NSG-322 PRACTICE HESI

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

Tell the client that therapy cannot take place while she is intoxicated.

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

Coping Skills

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

Do you frequently have temper tantrums?

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

Domestic violence interventions.

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

Express concern over his disappointment.

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

Focus on the client's positive or negative feelings toward the nurse.

A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement?

Inform the healthcare provider and document the plan in the record.

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

Global confusion and inability to recognize family members.

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

How did this happen to you?

Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care?

I have a necktie in my room that I can use to hang myself.

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

I manage our finances great because I buy in big quantities.

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

Inability to recognize one's location.

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

Increased thyroid stimulating hormone (TSH).

The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

Monitor vital signs.

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

Reality testing

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

Self-analysis

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

Tells when voices decrease.

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

You seem pretty upset. Tell me about it.

During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client?

Have you had any thoughts of hurting yourself?

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

By learning what led to my latest relapse, I know what to do in the future.

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

Psychoanalytical

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

Results show activity in various portions of the brain.

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

Self-Awareness.

At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first?

Ask a group member to seek help.

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

Identifies own strengths

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement?

Ask the client what name she had picked out for the infant.

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

Begin one-on-one supervision immediately.

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

Tell me more about what you mean when you say that your problems with alcohol are now behind you

A male client is brought to the emergency department by a police officer, who reports the client was "disturbing the peace" by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that apply.)

Threats to kill his friend, hears voices telling him to kill himself, reports he has not needed a bath in 4 months and says he has not eaten in 3 days.

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

Dietician.

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

Panic disorder is treatable in a number of different ways, including medication.

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

"Tell me more about how things are with you."

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

Reflect the client's behavior and its consequences.

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

Require the husband to leave the cubicle while the client is being treated.

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

Search the client's personal belongings.

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

The client will report feeling safe with his daughter's care at home.

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

Prepare the environment to prevent self-injury.

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

Administer acetylcysteine (Mucocyst).

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

Ask the family if they would like to see and hold the infant after birth.

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

Cannot mentally retrace objects that were recently misplaced.

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

Chemical messengers that cause brain cells to turn on or off.

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

Collect a complete substance abuse history.

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

Reassign an all-female healthcare team to the client until her fear subsides

The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action?

Reevaluate the client's blood pressure in an hour.

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

Drugs taken in last 7 days.

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

Ensure that there is physical space between the nurse and client.

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

Evaluate the child for other injuries.

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

Explain the rape protocol to the client.

A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take?

Inquire about emotional factors affecting the client's present condition.

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

Interpersonal and intrapersonal skills.

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

The client's consent may have been coerced.

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

Help summarize accomplishments.

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

High risk for fluid and electrolyte imbalance.

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

Suicidal ideation.

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

A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless."

Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby?

Keep the body available for a few hours in case they change their minds.

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

Provide information about infection prevention.

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

The client must participate in making decisions about one's own physical and mental health.

Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?

Establish rapport in each phase of the nurse-client relationship.

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

Escort the client to a quieter place

A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse?

Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.