(N125/4) HESI Practice

The nurse explores the possibility of joining Narcotics Anonymous (NA) with a client who has a history of drug abuse. What is a major reason that NA is helpful in treating addictive behavior? 1. More change will take place within the group. 2. Group members are supportive of one another's problems. 3. Group members share a common background and history. 4. Addiction problems are dealt with more effectively in a group.

2 Rationale; Although members of the group may become impatient with one another's problems at times, the group is usually supportive. Members share common goals, and the opportunity is available to test out new patterns of behavior. The rate and degree of change are individually based variables. People with addiction problems have varied backgrounds; the only common denominator may be the addiction. Although many clients function well in a group, some clients cannot.

A 19-year-old woman, arrested for assault and robbery, has a history of truancy and prostitution but is unconcerned that her behavior has caused emotional distress to others. The diagnosis of antisocial personality disorder is made. According to psychoanalytical theory, the client's lack of remorse and repetitive behavior probably are related to what underdeveloped aspect of personality? 1. Id 2. Ego 3. Superego 4. Limbic system

3 Rationale: Lack of remorse indicates a weak superego, the aspect of personality concerned with prohibitions. The id is not underdeveloped in this person; the id acts to achieve self-gratification. The ego is not related to acting-out behavior. The limbic system is not underdeveloped; it is related to the achievement of pleasure.

A nurse manager on the psychiatric unit discusses the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with a group of staff members. Which statement by the nurse manager reflects the primary purpose of the manual? 1. It aids in teaching psychopathology to mental health practitioners and nurses. 2. It facilitates research and improves communication between researchers and clinicians. 3. It provides clinicians with a classification of mental disorders and guidelines to aid diagnosis. 4. It assists in collecting and communicating accurate public health statistics through the use of specific diagnostic codes.

3 Rationale: The prime purpose of the DSM-5 is to serve as a guide in determining a client's mental health/psychiatric diagnosis. Although the manual can be used in teaching, research and communication, and the collection and communication of public health statistics, none is the prime purpose of this publication.

The nurse manager of a psychiatric unit informs the primary nurse that a client will be admitted to the unit within an hour. The client's admission diagnosis is paranoid schizophrenia. What classic clinical findings should the nurse anticipate? Select all that apply. 1. Mutism 2. Posturing 3. Flat affect 4. Extreme negativism 5. Prominent delusions 6. Auditory hallucinations

5, 6 Rationale: Prominent delusions are the essential feature of paranoid schizophrenia; delusions are typically persecutory, grandiose, or both, but delusions with other themes, such as jealousy, religiosity, or somatization, also may occur. Auditory hallucinations are a characteristic associated with paranoid schizophrenia; usually they are related to the delusional theme. Mutism is associated more commonly with the subtype of catatonic schizophrenia. Psychomotor retardation and posturing are associated with catatonic schizophrenia. A flat affect is associated more commonly with the subtype of disorganized schizophrenia. Extreme negativism is associated more commonly with the subtype of catatonic schizophrenia.

After a child's visit to a healthcare provider, the parent tells the nurse, "I'm so upset! The doctor prescribed an antidepressant!" What is the best response by the nurse? 1. "Tell me more about what's bothering you." 2. "Weren't you told why your child needs an antidepressant?" 3. "You need to speak with the healthcare provider about your concerns." 4. "Are you sure it's an antidepressant and not a drug for attention deficit disorder?"

1 Rationale: "Tell me more about what's bothering you" provides an opportunity to explore the parent's feelings. It is the nurse's responsibility, not the healthcare provider's, to assess the parent's concerns before planning further interventions. "Weren't you told why your child needs an antidepressant?" is a confrontational response that may put the parent on the defensive. "Are you sure it's an antidepressant and not a drug for attention deficit disorder?" is a judgmental, nontherapeutic response that may worsen the parent's concerns.

A 30-year-old female client asks the nurse to change her room, stating that she hates her roommate and can't stand to be in the same room with her. Just as she finishes speaking, her roommate enters and the client tells her she missed her and has been all over the unit looking for her. What does the nurse recognize the client to be using? 1. Projection 2. Sublimation 3. Reaction formation 4. Passive aggression

3 Rationale: The client's expressed feelings are opposite the client's behavior and are an acceptable substitute for repressed antisocial feelings when facing the roommate. The client's feelings are expressed to the nurse, not projected or attributed to others. The client has expressed real feelings to the nurse and has made no attempt to make an instinctual, socially unacceptable impulse into an acceptable behavior. The client has not masked covert hostility with overt compliance.

Which characteristic should the nurse predict will make an individual most likely to benefit from group therapy? 1. Dependence on others 2. Presence of a psychiatric illness 3. Having no one to listen to him or her 4. Recognizing that she or he has a problem

4 Rationale: The client must recognize that she or he has a problem or need before the client can share problems with others who have similar problems, thoughts, and feelings. All people are dependent on others to some degree; this is not a criterion for group therapy. It may be true in part that the person has no one to listen to her or him, but the client still should feel the need for help in coping with a problem. A psychiatric illness is not enough; the person must recognize that a problem exists and that help is necessary.

A psychiatric client recently admitted to the inpatient unit has a history of angry outbursts. The client's anger appears to be escalating, although the client still appears to be in control. What should the nurse do first to prevent an incident from developing? 1. Set a contract with the client to verbalize frustrations before acting out. 2. Establish firm control and use seclusion before the client acts out impulsively. 3. Show the client the seclusion room as a method of deterring acting-out behavior. 4. Call the health care provider for a prescription for an intramuscular sedative for the client.

1 Rationale: While the client is still in control, the nurse should formulate a contract with the client to prevent angry outbursts. Establishing firm control and using seclusion will violate the client's rights; also, these solutions are punitive and may interfere with the development of an effective therapeutic relationship. Showing the client the seclusion room is a threat that may increase agitation and provoke anger. Calling the health care provider for a prescription is premature.

After a modified radical mastectomy a client tells the nurse, "This diagnosis is as good as a death sentence, and I'd rather go now than suffer." What is the most important nursing intervention at this time? 1. Recommending that the client admit herself to the psychiatric unit of the hospital 2. Determining whether the client has experienced self-destructive suicidal thoughts 3. Exploring the possibility of a vacation after hospitalization to reduce the client's stress level 4. Encouraging the client to focus on the good things in her life to promote positive thinking

2 Rationale: A client in obvious crisis who appears depressed, anxious, and desperate should be questioned regarding the presence of suicidal thoughts. Further assessment and exploration are needed before the client is encouraged to admit herself to a psychiatric facility. It is difficult for a client overwhelmed with problems to think positively. Running away from problems does not help solve them, nor will escaping bring lasting relief.

A nurse is caring for a client who is angry and agitated. What is the best approach for the nurse to use with this client? 1. Confronting the client about the behavior 2. Turning on the television to distract the client 3. Maintaining a calm, consistent approach with the client 4. Explaining to the client why the behavior is unacceptable

2 Rationale: Consistency ensures an approach that is known and less frightening than the unknown. A calming approach can decrease agitation. Confronting the client about the behavior may escalate the client's anger and agitation. Environmental stimulants should be decreased, not increased. An agitated client is not capable of comprehending logical explanations; the nurse must avoid criticisms and arguments with the client.

A nurse is concerned about helping reduce the incidence of mental illness in the community. What action is most appropriate for the nurse to implement? 1. Encouraging individuals to attend religious services 2. Speaking to high school students about coping with anxiety 3. Teaching families to control the expression of negative feelings 4. Encouraging genetic counseling for families with members who are mentally ill

2 Rationale: Education about strategies to cope with problems may reduce anxiety and help prevent mental illness. Encouraging individuals to attend religious services may or may not be helpful in reducing anxiety and mental illnesses. Controlling the expression of negative feelings may increase, rather than decrease, anxiety. There are few genetic markers or specific hereditary patterns for most mental illnesses.

A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's what? 1. Developmental history 2. Available situational supports 3. Underlying unconscious conflict 4. Willingness to restructure the personality

2 Rationale: Personal internal strengths and supportive individuals are critical to the development of a crisis intervention plan; they must be explored with the client. Although developmental history information may be helpful, it is not essential; factors concerning the current situation are paramount. Identifying unconscious conflicts takes a long time and is inappropriate for crisis intervention. Willingness to restructure the personality is a goal of psychotherapy, not crisis intervention.

A nurse is assessing a client for the use of defense mechanisms. In the presence of which defense mechanism does the client express emotional conflicts through motor, sensory, or somatic disabilities? 1. Projection 2. Conversion 3. Dissociation 4. Compensation

2 Rationale: The defense mechanism is called conversion because the individual reduces emotional anxiety to a physical disability. Projection occurs when people assign their own unacceptable thoughts and feelings to others. With dissociation there is separation of certain mental processes from consciousness as though they belonged to another; a dissociative reaction is expressed as amnesia, fugue, multiple personality, aimless running, depersonalization, sleepwalking, and other behaviors. Compensation is a mechanism used to make up for a lack in one area by emphasizing capabilities in another.

A client who has a history of psychiatric problems, including an antisocial personality disorder, is admitted to the hospital. What typical behavior does the nurse anticipate? 1. Sexual acting out 2. Interpersonal difficulties 3. Diminished contact with reality 4. Compulsive behaviors associated with following rules.

2 Rationale: These clients usually have a history of interpersonal difficulties. They are unable to engage in the give-and-take a relationship requires because of their consistent disregard for and exploitation of others. There is no direct relationship between antisocial personality disorders and sexual acting out. These clients are in contact with reality. Compulsive behaviors are typical of clients with obsessive-compulsive disorder, not antisocial personality disorder. These clients typically do not conform to societal rules.

A client's admitting history indicates signs of akathisia. What clinical finding should the nurse expect when assessing for this condition? 1. Facial tics 2. Motor restlessness 3. Maintaining a body position for hours 4. Repeating the movements of another person

2 Rationale: With akathisia the client exhibits a constant state of movement; this is characterized by restlessness and difficulty sitting still, including constant jiggling of the arms or legs. The distortion of voluntary movements, such as tics, spasms, or myoclonus, is known as dyskinesia. Maintaining a body position for hours is a form of catatonia known as waxy flexibility. Repeating the movements of another person is known as echopraxia.

A client is exhibiting a pattern of withdrawn behavior. What feelings does the nurse anticipate that this type of behavior will eventually produce? 1. Anger 2. Paranoia 3. Loneliness 4. Repression

3 Rationale: A pattern of withdrawn behavior prevents the individual from reaching out to others for sharing; the isolation produces feelings of loneliness. Feelings of anger may result in withdrawal, but withdrawal does not produce feelings of anger. Feelings of paranoia may result in withdrawal, but withdrawal does not produce these feelings. Repression is an unconscious defense whereby the individual excludes ideas, feelings, or situations from the conscious level of thought; this does not result from withdrawal.

A nurse leads an assertiveness training program for a group of clients. Which statement by a client indicates that the treatment has been effective? 1. "I know that I should put the needs of others before mine." 2. "I won't stand for it, so I told my boss he's a jerk and to get off my back." 3. "It annoys me when people call me 'sweetie,' so I told him not to do it anymore." 4. "It's easier for me to agree up front and then do just enough so that no one notices."

3 Rationale: Announcing that "sweetie" is annoying is an assertive statement; it clearly indicates what the problem is and sets limits on undesired behavior without being demeaning. A client stating that he or she should put the needs of others before his or her own is nonassertive or passive and denies the individual's own needs and desires. A client stating that he or she won't stand for someone else's behavior and calling the person a jerk is an aggressive statement that is demeaning and intimidating. A client stating that it's easier to agree up front and then do just enough so no one notices is a passive-aggressive response that avoids direct, honest confrontation in favor of devious manipulation.

A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information? 1. "Why did you fall down the stairs?" 2. "Did you really fall down those stairs?" 3. "Show me how you fell down the stairs." 4. "Your mommy must have told you to say you fell down the stairs."

3 Rationale: The response "Show me how you fell down the stairs" will allow the child to show what happened; it removes the pressure of verbalization. Children have difficulty answering "why" questions; asking why the child fell may add to the guilty feelings of the abused child. Asking, "Did you really fall down those stairs?" will confuse the child because it might become necessary to verify a lie. The response "Your mommy must have told you to say you fell down the stairs" will confuse the child because of his or her dependence on the mother; the child may be afraid of contradicting the mother.

A parent who is visiting a hospitalized adolescent gets into an argument with the adolescent. Leaving the adolescent's room in tears, the parent meets the nurse and relates the argument, saying, "I can't believe I got so angry that I could have hit my child." What is the most therapeutic response by the nurse? 1. "Teenagers really can drive you to distraction." 2. "Bring a surprise for the child next time. It'll make you both feel better." 3. "Sometimes we find it difficult to live up to our own expectations of ourselves." 4. "You can't compare yourself to an abusive parent—after all, you didn't beat your child."

3 Rationale: The response "Sometimes we find it difficult to live up to our own expectations of ourselves" is the best response because it reflects the feelings being expressed at this time. "Teenagers really can drive you to distraction" avoids the real issue. Telling the parent to bring a surprise for the adolescent on the next visit does not address the real concern; the parent's argument may have been justified, and the child's behavior should not be rewarded. The response "You can't compare yourself to an abusive parent—after all, you didn't beat your child" avoids the issue; the parent may fear that next time control will be lost and abuse will occur.

A client with a history of substance abuse is brought to the emergency department for possible overdose. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing? 1. Alcohol 2. Fentanyl 3. Oxycodone 4. Methamphetamine

4 Rationale: Methamphetamine is a stimulant that increases the heart rate and blood pressure. It can cause hyperthermia, convulsions, and death. Alcohol is a central nervous system (CNS) depressant. Overdose of alcohol leads to a decreased level of consciousness, hypotension, hypothermia, and respiratory depression. Fentanyl and oxycodone are opioid and CNS depressants. Overdose leads to hypotension, a decreased level of consciousness, and respiratory depression.

A child in the first grade is murdered, and counseling is planned for the other children in the school. What should a nurse identify first before assessing a child's response to a crisis? 1. Developmental level of the child 2. Quality of the child's peer relationships 3. Child's perception of the crisis situation 4. Child's communication patterns with family members

1 Rationale: Knowledge of the developmental level is essential to understanding a child's response to a crisis situation; the variety of coping abilities usually increases as the child progresses through the stages of growth and development. The child's perception of the crisis situation should be assessed after the child's developmental level is identified. Although the quality of peer relationships, perception of the situation, and communication patterns with family members are all important pieces of information that should eventually be elicited, none is the initial assessment.

What is the most important tool a nurse brings to the therapeutic nurse-client relationship? 1. The self and a desire to help 2. Knowledge of psychopathology 3. Advanced communication skills 4. Years of experience in psychiatric nursing

1 Rationale: The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model, but none is the most important tool used by the nurse in a therapeutic relationship.

A client with schizophrenia sees a group of visitors sitting together talking. The client tells the nurse, "I know they're talking about me." Which altered thought process should the nurse identify? 1. Flight of ideas 2. Ideas of reference 3. Grandiose delusion 4. Thought broadcasting

2 Rationale: Ideas of reference, seen with psychotic thinking, is a delusional belief that others are talking about the client. Flight of ideas is the rapid thinking seen in clients in a manic state. Grandiose delusions are irrational beliefs that overestimate one's ability or worth. Thought broadcasting is the delusional belief that others can read one's thoughts.

A nurse in the mental health clinic concludes that a client is using confabulation when the client does what? 1. The flow of thoughts is interrupted. 2. Imagination is used to fill in memory gaps. 3. Speech flits from one topic to another with no apparent meaning. 4. Connections between statements are so loose that only the speaker understands them.

2 Rationale: Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting of speech from one topic to another with no apparent meaning is the definition of flight of ideas. The definition of associative looseness is connections between statements so loose that only the speaker understands them.

A registered nurse who is a beginning group leader in a community mental health center has been assigned to start a new group with regressive long-term clients. The nurse manager explains that in the beginning new group leaders are expected to do what? 1. Talk extensively about their own experiences. 2. Confront group members about a variety of issues. 3. Feel uncomfortable handling conflicts between members of the group. 4. Have little difficulty with long-term clients who do not have acute emotional problems.

3 Rationale: New group leaders experience anxiety and insecurity, limiting their ability to mediate conflicts between members. Talking extensively about their own experiences is self-serving and disruptive to the group process. Confronting group members about a variety of issues is often counterproductive, especially with regressed long-term clients, who may decompensate when confronted with their behavior. Regressed long-term clients need more help with communication than clients with acute problems.

The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention? 1. Passive listener 2. Friendly advisor 3. Active participant 4. Participant observer

3 Rationale: To intervene in a crisis, the nurse must assume a direct, active role because the client's ability to cope is lessened and help is needed to solve problems. Being a passive listener is insufficient to help the client. Being a friendly advisor can blur the boundaries between a professional and a social relationship. The role of the nurse should not include giving advice. Being a participant observer is insufficient to help the client.

A psychiatric nurse is working at a community mental health clinic. Which activity demonstrates that the nurse knows the importance of engaging in effective self-awareness? 1. Discussing with unit staff the role played by formal religion in personal happiness 2. Becoming aware of the cultural practices of the Hispanic clients served by the clinic 3. Refusing to engage in a discussion regarding alternative views on physician-assisted suicide 4. Accepting a client's decision to refuse electroconvulsive therapy as a treatment for chronic depression

4 Rationale: Effective self-awareness is demonstrated by an accepting attitude toward clients' values, beliefs, and decisions when they differ from our own. Although formal religion is a source of happiness for many, it is not an important component of life for everyone. Biases are not acted upon when a nurse is effectively self-aware. Cultural awareness is a component of good nursing practice. Knowledge of cultural practices in and of itself is not a reflection of acceptance, which is a necessary component of self-awareness. Seeking alternative points of view is a characteristic of effective self-awareness because it aids in the acceptance of differing viewpoints.

The spouse of a client who is dying tells the primary nurse that the client is asking the nurses to leave the pain medication on the bedside table and fears they are being saved for a suicide attempt. The nurse knows that the staff members have mixed feelings about the client's terminal status and prolonged pain. What is the most ethically appropriate intervention by the nurse? 1. Reporting the information about the medication to the nurse manager 2. Reminding the nurses that they should not leave the medication at the bedside 3. Asking the nurse manager to address the medication problem and the staff's feelings 4. Suggesting a nursing conference to discuss the medication problem and the staff's feelings

4 Rationale: Suggesting a nursing conference to discuss the medication problem and the staff's feelings is a positive approach because it attempts to address staff members' feelings as well as the medication problem; the nurse therefore is taking an ethically appropriate action without being moralistic or authoritarian. Reporting the information about the medication to the nurse manager abdicates the primary nurse's responsibility and may prompt anger and guilt among the staff members. Reminding the nurses that they should not leave the medication at the bedside does not address the nurses' feelings. Asking the nurse manager to address the medication problem and the staff's feelings abdicates the primary nurse's responsibility and may create anger and guilt among the staff members.

A husband is upset that his wife's alcohol withdrawal delirium has persisted for a second day. What is the most appropriate initial response by the nurse? 1. "I see that you're worried. We're using medication to ease your wife's discomfort." 2. "This is expected. I suggest that you go home because there's nothing you can do to help." 3. "Are you afraid that your wife will die? I assure you, very few alcoholics die during the detoxification process." 4. "Are you worried that your wife is uncomfortable while she's going through withdrawal? I'm sure that she's not in pain."

1 Rationale: Recognizing the spouse's feelings and giving simple factual information help to allay anxiety. Telling the husband that the prolonged delirium is expected, encouraging him to go home, and saying that there is nothing he can do discourages further verbalization of concerns and promotes feelings of isolation and helplessness. Asking whether the husband is afraid that his wife will die and assuring him that very few alcoholics die during the detoxification process is inappropriate, especially during this time of stress; it also gives little assurance to the husband. Asking whether the husband thinks that his wife is uncomfortable and assuring him that she is not constitutes false reassurance and does not allow the man to verbalize anxieties or fears.

What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program? 1. Alcoholism involves the entire family. 2. Alcoholics try to hide their drinking from their families. 3. Family members provide insights into the dynamics behind the drinking. 4. Family members have been most successful in providing necessary support.

1 Rationale: Research indicates that alcoholism is a family disease, with its roots in the family of origin. Although alcoholics may try to hide their drinking from their families, this is not the reason for including the family in the treatment program. Family members often have no understanding of the dynamics behind the drinking and often need assistance with coping and counseling. Family members often do not understand the dynamics behind the drinking and often are enablers; they also need assistance with coping and counseling.

Which statement demonstrates that a psychiatric nurse has fostered the most therapeutic nurse-client relationship? 1. "My clients and I are partners in the planning that helps meet their physical and mental health needs." 2. "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." 3. "Mental health is best achieved and maintained when the nurses and the clients exhibit respect and caring for each other." 4. "Without a mutually satisfying relationship between nurse and client, the process needed to maximize mental and physical wellness is greatly hindered."

1 Rationale: Today's nurse-client relationship is one that demonstrates the nurse's clinical competence while recognizing the client's right to self-determination in decisions affecting both physical and mental health. Although the development of a true therapeutic relationship is a goal, when that is not achievable because of the client's mental health status, appropriate nursing care is still achievable. Although the demonstration of mutual respect and caring are basic elements, other factors also have an impact on the formation of a therapeutic nurse-client partnership. A truly therapeutic nurse-client relationship provides satisfaction for both nurse and client; that may not be achievable because of the client's mental health status. The nursing process can still provide care that strives to meet client outcomes that are reflective of their potential for both physical and mental wellness.

A 37-year-old man has been remanded by the court to the drug rehabilitation unit of a psychiatric facility for treatment of cocaine addiction. When taking his health history, what characteristics should the nurse expect the client to report? Select all that apply. 1. Anxiety 2. Palpitations 3. Weight loss 4. Sedentary habits 5. Difficulties with speech

1, 2, 3 Rationale: Cocaine, an alkaloid stimulant, can precipitate anxiety, hypervigilance, euphoria, agitation, and anger. The loss of appetite and increased metabolic rate associated with cocaine addiction both promote weight loss. Cocaine is a stimulant that has cardiac effects such as tachycardia and dysrhythmias. Sedentary habits are associated with barbiturate addiction. Difficulties with speech are associated with other addictions such as alcohol and methadone.

A client with a diagnosis of schizophrenia, undifferentiated type, is being admitted to the psychiatric unit. What clinical manifestations does the nurse expect when assessing this client? Select all that apply. 1. Excited behaviors 2. Loose associations 3. Inappropriate affect 4. Feelings of depression 5. Hypervigilant behavior

1, 2, 3 Rationale: Excited behaviors, such as aggressive hitting or biting, often are associated with an acute onset of undifferentiated schizophrenia. Loose association is a characteristic related to thought disorders such as schizophrenia, undifferentiated type. The affect usually is inappropriate, rather than flat, in undifferentiated schizophrenia. Depression is not characteristic of undifferentiated schizophrenia. Hypervigilant behaviors generally are associated with paranoid schizophrenia, not undifferentiated schizophrenia.

The home care nurse visits a child in whom failure to thrive has been diagnosed and makes observations that lead the nurse to suspect that the house is being used as a methamphetamine laboratory. Which observations support this conclusion? Select all that apply. 1. Many small plastic bags 2. A strong odor of acetone 3. Many empty cold medicine bottles 4. A pot of tall plants with broad leaves 5. Jars containing crystals

1, 2, 3, 5 Rationale: Methamphetamine is often packaged in small plastic bags for sale. An odor of acetone may be produced in the process of making methamphetamine. The pseudoephedrine in cold medicine is used in the production of methamphetamine. Methamphetamine may appear as crystals. These plants are not a sign of methamphetamine production but may be marijuana.

The nurse is involved in a therapeutic relationship with a depressed client. Which question and/or statement by the nurse is appropriate for stage 1 of this relationship? Select all that apply. 1."I'm here to talk with you about how you've been feeling." 2. "How do you feel about keeping a journal regarding how you are feeling?" 3. "Are you experiencing any suicidal or homicidal thought?" 4. "Are you open to the prospect of being prescribed antidepressant medication?" 5. "What we talk about will be shared only with your treatment team."

1, 3, 5 Rationale: Stage 1, the orientation phase of the therapeutic relationship, involves the nurse learning about the client and their initial concerns and needs. Discussing how the client feels is an initial focus of the communication. Assessing for specific problems, such as suicidal thoughts, is appropriate because it addresses this client's safety needs. Assuring confidentiality helps build trust and so is appropriate for this stage. Discussions concerning treatment techniques, such as journaling and medication, are reserved for stage 2 of the working phase of the relationship.

A nurse is assessing a client with chronic schizophrenia. Which effects will the client most likely exhibit? Select all that apply. 1. Apathy 2. Hostility 3. Flatness 4. Sadness 5. Happiness 6. Depression

1, 3 Rationale: Apathy (indifference) is common among people with chronic schizophrenia because negative symptoms are more apparent. Flatness, with few extremes of emotion, is common among people with chronic schizophrenia because negative symptoms are more apparent. Extremes in emotions are not associated with chronic schizophrenia. Sadness is related more to mood disorders, such as a depressive episode of bipolar disorder or major depression. Hostility may be seen in some forms of schizophrenia, such as paranoid schizophrenia, but it is rarely seen in the chronic stages. Happiness and elation are associated with manic episodes of bipolar disorder, not chronic schizophrenia. Depression is related to mood disorders, such as a depressive episode of bipolar disorder or major depression.

A nurse is assessing a client with dementia. Which clinical manifestations are expected? Select all that apply. 1. Agitation 2. Pessimism 3. Short attention span 4. Disordered reasoning 5. Impaired motor activities

1, 3, 4, 5 Rationale: The behavior of clients with dementia tends to be inappropriate, restless, and agitated. Cognitive abilities are impaired, as evidenced by a short attention span, limited ability to focus, and limited judgment and insight. Reasoning is disordered, speech may be incoherent, and memory, particularly short-term memory, is impaired. Impaired motor activity (apraxia) and impaired coordination (ataxia) are associated with dementia. Pessimism is more characteristic of depression, not dementia.

When attempting to assess the behavior of an older adult with a diagnosis of vascular dementia, what does the nurse know is probable about the client's use of defense mechanisms? 1. Incapable of using any defense mechanisms 2. Using one method of defense for every situation 3. Making exaggerated use of old, familiar mechanisms 4. Attempting to develop new defense mechanisms to meet the current situation

3 Rationale: Clients with dementia try to use defense mechanisms that have worked in the past but use them in an exaggerated manner. The client can use defense mechanisms but is not capable of focusing on one defense mechanism. Because of brain cell destruction clients are unable to develop new defense mechanisms.

A nurse considers the cultural factors that may influence the development of eating disorders. Where does the nurse recall that eating disorders are more frequently found? 1. Affluent families 2. European countries 3. Industrialized societies 4. Men rather than women

3 Rationale: Eating disorders are prevalent in industrialized societies that have an abundance of food; affected individuals likely equate food with pleasure, comfort, and love and may have been nurtured, punished, or rewarded with food. Eating disorders occur in all socioeconomic groups. The incidence and prevalence of eating disorders around the world are similar in European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries with plentiful food supplies. Studies indicate that 95% to 99% of persons with eating disorders are women, not men.

What does the nurse leader expect all members to be doing when a therapy group is achieving its objective? 1. Attending every session of the group 2. Commenting on each topic discussed by the group 3. Making an effort to include one another in discussions 4. Following through on obeying rules governing behavior

3 Rationale: Making an effort to include one another in discussions demonstrates an increase in socialization and an awareness of the behavior of others. Attendance alone is an insufficient basis for evaluation of the effectiveness of group therapy. The quantity and extent of comments are not significant. Following through on obeying rules governing behavior may indicate a greater degree of impulse control on the part of the members, but this is not the primary goal of group therapy.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1. Trust 2. Growth 3. Belonging 4. Independence

3 Rationale: Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on trust, growth, and independence.

According to Erikson, a young adult must accomplish the tasks associated with which stage? 1. Trust versus mistrust 2. Intimacy versus isolation 3. Industry versus inferiority 4. Generativity versus stagnation

2 Rationale: Major tasks of young adulthood are centered on human closeness and sexual fulfillment; lack of love results in isolation. The trust-versus-mistrust stage is associated with infancy. The industry-versus-inferiority stage is associated with middle childhood. The generativity-versus-stagnation stage is associated with middle adulthood.

A client who has been pregnant for 5 months experiences a spontaneous abortion after an accident. The client tells the nurse that she feels depressed over the loss of her son. She describes how he would have looked and how bright he would have been. What is the client demonstrating? 1. Panic level of anxiety 2. Typical grief syndrome 3. Pathological grief reaction 4. Diminished ability to test reality

2 Rationale: The client is grieving the loss of a fantasized child; talking about it is part of the typical grief reaction. The client is sad, not out of control or immobilized. The client is coping with the loss effectively. The client recognizes the loss, but is lamenting what could have been.

The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? 1. Apraxia 2. Agnosia 3. Aphasia 4. Amnesia

2 Rationale; Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting on clothing properly.

As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of what? 1. Setting of care 2. Anxiety disorder 3. Attitudes and beliefs 4. Cultural and ethnic disparities

3 Rationale: Some attitudes and beliefs include reluctance by older people to seek help because of pride in their independence, stoic acceptance of difficulty, unawareness of resources, and fear of being "put away." Although the client mentions "being put away", that is an attitude. The client is not talking about all the resources that might be available. Anxiety is defined as an unpleasant and unwarranted feeling of apprehension. The client does not mention any cultural or ethnic issues, just his or her own feelings.

A nurse is caring for a depressed client admitted to the psychiatric unit because of the risk for suicide. In which order, from lowest risk to highest, should these behaviors be placed by the nurse? 1. Threats of suicide 2. Suicidal ideation 3. Attempts at suicide 4. Suicidal gestures

2, 1, 4, 3 Rationale: Agnosia [1] [2] is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.

A young woman is brought to the emergency department by friends after being sexually assaulted. The client has a small but deep laceration on her chin, as well as contusions on her arms and legs. The client appears withdrawn but calm. Place the following nursing interventions in the appropriate order to best address the client's immediate needs. 1. Provide care for her laceration and contusions. 2. Talk to her in a calm, nonjudgmental manner. 3. Provide her with clear, concise explanations of care that will be provided. 4. Encourage her to express her feelings concerning the assault. 5. Advise her of the potential related health risks and the treatments that are available.

2, 3, 1, 4, 5 Rationale: The establishment of a trusting, mutually respectful nurse-client relationship is the initial focus in this particular scenario. To best minimize further trauma, the nurse will provide the client with an explanation of all care (physical contact) that will take place. Attention is first focused on physical needs because the client appears to be in control emotionally at the moment. When the physical needs are met, the nurse will encourage the client to express her feelings; this is done most effectively once a therapeutic nurse-client relationship has been established. The last issue to be addressed in this scenario is that of potential health issues such as sexually transmitted diseases, HIV, and pregnancy.

A nurse on the psychiatric unit of the hospital has been assigned four clients for the shift. The assignment includes an 84-year-old client who is severely depressed, a 73-year-old client who is being discharged, a 53-year-old client who was admitted for lithium toxicity, and a 48-year-old client who has panic attacks. Which client should the nurse assess first after receiving report? 1. 84-year-old client 2. 73-year-old client 3. 53-year-old client 4. 48-year-old client

3 Rationale: The 53-year-old client should be assessed first because of the severity of adaptations associated with lithium toxicity. A severely depressed client has a low energy level and is not at the greatest risk at this time. A client who is stable enough to be discharged does not need immediate attention. Clients with panic attacks usually seek immediate attention when it is needed.

During a phone conversation to a crisis hotline a client states, "I'm falling apart and can't put myself together. This goes on and on." What is the most therapeutic response by the nurse? 1. "Is there anyone there with you?" 2. "What do you think this means?" 3. "How do you usually handle this type of situation?" 4. "What's happening right now that prompted you to call?"

4 Rationale: Getting the client's perception of what has prompted the call is essential to determining whether the client is in danger. The client has chosen to call the crisis line as a help-seeking behavior; asking whether someone else is there does not focus on the client's reaching out. "What do you think this means?" is a question that can be asked later to assist the client in gaining insight into the present situation. "How do you usually handle this type of situation?" is a question that may follow assessment of the situation.

Which client statement supports the diagnosis of somatic delusions? 1. "I wear this coat all the time to keep them from x-raying my organs." 2. "The president of France and I will be announcing our engagement soon." 3. "My heart stopped beating three days ago, and now my lungs are rotting away." 4. "The government has assigned a team of assassins to kill me because I know too much."

3 Rationale: A somatic delusion is a belief that the body is changing or behaving in an unusual way (e.g., the client's heart stopping and the lungs rotting away). Control delusions center on the belief that others are attempting to control or affect the person in some manner. Erotomanic delusions are focused on the belief that another person (usually famous or otherwise unattainable) is romantically interested in the client. Persecutory delusions involve beliefs that one is being singled out for harm.

The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? 1. Apraxia 2. Aphasia 3. Agnosia 4. Amnesia

3 Rationale: Agnosia [1] [2] is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.

A high school-age adolescent undergoing lithium therapy has not been following the prescribed pharmacologic regimen. What should the school nurse do to help promote adherence to the regimen? 1. Call the homeroom every day to remind the adolescent to take the medication. 2. Elicit help from peers to remind the adolescent to come to the nurse's office for medication. 3. Suggest that the primary healthcare provider explain to the adolescent the importance of taking the medication. 4. Talk with the adolescent about the importance of a consistent lithium blood level in ensuring that the medication will be effective.

4 Rationale: Knowledge may promote adherence to the pharmacologic regimen and motivate and empower the client. Calling the homeroom every day promotes dependence; independence and responsibility for one's own therapeutic regimen are the desired outcomes. Eliciting help from the client's peers violates confidentiality. Suggesting that the primary healthcare provider explain abdicates the nurse's responsibility to provide teaching.

A 3-year-old child is found to have autism. Which behaviors should the nurse expect when assessing this child? Select all that apply. 1. Imitates others 2. Seeks physical contact 3. Avoids eye-to-eye contact 4. Engages in cooperative play 5. Performs repetitive activities 6. Displays interest in children rather than adults

3, 5 Rationale: Impairment of social interaction manifests as a lack of eye contact, a lack of facial responses, and a lack of responsiveness to and interest in others. Children with autism display obsessive ritualistic behaviors such as rocking, spinning, dipping, swaying, toe-walking, head-banging, and hand-biting because of their self-absorption and need to stimulate themselves. The impairments in communication and imaginative activity result in a failure to imitate others. Children with autism are indifferent to or have an aversion to affection and physical contact. Impairments in social interaction and imaginative activity manifest as failure to engage in cooperative or imaginative play with others. They are unable to establish meaningful relationships with adults or children because of their lack of responsiveness to others.

A mental health crisis occurs as a result of what stress-related factor? 1. The stress is chronic and maturational in nature. 2. The stress is perceived rather than real in nature. 3. The stress is extremely severe and situational in its origin. 4. The stress is not managed by the individual's usual methods.

4 Rationale: An individual experiences a crisis when stress, either real or imagined, cannot be controlled by the person's usual coping mechanisms. It would not be considered a crisis if it was chronic and maturational, severe and situational, or perceived rather than real.

A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display? 1. Elated affect related to reaction formation 2. Loose associations related to a thought disorder 3. Physical exhaustion related to decreased physical activity 4. Decrease of verbal expression related to slowed thought processes

4 Rationale: As depression increases, thought processes become slower and verbal expression decreases due to lack of emotional energy. Elation is associated with bipolar disorder, manic episode; the affect of a depressed person is usually one of sadness, or it may be blank. Loose associations are related to schizophrenia, not depression. Physical exhaustion is associated with bipolar disorder, manic episode; decreased physical activity does not produce physical exhaustion.

During a well-baby visit, the parents complain that their 2-year-old daughter soils herself because she is lazy. The parents plan to make her wear her soiled clothing to teach her a lesson. The nurse is concerned about the potential for child neglect and abuse. Which nursing intervention will be most therapeutic at this time? 1. Having child protective services remove the daughter from the home 2. Providing a toileting schedule and information regarding effective hygiene 3. Referring the parents to classes on anger management and communication skills 4. Teaching the parents developmental milestones in relation to acceptable discipline methods

4 Rationale: The parents' expectation of accident-free toilet training by age 2 years is developmentally unrealistic, and their methods of discipline may cause harm. Teaching them what to expect of their child and how to respond more appropriately is critical at this time. Having child protective services remove the daughter from the home is an unnecessary intervention; this intervention is appropriate for more serious situations of child endangerment. Although instruction in the importance of hygiene is helpful, the underlying issue is the parents' choice of inappropriate discipline for a 2-year-old child. Anger management and communication skills are not the problems.

A group of clients from a psychiatric unit are going to a professional baseball game accompanied by staff members. What is the purpose of visits into the community under the supervision of staff members? 1. They help clients adjust to stressors in the community. 2. They help clients return to reality under controlled conditions. 3. They broaden the clients' experiences by providing exposure to cultural activities. 4. The staff members can observe the clients' abilities to cope with a more complex society.

4 Rationale: The staff members' observations can help identify those clients who are ready to cope with outside stress and those who are not. Attendance at a ball game will not help clients adjust to community stressors or return to reality under controlled conditions. There is nothing to indicate that any of these clients needed to broaden their cultural experiences.

A nurse is caring for a client with the diagnosis of schizophrenia. During assessment the nurse identifies both positive (type I) and negative (type II) signs and symptoms. Which clinical findings should the nurse document as positive? Select all that apply. 1. Anergy 2. Flat affect 3. Social withdrawal 4. Disorganized thoughts 5. Auditory hallucinations

4, 5 Rationale: Disorganized thoughts (e.g., derailment, tangentiality, illogicality, incoherence, and circumstantiality) are a positive sign of schizophrenia. Positive signs and symptoms, referred to as "florid psychotic symptoms," are related to alterations in thinking, speech, perception, and behavior. They usually respond to antipsychotic medications. Positive symptoms reflect an excess or distortion of function and include delusions, hallucinations, increased speech production with associations, and bizarre behavior. A lack of energy (anergy) is a negative symptom associated with schizophrenia. Negative symptoms reflect a lessening or loss of normal function. A lack of emotional expression (flat affect) is a negative sign associated with schizophrenia. Inadequate social skills leading to withdrawal and isolation are negative symptoms associated with schizophrenia.

Which feelings should a nurse anticipate a client with bulimia nervosa to report experiencing during the time following an episode of binge eating? Select all that apply. 1. Happiness 2. Sleepiness 3. Loneliness 4. Hopelessness 5. Powerlessness

4, 5 Rationale: When clients feel powerless and helpless, they often lose hope. They feel desperate, despondent, and dejected. Clients with bulimia nervosa have a sense of being out of control that accompanies the excessive or compulsive consumption of large amounts of food, resulting in feelings of powerlessness, helplessness, and hopelessness. They tend to feel depressed rather than happy. Sleepiness is not experienced during an episode following binge eating; however, severe electrolyte imbalances caused by binge eating may result in weakness and fatigue. Although people with bulimia nervosa tend to binge alone and in secret, loneliness is not the primary feeling experienced during binge eating.