which nursing reply best addresses the mother's concern? A. "The physician will probably switch from Ritalin to a central nervous system stimulant." B. "The physician may prescribe an antihistamine with the Ritalin to improve effectiveness." C. "Your child has probably developed a tolerance to Ritalin and may need a higher dosage." D. "Your child has developed sensitivity to Ritalin and may be exhibiting an allergy."

ANS: C The nurse should explain to the mother that the child has probably developed a tolerance to Ritalin and may need a higher dosage. Methylphenidate (Ritalin) is a central nervous system stimulant in which tolerance can develop rapidly. Physical and psychological dependence can also occur.

19. Which reaction to a compliment from another client should a nurse identify as a typical response from a client diagnosed with avoidant personality disorder? A. Interpreting the compliment as a secret code used to increase personal power B. Feeling the compliment was well deserved C. Being grateful for the compliment but fearing later rejection and humiliation D. Wondering what deep meaning and purpose are attached to the compliment

ANS: C The nurse should identify that a client diagnosed with avoidant personality disorder would be grateful for the comment but would fear later rejection and humiliation. Individuals with avoidant personality disorder are extremely sensitive to rejection and are often awkward and uncomfortable in social situations.

18. Looking at a slightly bleeding paper cut, the client screams, Somebody help me, quick! Im bleeding. Call 911! A nurse should identify this behavior as characteristic of which personality disorder? A. Schizoid personality disorder B. Obsessive-compulsive personality disorder C. Histrionic personality disorder D. Paranoid personality disorder

ANS: C The nurse should identify this behavior as characteristic of histrionic personality disorder. Individuals diagnosed with this disorder tend to be self-dramatizing, attention seeking, over-gregarious, and seductive.

20. Which client symptoms should lead a nurse to suspect a diagnosis of obsessive-compulsive personality disorder? A. The client experiences unwanted, intrusive, and persistent thoughts. B. The client experiences unwanted, repetitive behavior patterns. C. The client experiences inflexibility and lack of spontaneity when dealing with others. D. The client experiences obsessive thoughts that are externally imposed.

ANS: C The nurse should suspect a diagnosis of obsessive-compulsive personality disorder when a client experiences inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious and formal and have difficulty expressing emotions. They are perfectionistic and preoccupied with rules.

22. When planning care for clients diagnosed with personality disorders, what should be the anticipated treatment outcome? A. To stabilize pathology with the correct combination of medications B. To change the characteristics of the dysfunctional personality C. To reduce inflexibility of personality traits that interfere with functioning and relationships D. To decrease the prevalence of neurotransmitters at receptor sites

ANS: C The outcome of treatment for clients diagnosed with personality disorders should be to reduce inflexibility of personality traits that interfere with functioning and relationships. Personality disorders are often difficult and, in some cases, seem impossible to treat.

19. Which should be the priority nursing intervention when caring for a child diagnosed with conduct disorder? A. Modify the environment to decrease stimulation and provide opportunities for quiet reflection. B. Convey unconditional acceptance and positive regard. C. Recognize escalating aggressive behaviors and intervene before violence occurs. D. Provide immediate positive feedback for appropriate behaviors.

ANS: C The priority nursing intervention when caring for a child diagnosed with conduct disorder should be to recognize escalating aggressive behaviors and to intervene before violence occurs. This intervention serves to keep the client and others safe. This is the priority nursing concern.

3. Joshua, a 15-year-old whose father has been suffering from PTSD since returning from combat, is now seeing a counselor himself with reports of "flashbacks" that are similar to his father's symptoms. Which of the following interpretations of Joshua's behavior is supported by evidence? A. Military children often pretend to have symptoms of PTSD to get secondary gains. B. This is a common symptom of substance abuse and drug-seeking behavior. C. It is not uncommon for children of parents with PTSD to experience secondary trauma. D. Joshua's experience is indicative of impending psychosis.

ANS: C Children and caregivers of people with PTSD have been identified as at risk for similar PTSD symptoms as a result of secondary trauma.

10. When questioned about bruises, a woman states, It was an accident. My husband just had a bad day at work. Hes being so gentle now and even brought me flowers. Hes going to get a new job, so it wont happen again. This client is in which phase of the cycle of battering? A. Phase I: The tension-building phase B. Phase II: The acute battering incident phase C. Phase III: The honeymoon phase D. Phase IV: The resolution and reorganization phase

ANS: C The client is in the honeymoon phase of the cycle of battering. In this phase, the batterer becomes extremely loving, kind, and contrite. Promises are often made that the abuse will not happen again.

7. A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, The beatings have been getting worse, and Im afraid that next time he might kill me. Which is the appropriate nursing reply? A. Leopards dont change their spots, and neither will he. B. There are things you can do to prevent him from losing control. C. Lets talk about your options so that you dont have to go home. D. Why dont we call the police so that they can confront your husband with his behavior?

ANS: C The most appropriate reply by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions independently without the nurse being the rescuer. Imposing judgments and giving advice is nontherapeutic.

9. A nursing student asks an emergency department nurse, Why does a rapist use a weapon during the act of rape? Which nursing reply is most accurate? A. A weapon is used to increase the victimizers security. B. A weapon is used to inflict physical harm. C. A weapon is used to terrorize and subdue the victim. D. A weapon is used to mirror learned family behavior patterns.

ANS: C The nurse should explain that a rapist uses weapons to terrorize and subdue the victim. Rape is the expression of power and dominance by means of sexual violence. Rape can occur over a broad spectrum of experience, from violent attack to insistence on sexual intercourse by an acquaintance or spouse.

12. A client who has been raped is crying, pacing, and cursing her attacker in an emergency department. Which behavioral defense should a nurse recognize? A. Controlled response pattern B. Compounded rape reaction C. Expressed response pattern D. Silent rape reaction

ANS: C The nurse should recognize that this client is exhibiting an expressed response pattern. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension. In the controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen.

8. Sam, a 50-year-old veteran with a traumatic brain injury (TBI), was recently diagnosed with Alzheimer's disease. His sister asks the nurse, "How can this be an accurate diagnosis? There is no incidence of this in our family." Which of these teaching points is accurate for the nurse to share with Sam's sister? A. Alzheimer's disease doesn't tend to run in families. B. Alzheimer's disease is often misdiagnosed in patients with PTSD. C. Alzheimer's disease is more common in patients with TBI than in the general population. D. Alzheimer's disease in patients with TBI is not like traditional Alzheimer's disease.

ANS: C There is a 2.3 times greater incidence of Alzheimer's disease in patients with TBI than in the general population.

7. The nurse is conducting an assessment for Don, a 5-year veteran with a traumatic brain injury (TBI). He was referred to the clinic for evaluation of movement disorders. He reports taking alprazolam (Xanax) for the last 3 months and wonders if that is contributing to his tremors and shuffling gait. Which of these understandings is most important in guiding the nurse's further assessment and response to Don? A. Alprazolam (Xanax) has a high risk potential for extrapyramidal side effects. B. Don's symptoms are likely related to alprazolam (Xanax) addiction. C. There is an associated risk for Parkinson's disease in patients with TBI. D. Don's symptoms are most likely symptoms of PTSD.

ANS: C There is an association between TBI and the development of Parkinson's disease. Antipsychotic agents rather than antianxiety agents have a higher risk for extrapyramidal symptoms. Although Don's tremors could signal drug withdrawal, the concurrent shuffling gait suggests a movement disturbance. Finally, movement disturbances are not a symptom of PTSD.

5. In the emergency department, a raped client appears calm and exhibits a blunt affect. The client answers a nurses questions in a monotone using single words. How should the nurse interpret this clients responses? A. The client may be lying about the incident. B. The client may be experiencing a silent rape reaction. C. The client may be demonstrating a controlled response pattern. D. The client may be having a compounded rape reaction.

ANS: C This client is most likely demonstrating a controlled response pattern. In a controlled response pattern, the clients feelings are masked or hidden, and a calm, composed, or subdued affect is seen. In the expressed response pattern, feelings of fear, anger, and anxiety are expressed through crying, sobbing, smiling, restlessness, and tension.

1. Susan returned from active duty and is being treated for PTSD. She tells the nurse that she was never in a combat zone during her deployment, and her commanding officer told her that you can't have PTSD unless you were in active combat. Which of these responses by the nurse is an accurate reflection about PTSD in military personnel? A. Women may experience other anxiety disorders but rarely experience PTSD as a result of being in the military. B. PTSD after serving in the military is almost always related to trauma associated with active combat. C. Women in the military more often experience PTSD secondary to sexual assault. D. All of the above.

ANS: C Women are at risk for PTSD as a result of experiences in the military, and it is more often secondary to sexual assault rather than combat trauma. The other distractors are incorrect assumptions.

12. Which nursing diagnosis should a nurse identify as appropriate when working with a client diagnosed with schizoid personality disorder? A. Altered thought processes R/T increased stress B. Risk for suicide R/T loneliness C. Risk for violence: directed toward others R/T paranoid thinking D. Social isolation R/T inability to relate to others

ANS: D An appropriate nursing diagnosis when working with a client diagnosed with schizoid personality disorder is social isolation R/T inability to relate to others. Clients diagnosed with schizoid personality disorder appear cold, aloof, and indifferent to others. They prefer to work in isolation and are unsociable.

25. Which client statement would demonstrate a common characteristic of Cluster B personality disorder? A. I wish someone would make that decision for me. B. I built this building by using materials from outer space. C. Im afraid to go to group because it is crowded with people. D. I didnt have the money for the ring, so I just took it.

ANS: D Antisocial personality disorder is included in the Cluster B personality disorders. In this disorder there is a pervasive pattern of disregard for and violation of the rights of others.

25. A nursing instructor is teaching about pharmacological treatments for attention deficit-hyperactivity disorder (ADHD). Which information about atomoxetine (Strattera) should be included in the lesson plan? A. Strattera, unlike methylphenidate (Ritalin), is a central nervous system depressant. B. When taking Strattera, a client should eliminate all red food coloring from the diet. C. Strattera will be a life-long intervention for clients diagnosed with this disorder. D. Strattera, unlike methylphenidate (Ritalin), is a selective norepinephrine reuptake inhibitor.

ANS: D Strattera is a selective norepinephrine reuptake inhibitor. Ritalin is classified as a stimulant. The exact mechanism by which these drugs produce a therapeutic effect in ADHD is unknown.

14. Which client situation should a nurse identify as reflective of the impulsive behavior that is commonly associated with borderline personality disorder? A. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and whispers, The night nurse is evil. You have to stay. B. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm and states, I will be up all night if you dont stay with me. C. As the day shift nurse leaves the unit, the client suddenly hugs the nurses arm, yelling, Please dont go! I cant sleep without you being here. D. As the day shift nurse leaves the unit, the client suddenly shows the nurse a bloody arm and states, I cut myself because you are leaving me.

ANS: D The clients statement I cut myself because you are leaving me reflects impulsive behavior that is commonly associated with the diagnosis of borderline personality disorder. Repetitive, self-mutilative behaviors are common and are generated by feelings of abandonment following separation from significant others.

10. During an interview, which client statement indicates to a nurse that a potential diagnosis of schizotypal personality disorder should be considered? A. I really dont have a problem. My family is inflexible, and every relative is out to get me. B. I am so excited about working with you. Have you noticed my new nail polish, Ruby Red Roses? C. I spend all my time tending my bees. I know a whole lot of information about bees. D. I am getting a message from the beyond that we have been involved with each other in a previous life.

ANS: D The nurse should assess that a client who states that he or she is getting a message from the beyond indicates a potential diagnosis of schizotypal personality disorder. Individuals with schizotypal personality disorder are aloof and isolated and behave in a bland and apathetic manner. The individual experiences magical thinking, ideas of reference, illusions, and depersonalization as part of daily life.

17. A nurse tells a client that the nursing staff will start alternating weekend shifts. Which response should a nurse identify as characteristic of clients diagnosed with obsessive-compulsive personality disorder? A. You really dont have to go by that schedule. Id just stay home sick. B. There has got to be a hidden agenda behind this schedule change. C. Who do you think you are? I expect to interact with the same nurse every Saturday. D. You cant make these kinds of changes! Isnt there a rule that governs this decision?

ANS: D The nurse should identify that a client diagnosed with obsessive-compulsive personality disorder would have a difficult time accepting change. This disorder is characterized by inflexibility and lack of spontaneity. Individuals diagnosed with this disorder are very serious, formal, over-disciplined, perfectionistic, and preoccupied with rules.

1. Which developmental characteristic should a nurse identify as typical of a client diagnosed with severe intellectual disability? A. The client can perform some self-care activities independently. B. The client has advanced speech development. C. Other than possible coordination problems, the client's psychomotor skills are not affected. D. The client communicates wants and needs by "acting out" behaviors.

ANS: D The nurse should identify that a client diagnosed with severe intellectual disability may communicate wants and needs by "acting out" behaviors. Severe intellectual disability indicates an IQ between 20 and 34. Individuals diagnosed with severe intellectual disability require complete supervision and have minimal verbal skills and poor psychomotor development.

9. A nursing instructor is teaching about the developmental characteristics of clients diagnosed with moderate intellectual disability (ID). Which student statement indicates that further instruction is needed? A. "These clients can work in a sheltered workshop setting." B. "These clients can perform some personal care activities." C. "These clients may have difficulties relating to peers." D. "These clients can successfully complete elementary school."

ANS: D The nursing student needs further instruction about moderate mental retardation because individuals diagnosed with moderate ID are capable of academic skill up to only a second-grade level. Moderate ID reflects an IQ range of 35 to 49.

6. A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, Why doesnt she just leave him? Which is the nursing supervisors most appropriate reply? A. These clients dont know life any other way, and change is not an option until they have improved insight. B. These clients have limited skills and few vocational abilities to be able to make it on their own. C. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation. D. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.

ANS: D The nursing supervisor is accurate when stating that clients in severely abusive relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner for some of the following reasons: for the children, financial reasons, fear of retaliation, lack of a support network, religious reasons, and/or hopelessness.

23. An 8-year-old client diagnosed with attention deficit-hyperactivity disorder (ADHD) was admitted 5 days ago for management of temper tantrums. What would be a priority nursing intervention during the termination phase of the nurse-client relationship? A. Set a contract with the client to limit acting-out behaviors while hospitalized. B. Teach the importance of taking fluoxetine (Prozac) consistently, even when feeling better. C. Discuss behaviors that are and are not acceptable on the unit. D. Ask the client to demonstrate learned coping skills without direction from the nurse.

ANS: D The priority nursing intervention during the termination phase of the nurse-client relationship should include encouraging the client to demonstrate the coping skills learning during the working phase of the nurse-client relationship.

23. The nurse plans to confront a client about secondary gains related to extreme dependency on her spouse. Which nursing statement would be most appropriate? A. Do you believe dependency issues have been a lifelong concern for you? B. Have you noticed any anxiety during times when your husband makes decisions? C. What do you know about individuals who depend on others for direction? D. How have the specifics of your relationship with your spouse benefited you?

ANS: D When a client goes to excessive lengths to obtain nurturance and support from others, the client is seeking secondary gains. Secondary gains provide clients the support and attention that they might not otherwise receive.

5. Carl is being treated for PTSD after return from military combat. He also sustained a mild traumatic brain injury secondary to an explosive device while in combat. The nurse decides to conduct additional screening assessments on the basis of common comorbidities that occur with these conditions. Which of these screening assessments would be relevant? A. CAGE screen for alcohol abuse B. Beck Depression Inventory C. Mini Mental Status Exam D. All of the above

ANS: D Alcohol abuse and depression are common comorbidities with PTSD. Cognitive deficits, including memory problems, may accompany traumatic brain injury, so all three of these screens would be relevant.

9. Brian is seeking treatment for PTSD following his tour of duty in a combat zone. He reports to the assessment nurse that he has been smoking pot and drinking alcohol daily for the past 4 days because he just can't stand feeling depressed all the time. Which of these assessments is the highest priority considering Brian's symptoms? A. Amount of current cannabis use B. Marital status C. Neurological assessment D. Suicide risk assessment

ANS: D Because of a high correlation between PTSD, depression, substance abuse, and risk for suicide, the risk for suicide assessment is the highest priority to establish patient safety.

4. Bill is an only child whose parents are both career military personnel. He is being seen by the school nurse for complaints of fever and wants to be sent home. On examination he is afebrile. He tells the nurse he doesn't like this school anyway and the nurse notes that this is his third school transition in four years. Which of these understandings about the experience of military family members is important to providing compassionate care for this child? A. Military children are more often exposed to unusual viruses, so he should be sent for a complete evaluation and bloodwork. B. Military children are generally healthier than their nonmilitary peers, so he should be given strict consequences for pretending to be ill. C. Children of military personnel are often victims of physical abuse, so he should be asked direct questions about whether or not his parents have been physically aggressive with him. D. Isolation and alienation are common experiences of military family members, so it is important to assess further his adjustment in the current school setting.

ANS: D Isolation and alienation have been identified as a common experience of military family members. This experience may be exacerbated in children by frequent moves and changes in school environments.

11. Which teaching should the nurse in an employee assistance program provide to an employee who exhibits symptoms of domestic physical abuse? A. Have ready access to a gun and learn how to use it B. Research lawyers who can aid in divorce proceedings C. File charges of assault and battery D. Have ready access to the number of a safe house for battered women

ANS: D The nurse should provide information about safe houses for battered women when working with a client who has symptoms of domestic physical abuse. Many women feel powerless within the abusive relationship and may be staying in the abusive relationship out of fear for their lives.

2. A woman describes a history of physical and emotional abuse in intimate relationships. Which additional factor should a nurse suspect? A. The woman may be exhibiting a controlled response pattern. B. The woman may have a history of childhood neglect. C. The woman may be exhibiting codependent characteristics. D. The woman might be a victim of incest.

ANS: D The nurse should suspect that this client might be a victim of incest. Women in abusive relationships often grew up in abusive homes.

As a domestic violence nurse specialist, you are asked to testify in a court case involving intimate partner abuse. The defense attorney asks, "When Mr. and Mrs. Smith came to the emergency room, several people were around, yet Mrs. Smith still did not say that Mr. Smith hit her." Which statement describes the rationale for Mrs. Smith not accusing her husband?

Abuse victims who are accompanied by the person who battered them are not likely to be truthful about the cause of the injuries.

The client has been newly diagnosed with comorbid psychosis. With an understanding of the neurobiology of violence, which of the following classifications of medication will the physician likely prescribe to help control aggression and violence?

Antipsychotics (typical and atypical)

When Beverly told her sister Liz about the repeated episodes of abuse she'd experienced, her sister replied, "If you leave him, how will you be able to pay your bills?" Liz's reply supports which notion?

Battered women may be encouraged by their social network to remain in the abusive relationship.

A student at a local college attended a party with a classmate. After a few alcoholic beverages, she reported he raped her, and she does not remember anything. Which type of rape does this describe?

Date

____________________ refers to a chronic failure by the parent or caretaker to provide the child with the hope, love, and support necessary for the development of a sound, healthy personality

Emotional neglect

Which are behavioral indicators of emotional maltreatment? Select all that apply

Extreme aggression Suicide attempts Inappropriately adult behavior for a chil

Which statement describes the main goal of crisis intervention for sexual assault?

Help survivors return to their previous lifestyle as quickly as possible.

A client and his spouse arrived for the client's follow-up appointment 10 minutes late. The client appeared to be very frustrated and aggravated. The spouse repeatedly asked the client to keep his voice down and apologized to the receptionist when checking in. "I sure hope you figure out what is causing this change in his behavior. He's starting to scare me," said the spouse. Which statements are true regarding possible causes of the change in the client's behavior? Select all that apply.

High plasma concentrations of 5-hydroxyindoleacetic acid (HIAA) Adverse side effect of testosterone therapy Amygdala dysfunction

A child is brought in to the emergency room with physical injuries being reported as an accident. The nurse should consider if the explanation is reasonable, if the injury is consistent with the explanation, and which of the following?

If it is consistent with the child's developmental capabilities

A care plan for the child with ID states that the child "will attempt to interact with others in the presence of trusted caregiver." This is an example of an outcome criterion for which nursing diagnosis?

Mental Health Final

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