MH Psychiatric HESI RN EXAM & Case Study

Which action should the nurse implement during the termination phase of the nurse-client relationship?

Help summarize accomplishments. Rationale By noting the client's accomplishments, the client's progress and self-confidence can be summarized. The other phases of the nurse-client relationship focus on assessment, problem identification, confronting necessary changes.

The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing problem?

High risk for fluid and electrolyte imbalance. Rationale Maintaining physiological stability by first addressing basic physiological needs is the priority. A client who is in a catatonic or stuporous state is at risk for malnutrition and dehydration. Fluid and electrolyte imbalance is the priority nursing problem for this client at this time. The other problems are not life-threatening.

A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. Which defense mechanism is the client using?

Identification. Identification is an attempt to be like someone or emulate the personality traits of another. The client is not demonstrating the other psychosocial mechanisms.

The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?

Increased self-understanding. Middle adulthood is characterized by self-reflection, understanding, acceptance, and generativity or guidance of children. The other developmental tasks are not specific to middle adulthood.

On admission to a residential care facility, an older female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. Which activity should the nurse encourage the client to become involved and participate?

Participate in a group quilting project. Peer interaction in a group activity that is identified by the client has a hobby or diversion helps to engage the client with others, which prevents social isolation and withdrawal. The other activities do not involve peer interaction and may promote social isolation.

What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable?

Reflect the client's behavior and its consequences. Rationale A client who is psychotic is unable to visualizing the consequences of proposed goals. The use of reflection about the client's behavior and its consequences is a therapeutic response. The other responses halt therapeutic communication.

A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?

Results show activity in various portions of the brain. Rationale The result of a PET scan, which is used to detect cerebral activity in depression, schizophrenia, and Alzheimer's disease, shows brightly colored cerebral areas where an accumulation of a radioactively tagged glucose is used as a tracer to visualize brain activity, blood flow, and glucose metabolism.

Which client outcome during hospitalization indicates improvement for a client who is admitted with auditory hallucinations?

Tells when voices decrease. Rationale Hallucinations are defined as false sensory perceptions. The goal of nursing interventions with clients who are hallucinating is to help them to increase awareness of symptoms and distinguish between the world of psychosis and reality. The client outcome that shows improvement is the client can tell when the voices decrease. The other client behaviors do not indicate improvement towards a client outcome.

A client is pacing in the hall near the nurses' station and swearing loudly. What response is best for the nurse to provide?

You seem pretty upset. Tell me about it. Rationale A client who is distressed and acting out angrily should be assessed for additional information about what may be causing a change in the client's behavior. Therapeutic responses to disruptive behavior or language should begin with the nurse's reflective interpretation of the client's distress, and followed with an open-ended statement. The other responses are not client-centered.

The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?

"Black-out" after one drink last night on a date. A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a "black-out" after one drink is suspicious of the client receiving a "date rape" drug, such as flunitrazepam ("Rohypnol"), and needs additional follow-up. The other findings do not need follow-up at this time.

A client who reports feeling depressed tells the nurse on admitted, "I want to feel normal again." How should the nurse respond?

"Tell me more about how things are with you." Rationale When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings.

A male client is brought to the emergency department by a police officer, who reports the client was "disturbing the peace" by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that apply.) -Threats to kill his friend. -Disruptive behaviors in a community setting. -Hears voices telling him to kill himself. -Reports he has not needed a bath in 4 months. -Created extensive private property damage. -Says he has not eaten in 3 days.

-Threats to kill his friend -hears voices telling him to kill himself -reports he has not needed a bath in 4 months -says he has not eaten in 3 days. Rationale Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. Police officers and healthcare providers may be designated by statute to authorize the detention of persons who are a danger to themselves or others or who are unable to provide for their own basic needs due to mental illness. The other behaviors are civil issues, not factors related to involuntary commitment.

The nurse observes a female client with schizophrenia watching the news on television. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make?

What do you believe the news commentator said to you? It is imperative that the nurse determine what the client believes she heard. The idea of reference may be to hurt herself or someone else, and the main function of the psychiatric nurse is to maintain safety. The other responses are not the priority.

Which client should the nurse identify as the highest risk for the onset of stress-related problems?

A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." Rationale A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness is at the highest risk for a stress-related health problem. The other persons are coping with change using healthy strategies.

An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?

Administer acetylcysteine (Mucocyst). Rationale Tylenol overdose is treated with immediate administration of Mucomyst to prevent hepatic insult. The other actions are not indicated.

An adult female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. Which condition is this client likely manifesting?

Agoraphobia. Agoraphobia is the fear of crowds or being in an open place. The other anxiety and phobic conditions are not manifested by a fear of leaving a protected environment, such as home.

Over a period of several weeks, a male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

Allow the group to handle the problem. The phase the group process is in--initial, working, or termination--this will help determine communication styles between the group members. After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to address the situation.

Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?

Allow time for the ritualistic behavior, then redirect the client to other activities. Initially, the nurse should allow time for the ritual to prevent anxiety. The other actions may help reduce the client's anxiety, but do not address the ritualistic behavior associated with anxiety and ineffective coping ability.

An older female client reports to the nurse that recently she has been hearing voices. Which question should the nurse ask this client first?

Are you ever alone when you hear the voices? Determining if the client is alone when hearing voices will assist in differentiating between hallucinations and hearing loss, which is common in the aging population. Other follow-up questions should then be asked to further validate if the client is experiencing auditory hallucinations.

At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first? Ask a group member to seek help. Obtain the client's blood pressure. Position in a recovery position. Assess the client's level of orientation.

Ask a group member to seek help. Rationale First, help should be obtained while the nurse remains with the client. Next, assessment of the client should be completed. Lastly, the client should be positioned to prevent aspiration while recovering.

A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse? -Collect a specimen for a blood alcohol level (BAL). -Do nothing because the time for BAL determination is passed. -Review the results of a Breathalyzer obtained in the emergency department upon admission. -Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.

Ask the client about the quantity, frequency, and time the last alcohol drink was ingested. Rationale The priority assessment is to determine the client's risk for alcohol withdrawal, which can appear within 48 hours since the ingestion of the last alcoholic drink. The nurse should ask the client about quantity, frequency, and time of last drink. The other actions are not indicated at this time.

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? -Ready the client for discharge. -Notify pastoral care to offer the client a blessing. -Ask the client what name she had picked out for the infant. -Inquire if the client would like to see what was obtained from her D&C.

Ask the client what name she had picked out for the infant. Rationale: The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name provides an opportunity to offer support. The other actions are not indicated.

A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth?

Ask the family if they would like to see and hold the infant after birth. Rationale Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. Research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given this opportunity initially after birth. The other actions should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant.

The nurse is planning the care for an adult client with acute depression. Which intervention should the nurse implement to help the client deal with depression?

Assist the client in exploring feelings of shame, anger, and guilt. Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings with the client is an important nursing intervention for a client who is acutely depressed. The other interventions are not indicated.

A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time?

Begin one-on-one supervision immediately. Rationale One-on-one supervision ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Although the other actions may be indicated, they do not provide immediate assessment of the client's ongoing safety.

The community health nurse facilitates a substance abuse prevention group for a homeless population. Which statement demonstrates that a client has a realistic understanding of the recovery process?

By learning what led to my latest relapse, I know what to do in the future. Rationale Recovery is a lifelong process in which clients must constantly learn and apply new behaviors to replace ineffective ones. Long-term recovery improves when a client acquires new coping skills that are successful, so those who learn from their relapses and triggers demonstrate an understanding of the process. The other statements do not necessarily indicate a client who is addicted will maintain recovery.

A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take?

Calmly address the client's inappropriate behavior. Calmly addressing inappropriate behavior minimizes escalation of the issue, specifically that the behavior is unacceptable. The other approaches are not indicated.

The daughter of an older male client tells the nurse that her father is becoming increasingly forgetful. Which finding indicates that the client needs further evaluation of cognitive function?

Cannot mentally retrace objects that were recently misplaced. Rationale Inability to retrace misplaced objects is an indicator of possible cognitive impairment that requires further assessment.

At a support meeting for parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information?

Careful monitoring should be provided during withdrawal from the drugs. The priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide. The other responses are not indicated.

The client with depression asks the nurse, " What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain." What information should the nurse use to support an explanation of neurotransmitters?

Chemical messengers that cause brain cells to turn on or off. Rationale Neurotransmitters are chemicals manufactured in the brain that are responsible for exciting or inhibiting brain cells to produce an action. The other explanations address functions of neural structures and specific areas of the brain.

A client with substance abuse is admitted to the mental health unit. Which action should be implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)?

Collect a complete substance abuse history. Rationale As part of a comprehensive assessment, the nurse should assess the client for past and present alcohol, tobacco, prescription drug, over-the-counter drug, and illicit drug use. The nurse can delegate the other basic skills to the UAP.

An adult female client has been increasingly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make?

Come with me to your room and I will sit with you. The best response offers support without judgment or demands. The other responses are not therapeutic communication for a client who is hallucinating or experiencing a delusion, which are perceive by this client as a crisis.

The nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client?

Coping Skills Rationale Ineffective coping skills are characteristic of depression, and based on this client's symptoms, group therapy that focuses on coping skills is likely to be most beneficial. The other groups processes are less likely to be beneficial.

A client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which healthcare team member?

Dietician. Rationale The nurse should ask for a referral to the dietician who can assist the client with meal planning for weight reduction. The other members of the healthcare team do not give guidance about meal planning.

The nurse is assessing a client with a history of borderline personality disorder. Which question should the nurse include in the assessment?

Do you frequently have temper tantrums? Rationale A client with borderline personality disorder often has a history of intense outbursts of anger. The other questions may provide worthwhile information, but do not provide specific information about the client's symptomatology of borderline personality disorder.

A nurse is teaching about women's health with a female client who is in a homosexual relationship. Which topic is the most important for the nurse to address?

Domestic violence interventions. Rationale Since all women, regardless of sexual orientation, are at risk for domestic violence that can be potentially lethal, this is the most important topic for the nurse to address and is a policy that should be included in the nursing interview.

A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain?

Drugs taken in last 7 days. Rationale Use of prescribed, over-the-counter, and illicit drugs are the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations.

A client is responding to auditory hallucinations and shakes a fist at a nurse and says, "Back off, witch!" The nurse follows the client to the unit's day room. What action should the nurse implement?

Ensure that there is physical space between the nurse and client. Rationale Personal space should increase when a client feels anxious and threatened. An adequate social space (4 to 12 feet) between the nurse and the client should be maintained to minimize the client's escalation and physical contact with the nurse.

A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement?

Escort the client to a quieter place Rationale A client in the manic phase has an inflated ego, feelings of grandiosity, and is unlikely to respond to limit-setting. To curtail further escalation and disruption, the client should be escorted to a less stimulating environment. The other actions are not indicated and are ineffective for a client in the manic phase who often is unable to control their behavior.

Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit? Establish rapport in each phase of the nurse-client relationship. Determine the client's ability to communicate effectively. Reflect on previous psychiatric interviews the nurse has performed. Ensure data is collected and recorded in a systematic sequence.

Establish rapport in each phase of the nurse-client relationship. Rationale A client with whom the nurse establishes rapport during the initial interview and in each phase of the nurse-client relationship feels understood by the nurse and is more likely to cooperate and provide feedback during the admission process. The other actions not always needed to establish rapport or maintain the therapeutic self in a therapeutic relationship.

A school-aged girl with severe birth defects and mental retardation is brought to the emergency room because of a possible broken arm. The caregiver reports that the girl sustained the injury when she fell from her wheelchair. Which intervention should the nurse implement?

Evaluate the child for other injuries. Rationale The nurse should evaluate the child for other injuries because this child with a low-level fall that results in a fracture should be considered a possible victim of child abuse, until unproven otherwise.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected therapeutic response has the highest priority during pharmacological management for withdrawal?

Excessive CNS stimulation will be reduced. Substitution therapy with another CNS depressant is intended to decrease excessive CNS stimulation that can occur during benzodiazepine withdrawal. The other effects are not the expected therapeutic response.

A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?

Explain the rape protocol to the client. Rationale Impact reactions of the acute phase of the rape-trauma syndrome include shock, emotional numbness, confusion, disbelief, restless, and agitated motor activity. First, the nurse should provide the client with an explanation of the forensic rape protocol and ask her permission to proceed with examination to minimize additional trauma during assessment and collection of evidence. After the collection of evidence, prophylactic antibiotic medication is provided and then crisis intervention counseling initiated.

A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation. What action should the nurse implement?

Express concern over his disappointment. Rationale The therapeutic action that is nonjudgmental and supportive should address the client's disappointment and feelings of frustration in a safe environment. The other actions are not supportive of the client's expressions and are not indicated as the first response to frustration and anger.

The nurse should withhold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding?

Fever of 102 F. A fever may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. The other findings are adverse effects of Haldol which are not life threatening.

A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is characteristic of a client with schizophrenia? Mood swings. Extreme sadness. Manipulative behavior. Flat affect.

Flat affect. Disinterest, and diminished or lack of facial expression is characteristic of schizophrenia and is referred to as a flat affect. The other findings are not associated with schizophrenia.

The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include in the plan of care?

Focus on the client's positive or negative feelings toward the nurse. Rationale Interactions and interventions that focus on the client's positive or negative feelings toward the nurse are based on the psychoanalytical model of mental health care.

The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider?

Global confusion and inability to recognize family members. Rationale Delirium tremens (DT), or alcohol withdrawal delirium,usually peaks 2 to 3 days (48 to 72 hours or later) after cessation or reduction of intake and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal manifested as global confusion and an inability to recognize family members is life-threatening and requires emergency medical intervention.

During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client? -On a scale of 1 to 10 how do you rate your anxiety level? -How would you describe your mood right now? -Have you had any thoughts of hurting yourself? -What medications have you taken in the last 24 hours?

Have you had any thoughts of hurting yourself? Rationale Assessing for suicidal ideation is most essential. The other assessments should be made, and to ensure client safety, thoughts of self-harm are most important.

A young adult male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

He is unresponsive to instructions and is unable to cooperate with emetic therapy. Because the client is unable to follow instructions, emetic therapy would be very difficult to implement, therefore gastric lavage is necessary. The other actions are not the basis for determining if gastric lavage is indicated.

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make?

How can I help? Offering self shows empathy and caring and is the best response to provide. The other responses do not convey that the nurse is listening to the client's distress.

An adult female who is married and works full-time in a factory has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question should the nurse use?

How did this happen to you? Rationale Domestic violence can present in several forms, including sexual, physical, mental, and neglect. The victim of spousal abuse is often frightened or may feel at fault about the abuse, so a therapeutic relationship should be established with the client using nonjudgmental, open-ended questions so that the client is comfortable to disclose details about the injury, if abuse is suspected. The other questions are close-ended questions that can be answered with "yes" or "no" answers and are not therapeutic.

Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care? -If I fail another class, I'm going to kill myself. -I have a necktie in my room that I can use to hang myself. -When I leave home to live on my own, I'm buying myself a gun. -I took two bottles of Mom's pills and had to have my stomach pumped.

I have a necktie in my room that I can use to hang myself. Rationale Assessment of suicidal ideations should include the degree of lethality of the method, the individual's access to whatever is needed to carry out the attempt, and the specifics of the plan. The more detailed the plan, the greater the risk for a successful attempt. A necktie in the adolescent's room implies a lethal plan with an accessible, available means to act and implement a suicidal ideation. The other client expressions are relative to time, that is, future suicidal plans with stipulations which allows time for intervention, ora historical account of a previous suicidal attempt.

Which client statement should the nurse identify as most typical of a client with mania?

I manage our finances great because I buy in big quantities. Rationale A client with bipolar disorder, mania, characteristically demonstrates thoughts of inflate self-esteem, grandiosity, and a tendency for excessiveness, such as excessive spending. The other client statements do not support a client's lack of insight, poor judgment, and inflated self view that is typically seen in mania.

At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things would one like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make?

I will be leading this group. What would you like to accomplish during this time? Anxiety about participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. The nurse should provide information that focuses the group back to defining its function. The other responses do not focus the group on its purpose or task.

An older female client is admitted to the psychiatric unit with a diagnosis of major depression. Which client statement indicates to the nurse that further assessment is indicated?

I will die if my cat dies. Clients who use an analogy, such as a cat's death, may be describing themselves and can indicate the client's thought of suicide, which needs further assessment. The other statements are examples of decreased energy and mood levels and are not suicidal ideation at this time.

A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make?

I'll leave your tray here. I am available if you need anything else. The nurse should not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. The other responses are not indicated.

The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, "Self-esteem, chronic low." Which client response indicates to the nurse that the client has improved self-esteem?

Identifies own strengths Rationale Identifying one's personal strengths is an important part of increasing self-esteem.

An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate?

Immediately transfer the client to intensive care unit. These symptoms are descriptive of a life threatening reaction to neuroleptic drugs, known as neuroleptic malignant syndrome (NMS) which is manifested by fever, rigidity, autonomic instability, and encephalopathy. This is an emergency reaction, and the client requires immediate critical care. The other actions do not address the potential of respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure that can result in death due to NMS.

The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes she should expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common?

Inability to recognize one's location. Rationale Evidence indicates that frequent incidences of confusion, such as being unable to recognize one's location in a familiar environment is associated with the early stages of Alzheimer's Disease. The other manifestations occur with later stages of AD.

An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately?

Increased thyroid stimulating hormone (TSH). Rationale The healthcare provider should be notified of TSH levels immediately. An increased TSH suggests a low thyroxine level because TSH is being secreted to stimulate thyroxine production, which is the pathophysiology of hypothyroidism that may present as depression. The other results should be evaluated but do not have the priority relative to the admission diagnosis.

A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement? -Keep this information confidential until the client's release. -Immediately contact the the client's spouse and the lover. -File oral and written reports with the local police department. -Inform the healthcare provider and document the plan in the record.

Inform the healthcare provider and document the plan in the record. Rationale The Tarasoff decision gives mental health professionals a duty to warn prospective victims, but the extent and discharge of the duty may vary from state to state. The healthcare provider should be notified, and the information documented in the client's record. The other actions are not indicated.

A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take? Assist the client in verbalizing distress about the disease. Inquire about emotional factors affecting the client's present condition. Assess priorities to be set for the client's overall nursing care plan. Encourage the client to emotionally accept the chronicity of the disease.

Inquire about emotional factors affecting the client's present condition. Rationale Holistic care considers biological, psychological, and sociocultural factors that influences one's health status. The client is giving clues to psychological distress, so assessment for emotional factors that have impacted the client's present condition should be made.

The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?

Intelligence is influenced by social and cultural beliefs. Social and cultural beliefs have significant impact on intelligence. The other factors do not necessarily suggest limited intelligence.

When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness?

Interpersonal and intrapersonal skills. Rationale Interpersonal and intrapersonal intelligence form one's emotional intelligence or "emotional quotient." The nurse should focus inquiries on social skills.

Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? -Tell them there is nothing to fear. -Insist that they hold infant so they can grieve. -Respect their wishes and release the body to the morgue. -Keep the body available for a few hours in case they change their minds.

Keep the body available for a few hours in case they change their minds. Rationale Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours in the event they change their mind after the initial shock. The other actions are not indicated.

An older female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response should the nurse provide?

Let's go back to the activity room and see what is going on in there. It is common for those with Alzheimer's disease (AD) to use the wrong words. Redirecting the client, using an accepting non-judgmental dialogue, to a safer place and familiar activities is most helpful because clients with AD experience short-term memory loss. The other responses dismiss the client's attempt to find order, do not help her relate to the surroundings, and are frustrating which increase anxiety level.

The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

Medication management. The most important nursing problem is medication management to help prevent hospitalization. The other behaviors are evidence of noncompliance with medication management.

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." Which assessment finding should the nurse reference when initiating a referral? Altered thought processes. Moderate levels of anxiety. Inadequate social support. Altered health maintenance.

Moderate levels of anxiety. The nurse should initiate a referral based on anxiety levels and feelings of nervousness that the client described as interfering with sleep, appetite, and the inability to solve problems. The other findings are not indicated based on the client's reported symptoms.

The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first? -Offer oral fluids. -Monitor vital signs. -Evaluate ECT effectiveness. -Encourage group participation.

Monitor vital signs. Rationale Sedatives, muscle relaxants, and an anticholinergic agent are often prescribed for a client during ECT. Vital signs should be monitored during recovery after the ECT procedure. The other actions are not indicated immediately post ECT.

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug?

My mouth feels like cotton. A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors, such as phenelzine sulfate (Nardil). The other subjective reports are not related to this medication.

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take?

Notify the healthcare provider of the symptoms prior to the next administration of the drug. Early side effects of lithium carbonate that occur with a serum lithium levels below 2.0 mEq/L generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. The nurse should notify the healthcare provider before giving the next dose, which can contribute to higher serum drug levels that may cause ataxia, tinnitus, blurred vision, and large dilute urine output. The other actions are not indicated.

The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?

Only my belief in God can help me. The most frequent cause of increased symptoms in clients who are psychotic is noncompliance with the medication regimen. If the client believes that "God alone" can help, which may be a delusion and not faith-based, the client may discontinue the prescribed medication. The other client statements do not pose the greatest threat to the client's prognosis.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

Others have had similar thoughts when under stress. The nurse should offer support by assuring the client that others have suffered as he has. The other responses are not therapeutic and not indicated.

A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will always be this way and that there's no hope for me." What information should the nurse provide?

Panic disorder is treatable in a number of different ways, including medication. Rationale To foster the client's ability to cope, effective treatment options for panic disorder, such as desensitization, cognitive restructuring, relaxation, and psychotropic medications, should be discussed. The other information does not provide accurate information.

The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.)

Permit rest periods as needed. Speaking slowly and simply. Place the client on suicide precautions. Observe and encourage food and fluid intake. Neurovegetative symptoms that accompany the mood disorder of depression include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's plan of care should include measures that promote the client's comfort and well-being, such as rest, nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not indicated for clients in a neurovegetative state.

Which action should the nurse implement first for a client experiencing alcohol withdrawal?

Prepare the environment to prevent self-injury. Rationale During alcohol withdrawal, self-destructive or violent behavior can occur due to agitation and hallucinations and cause a potentially immediate and life-threatening risk to the client and others. The nurse should first provide a safe environment by removing any potential objects that could inflict self-injury. Secondary prevention strategies, administration of medications, and nutrition needs are then indicated.

A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the nurse to implement?

Provide information about infection prevention. Rationale Several factors impact a client who is angry and providing nursing feedback may help lower the client's anger and impact readiness to accept the nurse's interventions in providing care. Since the dressing change is initiated, making the client aware of why the dressing change is necessary to control infection can be therapeutic in forming a nurse-client relationship. The other actions are not indicated and may only escalate the client's anger if the nurse offers no alternatives to addressing the presenting issues during the dressing change.

A female client responds to the nurse with negative comments and antagonistic behavior. The nurse tells the client that she is unconsciously casting the nurse in the role of the client's mother. The nurse's feedback is based on which model of therapy?

Psychoanalytical Rationale The psychoanalytical model uses concepts that interpret and focus on working through feelings and behaviors related to previously unresolved conflicts. The other are related to other theoretical frameworks and treatments.

On admission, a client who is highly anxious describes a delusion. The nurse understands that delusions are most likely to occur with which class of disorder?

Psychotic Delusions are false beliefs associated with psychotic behavior that is not in touch with reality. The other mental health disorders are not associated with hallucinations (false sensations such as hearing, or seeing) or delusions (false beliefs), which are a break in reality.

During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, "I look around to see who's talking to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found out they were my imagination. The voices you hear aren't real either." Which phenomenon, common to groups, is exemplified in this interchange?

Reality testing Rationale Reality testing is a process in which an individual validates one's perception of reality. Group members can provide reality testing by monitoring each member's reactions and behaviors and providing feedback in an open and nonthreatening manner. The other experiences occur during group sessions and not related to validating psychotic phenomena, as in this situation.

A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?

Reassess client's mental status for thought processes and content. The most important intervention is to reassess the client's mental status and to take further action based on the findings of this assessment. The other interventions are not likely to help a client who is having false beliefs.

An adolescent female client is admitted to the Emergency Department because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room. What action should the nurse implement?

Reassign an all-female healthcare team to the client until her fear subsides. Rationale An adolescent female who has been physically violated and emotionally traumatized needs a non-threatening environment, and reassigning this client to all-female personnel is best to reduce her fear and anxiety related to rape. The other actions do not specifically address the client's fear of the male UAP.

The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action? Encourage the client to stop pacing and sit down. Reevaluate the client's blood pressure in an hour. Direct the client to attend recreational therapy. Review the client's baseline blood pressure.

Reevaluate the client's blood pressure in an hour. Rationale The client is irritable and pacing, which can contribute to the elevated BP. A reevaluation of the client's BP in an hour allows time for the excitement and stress of the admission process to abate. The other actions are not indicated at this time.

A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the priority nursing intervention?

Require the husband to leave the cubicle while the client is being treated. Rationale This client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority. The nurse should require the husband to leave the cubicle while the client is being treated. The other interventions are not the priority.

A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature 100o F, pulse 100 beats/minute, and blood pressure 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority client problem?

Risk for injury related to alcohol detoxification. The most important client problem is alcohol detoxification because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety is the priority, and the risk for injury should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. The other problems are not the priority.

The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome? Dementia. Depression. Schizophrenia. Chronic brain syndrome.

Schizophrenia. The client is demonstrating disorganized speech that may include word salad using both real and imaginary words in no logical order, incoherent speech, and clanging (rhyming), which are positive symptoms of schizophrenia. The other syndromes are not manifested by word salad, clanging, or neologisms.

The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care?

Search the client's personal belongings. Rationale To safeguard that the client dose not have some means to inflict self harm, a routine search of personal belongings, which is a common safety policy, should be implemented until the client stabilizes and suicidal ideations abate. The other interventions are components of the plan of care that ensure a therapeutic milieu but are not the priority in ensuring safety from self-harm.

During a one-to-one interaction, a male client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse doing?

Self-Awareness. Rationale Self-awareness describes awareness of the nurse's own feelings while empathizing with the client. The other mechanisms are therapuetic communication skills that the nurse uses to allow a client to open up about experiences and feelings.

Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client?

Self-analysis Rationale Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs. The nurse's primary tool is self-analysis and use of the therapeutic self to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. The other techniques may occur in a nurse-client relationship, but do not contribute to establishing a therapeutic relationship.

A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

Stagnation. The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family. Stagnation occur if an individual is not successfully coping with a psychosocial developmental stage related to age.

A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care?

Suggest actions to control impulsive responses toward self and others. Those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior so that he can avert the social consequences related to such behaviors. The other goals do not address the acute issue of impulse control, which is necessary to minimize the likelihood of self harm and harm to others.

What nursing assessment is the priority focus for a client with major depression?

Suicidal ideation. Rationale Suicidal ideations are a major risk factor in a client with major depression. Although mood and affect are assessed while determining if the client has suicidal ideations, the client's risk for self-injury is the priority. The other assessments are not indicated at this time.

A client who abuses alcohol says to the nurse, "I am glad I went in for treatment. Now my problems with alcohol are all behind me." Which response is best for the nurse to provide?

Tell me more about what you mean when you say that your problems with alcohol are now behind you Rationale Those who attend alcohol treatment programs and Alcoholics Anonymous never put drinking problems behind them and describe alcoholics as only one step away from a slip with maintaining sobriety. The nurse should use reflection and encourage the client to further describe the feelings.

A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention should the nurse take at this time?

Tell the client that therapy cannot take place while she is intoxicated. Rationale Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur because the client's judgment is altered. The other interventions are not necessary.

A client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able to kick this habit." How should the nurse respond?

The client must participate in making decisions about one's own physical and mental health. Rationale The client has the right to self-determination and the responsibility to make a decision to pursue health or illness, so the client must actively participate, which the nurse should clarify with the client.

While assessing an older male client, a nurse working in the outpatient clinic notices bruises on the client's chest. The client admits that his daughter, who is his caregiver, becomes frustrated and sometimes hits him. What is the priority outcome for the client who is experience physical abuse at home?

The client will report feeling safe with his daughter's care at home. Rationale The priority outcome should the client feeling safe and satisfied with his care by his daughter at home. The other statements are not outcomes that are client-centered and measurable.

A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because my husband told me I will be deported if my depression is not cured." What information should the nurse report to the healthcare provider?

The client's consent may have been coerced. Rationale Informed consent requires that the choice is freely given. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced based on family pressure, which may require further interventions.

Based on noncompliance with the medication regimen, an adult client with a diagnosis of substance abuse and schizophrenia recently had a change in prescriptions from oral fluphenazine HCl (Prolixin) to fluphenazine decanoate (Prolixin IM). What is most important to teach the client and family about this change in medication regimen?

The effects of alcohol and drug interaction. Alcohol enhances the extrapyramidal side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin IM is 2 to 4 weeks. Drinking alcohol can be more severe when the client drinks alcohol after taking the long-acting Prolixin IM. The other information should be included in client teaching, but are not the priority with Prolixin.

The nurse is leading a "current events group" with client who have chronic psychiatric illnesses. One group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make? Clara Barton was not your nurse. What did she do to you that was so mean? I didn't know that Clara Barton was a nurse. Clara Barton started the American Red Cross.

Clara Barton started the American Red Cross. The historical fact that Clara Barton was a nurse during the Civil War is referencing the concept of universality in this group therapy discussion. Stating the original role of Clara Barton in nursing should be presented, which is the reality in nursing and the American culture. The other responses are not indicated.