module 4 exam

Clang associationRationale: Clang association is the meaningless rhyming of words in which the rhyming is more important than the context of the words.

A schizophrenic client says, "I'm away for the day ... but don't think we should play ... or do we have feet of clay?" Which alteration in the client's speech does the nurse document?

You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"

A student calls the campus crisis hotline and tells the nurse, "I went out to a sorority party last week and drank too much. Someone raped me, but when I told my folks about it, they acted like it was my fault. I feel so dirty and used." Which statement by the nurse would be most therapeutic?

"I think that you should stop giving this medicine to your son until I can check its content with the pharmacy. "Rationale: When a client is taking methylphenidate hydrochloride (Ritalin), no OTC medications should be administered without the approval of the pharmacist or physician. Such medications could contain caffeine, which must be avoided.

The mother of a child who is taking methylphenidate hydrochloride (Ritalin) tells the school nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which response by the nurse would be appropriate?

Weekends Rationale: Because there is less availability of nursing staff on the weekends, risk to client safety increases, necessitating extra attention on the part of staff. There is often less availability of staff during shift changes as well. The nurse should increase precautions at these times. The night shift is also a high-risk time.

Which of the following clients is at the highest risk for suicide?

"You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?"

A client who has twice attempted suicide says, "If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do." Which response should the nurse should give to the client?

"When I tell my child to do something, I don't expect to have to repeat myself." Rationale: One characteristic of abusive parents is too-high expectations. As a result, the child cannot live up to the expectation of the adult parent.

A 2-year-old child is a suspected victim of child abuse and the nurse is interviewing the child's parent. Which statement by the parent indicates the possibility of child abuse?

Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle

A 24-year-old schizophrenic client says, "I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester." Which of the following guidelines does the nurse plan to incorporate into teaching of the client and family about self-care on the client's return to college?

The risk for suicide exists and continued assessment is needed Rationale: The words "I want to die" indicate a suicide risk warranting continued assessment. Any language indicating a desire for self-harm must be viewed as serious. This question presents no data indicating a history of self-harm.

A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't know how in the world to do it." On the basis of the client's statement, the nurse determines that:

Listen quietly while the mother talks and cries

A client and her newborn infant have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time?

The physical condition of the client Rationale: The initial priority in the nursing assessment of a client in a crisis state is to assess physical condition, potential for self-harm, and potential for harm to others. Once these questions have been answered and the appropriate interventions have been initiated, the nurse may proceed in providing psychosocial care.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on:

Staying with the client Rationale: This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. Processing the anxiety (e.g., asking questions) at this point will further increase the client's anxiety. The client in a severe state of anxiety is not able to learn relaxation techniques.

A client brought to the emergency department by the police after being mugged is extremely agitated, trembling and hyperventilating. What is the appropriate initial nursing action?

Actions Rationale: A compulsion is a repetitive act, whereas an obsession is a repetitive thought.

A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse observes the client for compulsive behavior involving repetitive:

Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?

A client in a mental health unit gets into a fight with another client over the use of the public telephone on the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which of the following interventions by the nurse would be most therapeutic?

"This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest."

A client in a retirement center rings the night alarm and says to the nurse, "Look at this old man! He keeps breaking into my apartment! You've got to get him to stay out of here so I can sleep." Which statement by the nurse would be most therapeutic?

"Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move. "Rationale: In the correct option, the nurse employs the therapeutic communication technique of reflection, then offers a problem-solving strategy that will help improve the client's peripheral vision.

A client in halo traction says to the nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which response by the nurse is therapeutic?

Clang associations

A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes this as an example of:

he client is completely dependent on family members for food and medicine

A nurse collects data from an older client and monitors him for signs of abuse. Which of the following psychosocial factors does the nurse recognize as placing the client at risk for abuse?

"You're feeling that your folks didn't want you, but they chose to marry and have you. "Rationale: In the correct option, the nurse uses reflection to explore the client's lethality risk and then uses reframing to determine whether the client is able to view what happened in a different way.

An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad told me he had to marry Mom because she got pregnant." Which response by the nurse would be therapeutic?

Suggesting that the client's mother quit her job Rationale: Suggesting that the client's mother quit her job is clearly the least effective option because it disrupts family processes.

An adolescent is returning home after an acute psychiatric hospitalization for a suicide attempt. Which of the following strategies will be least effective in preparing the client for discharge?

"I can see that you are worried."

Family members awaiting the outcome of a suicide attempt are tearful. Which response by the nurse would be most therapeutic to the family at this time?

Providing a caring environment that fosters the development of trust

Which of the following steps should be included in the care of a 13-year-old hospitalized child who has been abused?

"I went out to lunch today with my cousin. "Rationale: Anorexia nervosa is usually seen in adolescent girls who try to establish identity and control through self-imposed starvation.

Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective?

Remain with the client at all times Rationale: Drug overdose constitutes a serious suicide attempt. The plan of care must comprise actions that will promote the client's safety. Constant observation by a staff member who is never less than an arm's length away is the best action.

A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. The priority nursing intervention is to:

"It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?"

A client in skeletal traction says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me she had other patients besides me! I'm very sick, but the nurses don't care!" Which response by the nurse would be therapeutic?

Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times

A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention does the nurse implement?

Removing perfume, shampoo, and other toiletries from the client's room Rationale: When suicide precautions are instituted, all of the client's belongings that are potentially harmful are removed and placed in a locked area from which the nursing staff can retrieve them as the client needs to use them.

A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which of the following interventions does the nurse implement?

"Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."

A schizophrenic client attending a support group held by a clinic nurse says to the nurse and the group, "I've been laid off from my job at the factory, and so have 300 other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be most therapeutic at this time?

"This morning you are participating in the tree-decorating ceremony for the unit. "Rationale: The most therapeutic technique for assisting a client whose speech is confused and unintelligible is to emphasize what is happening in the here and now and involve the client in simple reality-based activities.

A schizophrenic client exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic?

Evidence of persecutory delusions Rationale: A persecutory delusion is the false belief that one is being singled out for harm by others, generally in the form of a plot by other people against the client.

A schizophrenic client in the psychiatric inpatient unit is yelling, "The CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." On the basis of the client's statement, which clinical manifestation would the nurse document in the client record?

Inability to communicate effectively

A schizophrenic client is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing?

I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices." Rationale: The most therapeutic nursing statement is the one in which the nurse addresses the client's behavior and asks whether the client is hearing voices.

A schizophrenic client is seen seemingly talking to someone who isn't there. Which nursing statement would be most therapeutic initially?

Somatic Rationale: Somatic delusions are false beliefs that one's body is changing in an unusual way, such as rusting or rotting away. The most therapeutic intervention in such a situation is to gain the client's cooperation in taking the antipsychotic medication prescribed by the psychiatrist

A schizophrenic client says, "I feel like I'm rotting away inside and all of my organs are rusting." Which type of delusion does the nurse identify in the client's statement?

You've been feeling like a failure for some time now?"

A client with major depression says to the nurse, "I should have died. I've always been a failure." Which response by the nurse is therapeutic?

Risk for impaired breathing Rationale: NPO status for 6 to 8 hours before a procedure, removal of dentures during the procedure, and administration of medication as prescribed to diminish oral secretions are all safeguards against aspiration during ECT.

A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of the highest priority?

Reflecting back to the client that he appears upset

A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time?

"Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?"

A client says to the nurse, "I came in to see you because I've been off my medication for 4 years but I feel as though I may be getting depressed again. I've been despondent again and thinking I should have ended it. That's why I'm here to get help." Which response by the nurse would be therapeutic?

"You don't do anything right?" Rationale: The correct response allows the client to verbalize his feelings.

A client says to the nurse, "I don't do anything right. I'm such a loser." What is the appropriate response?

"You're feeling angry that your family continues to hope for you to be cured." Rationale: Reflection is the therapeutic communication technique in which the client's feelings are restated to validate what the client is saying. The correct option involves the use of reflection.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! I'm the one who's dying." Which response by the nurse would be most therapeutic?

"I can teach you strategies to help master your panic. An antianxiety medicine would also help you." Rationale: A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to a desire for avoidance or actual avoidance of the object, activity, or situation. The nurse can teach strategies, such as relaxation training and thought-stopping, to help the client master her anxiety. There are also medications that the psychiatrist can prescribe to help ease the client's phobia

A client says to the nurse, "I'm really phobic about flying, so my husband and I always drove or took the train everywhere. Now he's been offered a big job in Europe, and if I don't get over this and fly with him, he says we're done. I'll be left to bring up our three children by myself." Which statement by the nurse would be therapeutic?

"Your husband is displaying behaviors that indicate a risk for self-harm." Rationale: Risk factors for suicide include male gender, professional status (physician, attorney, dentist, military personnel), loss to death, financial problems, and physical illness. Other risk indicators include a suicide plan, depressed mood, and prior attempts at suicide.

A client says to the nurse, "I'm worried about my husband. He's talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose — but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is appropriate?

You seem to be saying that your choices are final and that you've lost any other opportunities." Rationale: The client in this question is engaging in catastrophizing rather than reframing and viewing other alternatives. The task for the nurse is to assess the lethality of the client's situation and to help the client feel empowered to take another course of action and find the perseverance and confidence to do so. The therapeutic response here is the one that is nonjudgmental.

A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for the rest of my life." Which response by the nurse is therapeutic?

"Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members.

A client says to the nurse, "It's over for me — the whole thing is over." Which response by the nurse would be therapeutic

"Have you been having any thoughts of hurting your baby? "Rationale: The most important statement is the one in which the nurse assesses the client for her risk of harming the baby.

A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most important?

"You talk about getting organized. Are you thinking of killing yourself? "Rationale: The client is exhibiting behaviors that indicate plans for suicide. Talking of suddenly "feeling so much better" and putting affairs in order are key verbal and behavioral clues that the client is planning to commit suicide.

A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, "Well, I'm feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney." Which response by the nurse is appropriate?

"Tell me what you mean by that. "Rationale: The correct statement allows the client to tell the nurse more about what the current thoughts are, a therapeutic communication technique.

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem worth it anymore. Why shouldn't I just end it all?" Which of the following statements should the nurse use to gather additional data from the client?

"Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police."

A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and states, "My priest assaulted me when I was an altar boy, and my dad just found out. He's got a gun, and he's driving over to the church rectory. I don't know what to do." Which response by the nurse is most appropriate initially?

Somatization disorder Rationale: Somatization disorder is characterized by a long history of multiple problems with no organic cause.

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse planning care for this client to understand that the client is afflicted with:

Removing both clients to safe locations

A client with obsessive-compulsive disorder who continually cleans her room with paper towels becomes enraged with her roommate for throwing the package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which of the following actions would the nurse take first?

C Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?"

A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication." Which response by the nurse is appropriate?

Mutism

A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The nurse plans care knowing that this condition is referred to as:

When no acts of aggression are observed in the hour following the release of two extremity restraints

A furious and aggressive client is put in restraints and told that the restraints will be removed once the she regains control. At which of the following times is removal of the restraints by the nurse appropriate?

Naloxone (Narcan) Rationale: An opioid antagonist such as naloxone would be prescribed to treat a heroin overdose to reverse central nervous system depression.

A heroin addict who overdoses on the drug is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are dilated. Which of the following interventions does the nurse anticipate that the emergency department physician will prescribe?

Calling an ambulance

A home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic antidepressant lying near the client. What action must the nurse take immediately?

Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide

A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, "I need to be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which nursing intervention would be therapeutic?

PTSD

A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relations are poor. He then tells the nurse that the symptoms started after his best friend was killed in the terrorist attack at the World Trade Center. The nurse suspects that the client is experiencing:

"I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."

A manic client who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite.'" Which statement by the nurse would be most therapeutic?

Protection from the risk of intimacy Rationale: Clients who become obese after a trauma such as the one described in the question may be trying unconsciously to present themselves as unattractive as a means of protecting themselves from the danger of intimacy.

A mental health nurse is conducting the initial assessment of an obese client. The client confides that she was sexually molested at age 7 and began putting on weight thereafter. The nurse determines that the client's symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents

Increasing the level of suicide precautions Rationale: A client who is moderately depressed and has only been hospitalized for 2 days is very unlikely to have had such a dramatic cure. When a depressed mood suddenly lifts, it is very likely that the client has made the decision to harm him- or herself. It is at this time that the client has the energy to perform the act. Therefore suicide precautions are necessary to keep the client safe.

A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reports that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by:

Having the client eat with other clients in the community dining room Rationale: Having the client eat with other clients in the community room decreases the amount of time in which the client can stay isolated and engage in suspicious thinking.

A nurse brings a meal tray to a psychotic client in his hospital room. The client refuses the meal and says, "I'm not eating any more poisoned food while I'm vacationing here. I'm starting on a fast to stay healthy and alive." Which nursing intervention would be most appropriate initially?

The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations. Rationale: Identifying the reoccurrence of hallucinations, refraining from responding to them, and reporting a significant decrease in the incidence of hallucinations are all positive client outcomes. Other positive outcomes include appropriately interacting with others, demonstrating thinking that is based in reality, and grasping others' ideas.

A nurse caring for a schizophrenic client is assessing the client's ability to control distorted thought processes. Which of the following findings indicates a positive outcome?

A Making a "no suicide" contract with the client Rationale: The nurse would first plan to implement a "no suicide" contract when a client is at risk for self-harm. The safety of the client is the priority. The nurse would encourage the client to express angry, hostile feelings, not suppress them. Providing a peaceful place for the client to meditate is incorrect because the nurse would not want the client to isolate himself. Rather, the nurse would promote social interaction for the client. The nurse would help the client express (not control expression of) feelings that are painful

A nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially?

"You seem to be having a very difficult time. "Rationale: The therapeutic statement is the one that helps the client explore his situation and express his feelings. The correct option involves the use of reflection and will help the client begin to express his feelings.

A nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which of the following statements by the nurse would be therapeutic?

The locations of shelters Rationale: Tertiary prevention of family violence includes assisting the victim once abuse has already occurred. The nurse should provide the client with information on where to turn for help. This includes a specific plan for removing oneself from the abuser and information on escaping, hotlines, and the locations of shelters

A nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. Which priority instruction does the nurse include in the discharge plan?

Initiating confinement measures Rationale: During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging the behavior, moving the client to a quiet area, and medicating the client as appropriate.

A nurse has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. Which nursing intervention would be least helpful to this client at this time?

Normal reactions to a devastating event

A nurse in the emergency department is helping care for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors as:

Personal relationships tend to become more superficial and distant Rationale: As anorexia nervosa develops, personal relationships tend to become more superficial and distant. Social contacts are avoided because of the fear of being invited to eat and being discovered. The client is preoccupied with food and meal planning (especially for others), his or her own caloric intake throughout the day, and ways to avoid eating. Anorexic persons are likely to become very emaciated and do not maintain a near-normal body weight.

A nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. Which of the following characteristics is a hallmark of this disorder?

Providing authority and action Rationale: A crisis is an acute time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor with the use of previously successful problem-solving methods. Someone who intervenes in this situation (the nurse) takes over for the client who is not in control and devises a plan (action) to secure and maintain the client's safety. The nurse then works collaboratively with the client, demonstrating confidence in the client's ability to cope and providing reassurance that the crisis is temporary. Displaying an attitude of detachment is inappropriate.

A nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client?

Removing the client from any immediate danger Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on determining whether the person is in any immediate danger and, if so, taking emergency action to remove the client from the situation. Notifying the caseworker of the situation, adhering to mandatory abuse reporting laws, and obtaining treatment for the abusing family member may be appropriate interventions but are not the priority.

A nurse is caring for a client who has been identified as a victim of physical abuse. Which of the following actions is the priority as the nurse plans care for the client?

Continue to attend Alcoholics Anonymous meetings Rationale: All of the outcomes deserve support by the nurse, but the option, continue to attend Alcoholics Anonymous (AA) meetings, will help the client abstain from alcohol and provide the client with a support group. This is the most positive outcome.

A nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the client's discharge outcomes, the most positive outcome is that the client states that he or she will:

"So you're saying that you want to talk to your physician?"

A nurse is caring for an older adult client who says, "I don't want to talk with you — you're only a nurse. I'll wait for my doctor." Which of the following responses by the nurse would be therapeutic?

The client has an immediate plan for a suicide attempt. Rationale: Clients at high risk for suicide include those with a history of a dual diagnosis of mental illness and substance abuse, a personal or family history of suicide attempts, depression, alcoholism, and psychotic episodes. Having a plan, however, particularly involving a method that is immediate and available, puts the client at very high risk.

A nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which of the following findings indicates that the client is at high risk for suicide?

"I'm no longer a threat to myself or others."

A nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client states:

Goals and objectives Rationale: Goals and objectives are a tool for both the client and the nurse, and the nurse should focus on them as the primary means of accomplishing work with this client.

A nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD). Which of the following should be the nurse's primary focus?

Contracts and immediate available crisis resources Rationale: Crises may occur between appointments. Contracts help make clients feel responsible for keeping their promises, giving them a feeling of control.

A nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should focus on:

Indications of dementia may be present in an older client with depression Rationale: Signs of dementia may be noted in an older client with depression. Often the older client is aware of the changes in mentation, leading to depression

A nurse is preparing a plan of care for an older client with a diagnosis of depression. In preparing the plan, the nurse recalls that:

Obtaining a hospital interpreter to communicate with the client

A nurse is preparing to provide nursing unit information to a client who does not speak English who is being admitted to the mental health unit. Which action is best for the nurse to take to ensure that the client understands the information?

Discussing suicide with a client is not harmful Rationale: An open discussion of suicide is not harmful, will not encourage a client to make the decision to commit suicide, and will, in fact, often help prevent it. Such a discussion gives healthcare personnel the opportunity to assess the likelihood of a suicide attempt by the client and take the necessary precautions to keep the client safe.

A nurse is providing information to a group of nursing staff members about caring for suicidal clients. The nurse tells the group that:

Standing close to the client and telling the client that the behavior is unacceptable Rationale: To deescalate aggressive behavior, the nurse should maintain calm and a nonaggressive posture. The nurse should also give the client clear instructions that are brief and assertive and negotiate options with the client. Negotiation of options allows the client to feel that he or she has some room in making decisions. The nurse needs to maintain personal space and should not stand closer than about 8 feet from the client, which would convey a threatening message.

A nurse is trying to deescalate aggressive behavior exhibited by a client with schizophrenia. Which nursing action would be contraindicated in this situation?

Independently but close to their children Rationale: Most older people prefer to maintain their independence while having the resource of children or family nearby to help in times of need.

A nurse is working with an older client who has been hospitalized and the client's family to formulate a plan for discharge. In guiding the discussion with the client and family, the nurse understands that most older persons prefer to live:

Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings Rationale: Sharing observations with clients may help them recognize and acknowledge their feelings.

A nurse notices a paranoid stare during a conversation with a client. The client then begins to fidget and gets up to pace around the room. Which of the following actions by the nurse would be beneficial?

Moving the client to a quiet room and talking about her feelings

A nurse observes that a client is pacing back and forth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels "out of control!" Which intervention is most appropriate initially to maintain a safe environment?

"No, I wasn't, but I am now, thanks to you."

A nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse?

Keeping the client active with hobbies, exercise, and work

A nurse plans outcomes for a client who is being treated for psychosis. Which of the following steps would be included during the stable or discharge phase of treatment?

Inflexibility Rationale: Inflexible behavior is characteristic of the client with OCD.

A nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the mental health unit observes the client for certain characteristic behaviors. What are they?

Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation

A nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. Which action should the nurse take?

Post-traumatic stress disorder

A nurse working in a mental health unit reads a client's medical record and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of:

The client lives with one of their children and requires extensive assistance with activities of daily living

A nurse working in the emergency department is performing an initial assessment on a client, and notes many physical injuries. The nurse suspects family-related violence. Which of the following findings are specific to this type of violence?

he client will verbalize her feelings about the event.

A nurse working with a victim of rape in a clinic setting is developing a plan of care for the client. Which short-term initial goal is most appropriate?

Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats

A nursing instructor enters a classroom to begin class and finds two students yelling and physically assaulting each other. Which intervention by the instructor would be most appropriate?

It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices. "Rationale: The client is experiencing serious postpartum psychosis and command hallucinations. They require immediate medical attention and intervention for the protection of both the mother and her baby.

A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through." Which statement by the nurse would be most therapeutic?

"I do not hear any voices. Has the voice said anything else? "Rationale: When caring for a client experiencing delusions or hallucinations, the nurse should listen to the client, present reality, and collect more data regarding the content of the delusion and/or hallucination.

A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, "The voice in my head is telling me that you're cheating." Which of the following responses by the nurse is therapeutic?

ndividuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine. Rationale: Clients with Alzheimer's disease, a form of dementia, are likely to be intolerant of excessive stimulation and changes in routine.

A resident of a long-term care facility who has Alzheimer's disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which of the following pieces of information should the nurse use when approaching the client about this behavior?

Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?"

A schizophrenic client arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client's hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate?

"Have you tried to count back from 100 or listen to music? "Rationale: Distracting ways of coping with voices include reading aloud, describing an object in detail, listening to music, and watching television. Having the client try to count back from 100 or listen to music will assist in distraction.

A schizophrenic client says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my doctor told me to." Which intervention would the nurse suggest as a distraction technique?

Severe

A woman is brought to the emergency department after an assault. She presents with complaints of dizziness, dyspnea, visual disturbance, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client's presentation?

"Try not to listen to the voices right now so that I can talk with you ."Rationale: The appropriate statement by the nurse is the one that does not acknowledge the client's hallucinations.

An acutely ill schizophrenic client says to the nurse, "He keeps saying that he likes you, and I keep telling him you're married, but he won't listen, and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement?

A maturational crisis

An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of:

"Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain. "Rationale: The therapeutic nursing statement is the one that educates the client and also debunks the myth, held by the client, that taking milk thistle excuses drinking.

An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic?

This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."

An alcoholic client who has been admitted to the mental health unit states to the nurse, "The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled me over in my car." Which statement by the nurse is most appropriate?