Mental Health Quiz

A delusion represents a problem in which of the following areas? A. Memory B. Motivation C. Orientation D. Thinking

D. Thinking A delusion is a fixed false idea or thought. Memory relates to the client's knowledge of past events. Motivation relates to the client's interest in doing things. Orientation relates to the client's perception of reality.

A nurse is assessing a depressed client. What question should be asked if the nurse is concerned about the client's life? A. "Are you thinking about killing yourself?" B. "Have you told anyone else about this?" C. "Do you want to share your feelings in group?" D. "Do I need to call someone for you to talk to about this?"

A. "Are you thinking about killing yourself?" The nurse must determine whether the depressed or hopeless client has suicidal ideation or a lethal plan. The nurse does so by asking the client directly. Calling someone else does not address this situation. Asking if the client has told anyone else does not matter in this situation. This is not likely something that would be shared in group until coping mechanism are in place.

Which of the following would indicate a duty to warn to a third party? A. A client states, "If I can't have my girlfriend back, then no one can have her." B. A hostile client says, "I hate all police." C. A client with delusions states, "I'm going to get them before they get me." D. A client says he plans to blow up the federal building.

A. A client states, "If I can't have my girlfriend back, then no one can have her."

Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply. A. Activities B. Occupation C. Hobbies D. Race E. Ethnicity F. Family

A. Activities B. Occupation C. Hobbies F. Family The number and type of roles may vary, but they usually include family, occupation, and hobbies or activities.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder disorder. Prior to administration of lithium carbonate, the client's blood lithium level 1.2meq/L. Which of the following actions should the nurse take? A. Administer the next dose of lithium carbonate as scheduled. B. Notify the provider for a possible increase in the dosage of lithium carbonate. C. Request a stat repeat of the client's lithium blood level. D. Prepare for administration of aminophylline.

A. Administer the next dose of lithium carbonate as scheduled.

A nurse is teaching on the effects of antipsychotic medications to the client and family.Which of the following disorders are extrapyramidal symptoms that may be caused by antipsychotic drugs? Select all that apply. A. Akathisia. B. Pseudoparkinsonism. C. Dystonia. D. Neuroleptic malignant syndrome.

A. Akathisia. B. Pseudoparkinsonism. C. Dystonia.

A client is admitted for major depression. The client has stated that nothing seems to bring him pleasure anymore. What should the nurse expect to find during assessment? A. Anhedonia, feelings of worthlessness, and difficulty focusing B. Changes in sleep pattern, fatigue, and grandiose mood C. Difficulty focusing, feelings of helplessness, and flight of ideas D. Depressed mood, guilt, and pressured speech

A. Anhedonia, feelings of worthlessness, and difficulty focusing Symptoms of major depressive disorder include depressed mood; anhedonia (decreased attention to and enjoyment from previously pleasurable activities); unintentional weight change of 5% or more in a month; change in sleep pattern; agitation or psychomotor retardation; constant fatigue; worthlessness or guilt inappropriate to the situation (possibly delusional); difficulty thinking, focusing, or making decisions; hopelessness, helplessness, and/or suicidal ideation. Grandiose mood, pressured speech, and flight of ideas are associated with mania.

During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling him to do anything harmful. The nurse documents that the client is experiencing which of the following? A. Auditory hallucinations B. Gustatory hallucinations C. Olfactory hallucinations D. Command hallucinations

A. Auditory hallucinations Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Olfactory hallucinations involve smells or odors. Gustatory hallucinations involve a taste lingering in the mouth or the sense that food tastes like something else.

Which statements are important reasons for why the problem of substance abuse must be addressed? Select all that apply. A. Chemical abuse results in increased violence. B. Alcohol abuse costs business and industry an estimated $223 billion annually. C. Alcohol abuse is a too frequent cause of or contributor to death. D. Substance abuse is decreasing. E. Increasing numbers of infants are suffering the physiologic and emotional consequences of prenatal exposure to alcohol or drugs.

A. Chemical abuse results in increased violence. B. Alcohol abuse costs business and industry an estimated $223 billion annually. C. Alcohol abuse is a too frequent cause of or contributor to death. E. Increasing numbers of infants are suffering the physiologic and emotional consequences of prenatal exposure to alcohol or drugs. Increasing numbers of infants are suffering the physiologic and emotional consequences of prenatal exposure to alcohol or drugs. Chemical abuse results in increased violence. Drug abuse costs business and industry an estimated $102 billion annually. Alcohol abuse is a too frequent cause of or contributor to death. Substance use/abuse and related disorders are a national health problem.

The client has been diagnosed with depression. He asks the nurse what imbalances influence depression. Which of the following best explains the neurochemical processes responsible for depression? A. Decreased serotonin and norepinephrine activity B. Increased activity of dopamine C. Decreased glucocorticoid activity D. Potentiating of the kindling process

A. Decreased serotonin and norepinephrine activity Deficits of serotonin, its precursor tryptophan, or a metabolite (5-hydroxyindole acetic acid, or 5-HIAA) of serotonin found in the blood or cerebrospinal fluid occur in people with depression. Norepinephrine levels may be deficient in depression and increased in mania. Elevated glucocorticoid activity is associated with the stress response, and evidence of increased cortisol secretion is apparent in about 40% of clients with depression. Kindling is the process by which seizure activity in a specific area of the brain is initially stimulated.

A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." The nurse knows the client is exhibiting which of the following? A. Delusion B. Loose associations C. Flight of ideas D. Thought broadcasting

A. Delusion The client has a delusion (a fixed false belief not based in reality) about his superiority over others. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Thought broadcasting is a delusional belief that others can hear or know what the client is thinking. Loose associations are disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts.

A client comes into a psychiatric office dressed in a bright pink dress, spiked heels, long red nails, theatrical hair and make up. The client speaks in a loud voice and expresses a wide range of emotional states. Which diagnosis should a nurse expect for this client? A. Histrionic personality disorder. B. Shizotypal personality disorder. C. Paranoid personality disorder. D. Obsessive compulsive personality disorder.

A. Histrionic personality disorder

In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as... A. Labile mood. B. Tangential thinking. C. Lack of insight. D. Flight of ideas.

A. Labile mood. Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight of ideas is manifested by excessive amount and rate of speech composed of fragmented or unrelated ideas. Lack of insight would be manifested by the lack of the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Tangential thinking would be manifested by wandering off the topic and never providing the information requested.

When working with a patient with a narcissistic personality disorder, the nurse would use which of the following approaches? A. Matter of fact. B. Cheerful. C. Friendly. D. Supportive.

A. Matter of fact.

For a client taking clozapine, which of the following symptoms should the nurse report to the physician immediately as it may be indicative of a potentially fatal side effect? A. Sore throat and malaise B. Mild rash C. Inability to stand still for 1 minute D. Photosensitivity reaction

A. Sore throat and malaise Clozapine produces fewer traditional side effects than do most antipsychotic drugs, but it has the potentially fatal side effect of agranulocytosis. This develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. This side effect may not be manifested immediately and can occur up to 24 weeks after the initiation of therapy. Any symptoms of infection must be investigated immediately. Agranulocytosis is characterized by fever, malaise, ulcerative sore throat, and leukopenia. Mild rash and photosensitivity reaction are not serious side effects.

The client is talking to staff members individually and attempting to manipulate them. Which of the following are important in the limit-setting technique to deal with manipulative behavior? Select all that apply. A. Stating the behavioral limit B. Identifying the consequences if the limit is exceeded C. Providing choices D. Allowing flexibility E. Identifying the expected or desired behavior

A. Stating the behavioral limit B. Identifying the consequences if the limit is exceeded E. Identifying the expected or desired behavior Limit setting is an effective technique that involves three steps: 1. Stating the behavioral limit (describing the unacceptable behavior) 2. Identifying the consequences if the limit is exceeded 3. Identifying the expected or desired behavior Providing choices and allowing flexibility would be counterproductive as the expectations must be consistent.

A concerned family member tells the nurse, "I am concerned about my brother. He has been acting very different lately." Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the brother has bipolar disorder? A. Taking unnecessary risks B. Sleeping more C. Intense focus D. Showing low self-esteem

A. Taking unnecessary risks The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments.

A client reports drinking one to two drinks when drinking behavior first began. Now the client reports drinking at least six drinks with every episode in order to "have a good time." Which term would best describe this phenomenon? A. Tolerance B. Withdrawal C. Intoxication D. Dependence

A. Tolerance As the person continues to drink, he or she often develops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect. Intoxication is use of a substance that results in maladaptive behavior. Withdrawal syndrome refers to the negative psychological and physical reactions that occur when use of a substance ceases or dramatically decreases. Substance dependence also includes problems associated with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance.

A client who is depressed states, "I think my family would be better off without me. They don't need to worry." Which would be the most appropriate response by the nurse? A. "Where are you going?" B. "Are you planning to commit suicide?" C. "You don't mean that. Your family loves you." D. "What do you think they are worried about?"

B. "Are you planning to commit suicide?" The nurse never ignores any hint of suicidal ideation regardless of how trivial or subtle it seems and the client's intent or emotional status. Asking clients directly about thoughts of suicide is important.

A client with schizophrenia is seen sitting alone and talking out loud. Suddenly, the client stops and turns as if listening to someone. The nurse approaches and sits down beside the client. Which of the following is the best initial response by the nurse? A. "I can tell you are hearing voices, but they are not real." B. "I don't hear or see anyone else; what are you hearing and seeing?" C. "How long have you known the person you are talking to?" D. "You must be pretty bored to be sitting here talking to an invisible person."

B. "I don't hear or see anyone else; what are you hearing and seeing?" Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client's response toward reality. Initially, the nurse must determine what the client is experiencing—that is, what the voices are saying or what the client is seeing. In command hallucinations, the client hears voices directing him or her to do something, often to hurt self or someone else. For this reason, the nurse must elicit a description of the content of the hallucination so that health-care personnel can take precautions to protect the client and others as necessary. The nurse might say, "I don't hear any voices; what are you hearing?" "How long have you known the person you are talking to?" would reinforce the client's hallucination.

A nurse can best assess a client's ability to use abstract thinking by asking the client which of the following questions? A. "What are you going to do next time you hear voices?" B. "What do I mean when I say, 'Don't sweat the small stuff?'" C. "What would you do if you found a wallet containing $100 on the sidewalk?" D. "Can you begin with the number 100 and subtract 7, and then subtract 7 again?"

B. "What do I mean when I say, 'Don't sweat the small stuff?'" The nurse assesses the client's ability to use abstract thinking, which is to make associations or interpretations about a situation or comment. The nurse usually can do so by asking the client to interpret a common proverb. If the client can explain the proverb correctly, his or her abstract thinking abilities are intact. Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as "serial sevens."

A client is being evaluated for dementia. The nurse knows that a client who is able to complete very few tasks is most likely to have... A. No bearing on mental status B. A greater cognitive deficit C. More potential for agitation D. A less precise mental status exam

B. A greater cognitive deficit The fewer tasks the client competes accurately, the greater the cognitive deficit. The other choices are not true.

A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm? A. On the anniversary of significant life events in the client's life B. Approximately 2 weeks after starting antidepressant medication C. During the first few days after admission D. Immediately after a family visit

B. Approximately 2 weeks after starting antidepressant medication Observe the client closely for suicide potential, especially after antidepressant medication begins to raise the client's mood. Risk for suicide increases as the client's energy level is increased by medication. The other choices are not significantly associated with increased risk for suicide.

When is a nurse legally obligated to breach confidentiality? A. Whenever the client becomes aggressive B. If threats are made to an identifiable third party C. At any time a client is threatening D. When the client violates the nurse's boundaries

B. If threats are made to an identifiable third party The duty to warn a third party exists when a client threatens harm to that identifiable third party; the client's confidentiality is overridden. The other choices are not representative of situations in which confidentiality may be breached. Decisions about the duty to warn third parties usually are made by psychiatrists or by qualified mental health therapists in outpatient settings. It is not permissible for a nurse to breach confidentiality at any time a client is threatening, or becomes aggressive or violates the nurse's boundaries.

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder.The nurse should include which of the following manifestations in the teaching? (Select all that apply) A. Tinnitus. B. Muscle weakness. C. Polyuria. D. Constipation.

B. Muscle weakness C. Polyuria

During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about which of the following? A. Personal needs. B. Perception of the problem. C. Communication skills. D. Admitting diagnosis.

B. Perception of the problem. The question will elicit information about the client's view or perspective of the problem.

The client tells the nurse that she takes a drink every morning to calm her nerves and stop her tremors. The nurse realizes the client is at risk for: A. Psychological addiction. B. Physical dependence. C. A neurologic disorder. D. An anxiety disorder.

B. Physical dependence.

Of the following personality disorders, which are most likely related to lack of caring about others? Select all that apply. A. Obsessive-compulsive personality disorder B. Schizotypal personality disorder C. Antisocial personality disorder D. Narcissistic personality disorder E. Borderline personality disorder

B. Schizotypal personality disorder C. Antisocial personality disorder D. Narcissistic personality disorder Schizotypal personality disorder is characterized by a pervasive pattern of social and interpersonal deficits, marked by acute discomfort with and reduced capacity for close relationships, as well as by cognitive or perceptual distortions and behavioral eccentricities. Borderline personality disorder is characterized by a pervasive pattern of unstable interpersonal relationships, self-image, and affect as well as marked impulsivity. Antisocial personality disorder is characterized by a pervasive pattern of disregard for, and violation of the rights of, others—and with the central characteristics of deceit and manipulation. Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy. Obsessive-compulsive personality disorder is characterized by a pervasive pattern of preoccupation with perfectionism, mental and interpersonal control, and orderliness at the expense of flexibility, openness, and efficiency.

The nurse notices the client with a shuffling gait walking in the hall. Which of the following would not be included as a symptom of drug-induced parkinsonism? A. Cogwheel rigidity B. Tachycardia C. Stooped posture D. Drooling

B. Tachycardia Bradycardia (not tachycardia), a stooped posture, cogwheel rigidity, and drooling are all symptoms of pseudoparkinsonism. Other symptoms of pseudoparkinsonism include mask-like facies, decreased arm swing, a shuffling, festinating gait, tremor, and coarse pill-rolling movements of the thumb and fingers while at rest.

The student nurse correctly recognizes that which one of the following findings is best supported by genetic studies in the etiology of schizophrenia? A. If a person has schizophrenia, distant relatives are also at risk. B. That schizophrenia is at least partially inherited. C. That there is a weak correlation between genetics and schizophrenia. D. That there is no relationship at all between schizophrenia and genetics.

B. That schizophrenia is at least partially inherited. The most important studies have centered on twins; these findings have demonstrated that if one identical twin has schizophrenia, the other twin has a 50% chance of developing it as well. Fraternal twins have only a 15% risk. This finding indicates that schizophrenia is at least partially inherited.

A nurse is preparing to interview a hostile client. Which location would the nurse avoid during this encounter? A. The common day room. B. The client's room with the door closed. C. The common dining room. D. A designated interview room with the door open.

B. The client's room with the door closed.

When assessing a client's mental health status, which of the following describes the purpose of the psychosocial assessment? Select all that apply. A. To assess the client's plan of care B. To assess the client's behavioral function C. To assess the client's current emotional state D. To assess the client's physical health status E. To assess the client's mental capacity

B. To assess the client's behavioral function C. To assess the client's current emotional state E. To assess the client's mental capacity The purpose of the psychosocial assessment is to construct a picture of the client's current emotional state, mental capacity, and behavioral function. This assessment serves as the basis for developing a plan of care to meet the client's needs. The client's physical health status would need to be completed as another assessment or an extended assessment.

Which of the following is an example of an open ended question? A. What is your address? B. What concerns you most about your health? C. Have you lost any weight recently? D. Who is the current president of the United States?

B. What concerns you most about your health?

One evening, a client with schizophrenia leaves his room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which of the following responses would be best? A. "This guarding responsibility can make you tired. You rest for now, and I'll guard a while." B. "You are just imagining these things. Do not pay any attention to the voices." C. "I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice." D. "The voices are part of your illness, and they will leave in time."

C. "I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice." Acknowledging that the client hears a voice validates that the client's experience is real to him, while presenting reality. "The voices are part of your illness, and they will leave in time," is not appropriate to the client's statement. "This guarding responsibility can make you tired. You rest for now, and I'll guard a while," reinforces the client's delusion. "'You are just imagining these things. Do not pay any attention to the voices," does not deal with the patient in a serious manner.

Which statement by a client would indicate the need for additional education regarding a prescribed lithium treatment regimen? A. "I will drink 8 to 12 glasses of liquids daily." B. "I will take my medications with food." C. "I will restrict my intake of processed foods high in sodium." D. "I will have my blood drawn on schedule."

C. "I will restrict my intake of processed foods high in sodium." Clients taking lithium must maintain a normal sodium intake or risk symptoms of lithium toxicity. The client should have 2 to 3 liters of fluid daily. Taking lithium with food minimizes gastrointestinal side effects. Regular monitoring of lithium levels is important to prevent toxicity.

Which of the following questions is best to ask when assessing the client's judgment? A. "Can you describe your usual daily activities for me?" B. "On a scale of 1 to 10, how stressed would you rate yourself?" C. "If you found yourself downtown without money or a car, how would you get home?" D. "What problem would you like to work on while you're hospitalized?"

C. "If you found yourself downtown without money or a car, how would you get home?" Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's own behavior and decisions accordingly. This question will elicit information about the client's problem-solving and decision-making abilities. The other choices do not assess the concept of judgment.

The nurse asks a patient to list the days of the week in reverse order. The nurse is assessing which of the following? A. Abstract thinking B. Orientation C. Concentration D. Memory

C. Concentration The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as repeating the days of the week backward. The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. Orientation refers to the client's recognition of person, place, and time. Abstract thinking is to making associations or interpretations about a situation or comment.

A clients showing no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the client's affect? A. Blunt affect B. Restricted affect C. Flat affect D. Broad affect

C. Flat affect Common terms used in assessing affect include blunted affect: showing little or a slow-to-respond facial expression; broad affect: displaying a full range of emotional expressions; flat affect: showing no facial expression; inappropriate affect: displaying a facial expression that is incongruent with mood or situation, often silly or giddy regardless of circumstances; restricted affect: displaying one type of expression, usually serious or somber.

Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide? A. It allows the nurse to gain valuable experience in these kind of difficult discussions. B. It is required by law by the federal government and by most states in the U.S. C. It is the nurse's professional responsibility to keep safety needs first and foremost. D. This is commonly required documentation for every encounter with every client.

C. It is the nurse's professional responsibility to keep safety needs first and foremost. It is the nurse's professional responsibility to keep the client's safety needs first and foremost, and this includes overcoming any personal discomfort in talking about suicide. This is not required by any laws nor is it commonly required documentation for every encounter with every client. The nurse needs to gain experience in these kind of difficult discussions, but that is not a compelling reason for the nurse to discuss it if not warranted.

The client suffer from Bi-Polar disorder. The client is experiencing a downward spiral. For which one of the following drugs should the nurse expect the client to require serum level monitoring? A. Anticonvulsants B. Wellbutrin C. Lithium D. Prozac

C. Lithium Toxicity is closely related to serum lithium levels and can occur at therapeutic doses. For clients taking lithium and the anticonvulsants, monitoring blood levels periodically is important.

All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client? A. Maintain reality through frequent contact. B. Assess community support systems. C. Observe for signs of fear or agitation.

C. Observe for signs of fear or agitation.

The nurse is assessing a client's risk factors for developing a substance abuse disorder. Which family characteristics would the nurse identify as a significant risk factor? A. Parents who practiced strict discipline B. Overprotective parents C. One parent who is an alcoholic D. Being raised in an urban area

C. One parent who is an alcoholic The strongest indication of risk factors comes from studies that indicate children of alcoholic parents are four times as likely to develop alcoholism that of nonalcoholic parents. Some theorists also believe that inconsistency in the parent's behavior, poor role modeling, and lack of nurturing pave the way for the child to adopt a similar style of maladaptive coping, stormy relationships, and substance abuse. Others hypothesize that even children who abhorred their family lives are likely to abuse substances as adults because they lack adaptive coping skills and cannot form successful relationships. Urban areas where drugs and alcohol are readily available also have high crime rates, high unemployment, and substandard school systems that contribute to high rates of cocaine and opioid use and low rates of recovery.

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse's priority? A. Encouraging the client to participate in counseling. B. Assisting the client to perform ADL's. C. Placing the client on one to one observation. D. Teaching the client about adverse effects.

C. Placing the client on one to one observation.

A nurse observes that a client is psychotic, pacing and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to: A. Offer the client a less stimulating area to calm down and gain control. B. Medicate the client with an anxiolytic medication. C. Provide safety for the client and the other clients of the unit. D. Provide the clients on the unit with a sense of comfort and safety. E. Assist the staff in caring for the client in a controlled environment.

C. Provide safety for the client and the other clients of the unit.

A client who is depressed and suicidal is scheduled for electroconvulsive therapy (ECT), which requires consent. After the physician has explained the procedure, the nurse knows that legally, who should sign the consent for this treatment? A. The client's spouse B. A member of the treatment team C. The client D. The psychiatrist

C. The client The client has the right to sign (or refuse to sign) the consent. The other parties listed do not have the legal right to sign for the client unless they are the client's legal guardian.

A client is being discharged from treatment for addiction to cocaine. Which statement made by the client would cause the most concern for the nurse? A. "I am going to take up a new hobby. It's time to start something new." B. "I'm not very comfortable with being alone yet." C. "Shooting baskets helps me not think about getting high." D. "I can still hang out with my old friends. I am just not going to use."

D. "I can still hang out with my old friends. I am just not going to use." Clients are likely to have exercised poor judgment. They may still believe they can control the substance use. The nurse can help clients to find ways to relieve stress or anxiety that do not involve substance use. Relaxing, exercising, listening to music, or engaging in activities may be effective. Clients also may need to develop new social activities or leisure pursuits if most of their friends or habits of socializing involved the use of substances. Acknowledging difficulties shows insight into the changes needed for recovery. Assuming that old friends will not be a relapse trigger shows a lack of understanding of the relapse dynamics associated with former leisure activities.

The nurse best assesses a client's memory by asking which of the following questions? A. "What did you have for lunch yesterday?" B. "Do you know where you are?" C. "Do you have any problems with memory?" D. "Who is the current president?"

D. "Who is the current president?" The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers such as "What is the name of the current president?" The nurse may not be able to verify the accuracy of the client's responses to questions such as "Do you have any memory problems?" or "What did you do yesterday?" Orientation refers to the client's recognition of person, place, and time

One week after beginning therapy with thiothixene, the client demonstrates muscle rigidity, a temperature of 103°F, an elevated serum creatinine phosphokinase level, stupor, and incontinence. The nurse should notify the physician because these symptoms are indicative of... A. Extrapyramidal side effects. B. Acute dystonic reaction. C. Tardive dyskinesia. D. Neuroleptic malignant syndrome.

D. Neuroleptic malignant syndrome. The client demonstrates all the classic signs of neuroleptic malignant syndrome. Dystonia involves acute muscular rigidity and cramping, a stiff or thick tongue with difficulty swallowing, and, in severe cases, laryngospasm and respiratory difficulties. Extrapyramidal side effects are reversible movement disorders induced by antipsychotic or neuroleptic medication. Tardive dyskinesia is a late-onset, irreversible neurologic side effect of antipsychotic medications characterized by abnormal, involuntary movements, such as blinking, chewing, and grimacing.

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has the highest priority? A. Ineffective coping related to inadequate stress management B. Hopelessness related to recent divorce C. Spiritual distress related to conflicting thoughts about suicide and sin D. Risk for suicide related to a highly lethal plan

D. Risk for suicide related to a highly lethal plan Safety is the priority. The overall goal for the client who is suicidal is first to keep the client safe, and later to help him or her to develop new coping skills that do not involve self-harm. The other choices would not be the highest priority diagnosis for this client.

A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within how much time after cessation or reduction of alcohol intake? A. In 2 hours. B. In 7 days. C. In 14 days. D. In 21 days. E. In 2 days.

E. In 2 days ***Early signs of alcohol withdrawal typically appear within 4-12 hours after cessation***