NSG 503P HESI Practice: Psychiatric/Mental Health Assignment Exam

The nurse should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (Select all that apply.) Select all that apply 1. Permit rest periods as needed. 2. Speaking slowly and simply. 3. Place the client on suicide precautions. 4. Observe and encourage food and fluid intake. 5. Encourage vigorous exercise and long walks on the unit.

ANS: 1, 2, 3, 4 1. Permit rest periods as needed. 2. Speaking slowly and simply. 3. Place the client on suicide precautions. 4. Observe and encourage food and fluid intake. Rationale: Neurovegetative symptoms that accompany the mood disorder of depression include physiological disruptions, such as anorexia, constipation, sleep disturbance, and psychomotor retardation. The client's plan of care should include measures that promote the client's comfort and well-being, such as rest, nutrition, suicide precautions, and simple communications. Vigorous exercise and long walks are not indicated for clients in a neurovegetative state.

A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (Select all that apply.) Select all that apply 1. Compulsions relieve anxiety. 2. Anxiety is the key reason for OCD. 3. Obsessions cause compulsions. 4. Obsessive thoughts are linked to levels of neurochemicals. 5. Antidepressant medications increase serotonin levels.

ANS: 1, 2, 4, 5 1. Compulsions relieve anxiety. 2. Anxiety is the key reason for OCD. 4. Obsessive thoughts are linked to levels of neurochemicals. 5. Antidepressant medications increase serotonin levels. Rationale: To promote client understanding and compliance, the teaching plan should include explanations about the origin and treatment options of OCD symptomatology. Compulsions are behaviors that help relieve anxiety, which is a vague feeling related to unknown fears, that motivate behavior to help the client cope and feel secure. OCD is supported by the neurophysiology theory, which attributes a diminished level of neurochemicals, particularly serotonin, and responds to selective serotonin reuptake inhibitors (SSRI). All obsessions do not result in compulsive behavior.

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? 1. Ask a group member to seek help. 2. Obtain the client's blood pressure. 3. Position in a recovery position. 4. Assess the client's level of orientation.

ANS: 1. Ask a group member to seek help. Rationale: First, help should be obtained while the nurse remains with the client. Next, assessment of the client should be completed. Lastly, the client should be positioned to prevent aspiration while recovering.

A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care? 1. Remind the client that his suspicions are not true. 2. Ask one nurse to spend time with the client daily. 3. Encourage the client to participate in group activities. 4. Assign the client to a room closest to the activity room.

ANS: 1. Ask one nurse to spend time with the client daily. Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationships, the plan of care should include providing one nurse to spend time with the client daily, which is likely to be therapeutic for this client. The other actions are too stressful for the client and not indicated.

A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider? 1. Decreased thyroid stimulating hormone level. 2. Elevated liver function profile. 3. Increased white blood cell count. 4. Decreased hematocrit and hemoglobin levels.

ANS: 1. Decreased thyroid stimulating hormone level.

A woman brings her husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. Which disorder manifests these behaviors? 1. Dissociative disorder. 2. Obsessive-compulsive disorder. 3. Panic disorder. 4. Post-traumatic stress syndrome.

ANS: 1. Dissociative disorder. Rationale: Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is exhibited in dissociative disorders. The other disorders do not manifest this client's behaviors.

An adult client who has been hospitalized for two weeks for chronic paranoia continues to state that someone is trying to steal the client's clothing. Which action should the nurse to take? 1. Encourage the client to actively participate in assigned activities on the unit. 2. Place a lock on the client's closet. 3. Ignore the client's paranoid ideation to extinguish these behaviors. 4. Explain to the client that his suspicions are false.

ANS: 1. Encourage the client to actively participate in assigned activities on the unit. Rationale: Diverting the client's attention from paranoid ideation and encouraging the client to complete unit assignments can be helpful in assisting develop a positive self-image. The other actions are not indicated.

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make? 1. How can I help? 2. Things probably aren't as bad as they seem right now. 3. Let's talk about what is right with your life. 4. I hear how miserable you are, but things will get better soon.

ANS: 1. How can I help? Rationale: Offering self shows empathy and caring and is the best response to provide. The other responses do not convey that the nurse is listening to the client's distress.

An older female client is admitted to the psychiatric unit with a diagnosis of major depression. Which client statement indicates to the nurse that further assessment is indicated? 1. I will die if my cat dies. 2. I don't feel like eating this morning. 3. I just went to my friend's funeral. 4. Don't you have more important things to do?

ANS: 1. I will die if my cat dies. Rationale: Clients who use an analogy, such as a cat's death, may be describing themselves and can indicate the client's thought of suicide, which needs further assessment. The other statements are examples of decreased energy and mood levels and are not suicidal ideation at this time.

A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response is best for the nurse to make? 1. I'll leave your tray here. I am available if you need anything else. 2. You're not being poisoned. Why do you think someone is trying to poison you? 3. No one on this unit has ever died from poisoning. You're safe here. 5. I will talk to your healthcare provider about the possibility of changing your diet.

ANS: 1. I'll leave your tray here. I am available if you need anything else. Rationale: The nurse should not argue with a client who is paranoid nor demand that the client eat, but should be supportive and convey the nurse's availability if needed. The other responses are not indicated.

The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes should she expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common? 1. Inability to recognize one's location. 2. Personality changes and agitation. 3. Depression and emotional lability. 4. Alterations in communication.

ANS: 1. Inability to recognize one's location. Rationale: Evidence indicates that frequent incidences of confusion, such as being unable to recognize one's location in a familiar environment is associated with the early stages of Alzheimer's Disease. The other manifestations occur with later stages of AD.

The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing problem for discharge planning? 1. Ineffective denial related to situational anxiety. 2. Ineffective coping related to inadequate support. 3. Social isolation related to difficult interactions. 4. Self-care deficit related to cognitive impairment.

ANS: 1. Ineffective denial related to situational anxiety. Rationale: The client is unable to acknowledge the move to a boarding home, which is related to denial related to situational anxiety. the other problem statements may also be indicated but the client's use of denial as a defense mechanism keeps the client from dealing with his feelings about living arrangements.

A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client? 1. Let me call and leave a message for your healthcare provider. 2. The healthcare provider should be here on Monday morning. 3. How can I help answer your questions? 4. What concerns do you have at this time?

ANS: 1. Let me call and leave a message for your healthcare provider. Rationale: Clients have the right to information about their treatment. The nurse should reassure the client that a call to notify the healthcare provider will be readily placed. The other responses are not the highest priority intervention.

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which side effect reported by the client is related to administration of this drug? 1. My mouth feels like cotton. 2. That stuff gives me indigestion. 3. This pill gives me diarrhea. 4. My urine looks pink.

ANS: 1. My mouth feels like cotton. Rationale: A dry mouth is an anticholinergic response that is an expected side effect of MAO inhibitors, such as phenelzine sulfate (Nardil). The other subjective reports are not related to this medication.

A client 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? 1. Panic disorder is treatable in a number of different ways, including medication. 2. Understanding the fact that a cure is not attainable helps the client learn to adjust. 3. This disorder is a biologically determined hereditary disease that has no cure. 4. Evidence based practice indicates that neuroleptic drugs can be used prophylactically.

ANS: 1. Panic disorder is treatable in a number of different ways, including medication. Rationale: To foster the client's ability to cope, effective treatment options for panic disorder, such as desensitization, cognitive restructuring, relaxation, and psychotropic medications, should be discussed. The other information does not provide accurate information.

An adult male who is a sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the client attempting to achieve? 1. Self-Actualization. 2. Loving and Belonging. 3. Basic Needs. 4. Safety and Security.

ANS: 1. Self-Actualization. Rationale: Self-actualization is the highest level of Maslow's development stages, which is an attempt to fulfill one's full potential. The other stages do not focus on this client's statement.

A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide? 1. Tell yourself that the voices are unreasonable. 2. Exercise when you hear the voices. 3. Talk to someone when you hear the voices. 4. The voices aren't real, so ignore them.

ANS: 1. Tell yourself that the voices are unreasonable. Rationale: The nurse should teach the client to use self-talk to disprove the voices since auditory hallucinations are often relentless and difficult to ignore. The other responses are not indicated because a client with schizophrenia uses concrete thinking and has difficulty interacting with others.

A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching? 1. When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. 2. While I am on vacation and when I return, I will not eat or drink anything that contains alcohol. 3. I will notify the healthcare provider if I have a sore throat or flu-like symptoms. 4. I will continue to take my benztropine mesylate (Cogentin) every day.

ANS: 1. When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection. Rationale: Photosensitivity is a side effect of Prolixin and a vacation in a tropical climate increases the client's chance of experiencing this side effect. The nurse should teach the client to avoid direct sun and wear sunscreen. The other client statements do not indicate the need for further teaching.

An older female client reports to the nurse that recently she has been hearing voices. Which question should the nurse ask this client first? 1. Do you have problems with hallucinations? 2. Are you ever alone when you hear the voices? 3. Has anyone in your family had hearing problems? 4. Do you see things that others cannot see?

ANS: 2. Are you ever alone when you hear the voices? Rationale: Determining if the client is alone when hearing voices will assist in differentiating between hallucinations and hearing loss, which is common in the aging population. Other follow-up questions should then be asked to further validate if the client is experiencing auditory hallucinations.

The nurse is planning the care for an adult client with acute depression. Which intervention should the nurse implement to help the client deal with depression? 1. Ensure that the client's day is filled with group activities. 2. Assist the client in exploring feelings of shame, anger, and guilt. 3. Allow the client to initiate and determine activities of daily living. 4. Encourage the client to explore the rationale for depression.

ANS: 2. Assist the client in exploring feelings of shame, anger, and guilt. Rationale: Depression is associated with feelings of shame, anger, and guilt. Exploring such feelings with the client is an important nursing intervention for a client who is acutely depressed. The other interventions are not indicated.

A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time? 1. Check on the client every 15 minutes. 2. Begin one-on-one supervision immediately. 3. Keep the room dimly lit and turn on the radio. 4. Push fluids and provide calorie-rich nutritional supplements.

ANS: 2. Begin one-on-one supervision immediately. Rationale: One-on-one supervision ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Although the other actions may be indicated, they do not provide immediate assessment of the client's ongoing safety.

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? 1. Encourage him to share his feelings more appropriately. 2. Express concern over his disappointment. 3. Arrange to have a clergy person visit. 4. Administer a PRN prescription for an antianxiety drug.

ANS: 2. Express concern over his disappointment. Rationale: The therapeutic action that is nonjudgmental and supportive should address the client's disappointment and feelings of frustration in a safe environment. The other actions are not supportive of the client's expressions and are not indicated as the first response to frustration and anger.

A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first? 1. The emergency room nurse. 2. His case manager. 3. The clinic healthcare provider. 4. His support group sponsor.

ANS: 2. His case manager. Rationale: The case manager is responsible for coordinating community services. Since this client has a dual diagnosis, the nurse should refer the client to the case manager to explore available treatment options. The other referrals are not indicated.

Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care? 1. If I fail another class, I'm going to kill myself. 2. I have a necktie in my room that I can use to hang myself. 3. When I leave home to live on my own, I'm buying myself a gun. 4. I took two bottles of Mom's pills and had to have my stomach pumped.

ANS: 2. I have a necktie in my room that I can use to hang myself. Rationale: Assessment of suicidal ideations should include the degree of lethality of the method, the individual's access to whatever is needed to carry out the attempt, and the specifics of the plan. The more detailed the plan, the greater the risk for a successful attempt. A necktie in the adolescent's room implies a lethal plan with an accessible, available means to act and implement a suicidal ideation. The other client expressions are relative to time, that is, future suicidal plans with stipulations which allows time for intervention, or a historical account of a previous suicidal attempt.

At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things would one like to do with the group. The older woman shrugs her shoulders and says, "You tell me, you're the leader." What is the best response for the nurse to make? 1. I am the leader today. Would you like to be the leader tomorrow? 2. I will be leading this group. What would you like to accomplish during this time? 3. I have been assigned to be the leader of this group. I will be here for the next six weeks. 4. I am the leader. You seem angry about not being the leader yourself.

ANS: 2. I will be leading this group. What would you like to accomplish during this time? Rationale: Anxiety about participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. The nurse should provide information that focuses the group back to defining its function. The other responses do not focus the group on its purpose or task.

A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. Which defense mechanism is the client using? 1. Sublimation. 2. Identification. 3. Introjection. 4. Repression.

ANS: 2. Identification. Rationale: Identification is an attempt to be like someone or emulate the personality traits of another. The client is not demonstrating the other psychosocial mechanisms.

An adult female client who has been taking antipsychotic neuroleptic medication for the past three days has a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action should the nurse initiate? 1. Place the client on seizure precautions and monitor carefully. 2. Immediately transfer the client to intensive care unit. 3. Describe the symptoms to the charge nurse and record on the client's chart. 4. No action is required at this time as these are known side effects of such drugs.

ANS: 2. Immediately transfer the client to intensive care unit. Rationale: These symptoms are descriptive of a life threatening reaction to neuroleptic drugs, known as neuroleptic malignant syndrome (NMS) which is manifested by fever, rigidity, autonomic instability, and encephalopathy. This is an emergency reaction, and the client requires immediate critical care. The other actions do not address the potential of respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure that can result in death due to NMS.

The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic? 1. Loss of independence. 2. Increased self-understanding. 3. Isolation from society. 4. Development of intimate relationships.

ANS: 2. Increased self-understanding. Rationale: Middle adulthood is characterized by self-reflection, understanding, acceptance, and generativity or guidance of children. The other developmental tasks are not specific to middle adulthood.

The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam? 1. Acute psychiatric illnesses impair intelligence. 2. Intelligence is influenced by social and cultural beliefs. 3. Poor concentration skills suggests limited intelligence. 4. The inability to think abstractly indicates limited intelligence.

ANS: 2. Intelligence is influenced by social and cultural beliefs. Rationale: Social and cultural beliefs have significant impact on intelligence. The other factors do not necessarily suggest limited intelligence.

When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness? 1. Linguistic and musical abilities. 2. Interpersonal and intrapersonal skills. 3. Bodily kinesthetic and spatial abilities. 4. Logical mathematics and linguistic abilities.

ANS: 2. Interpersonal and intrapersonal skills. Rationale: Interpersonal and intrapersonal intelligence form one's emotional intelligence or "emotional quotient." The nurse should focus inquiries on social skills. The other client capabilities do not assess emotional intelligence.

The wife of a male client recently diagnosed with schizophrenia asks the nurse, "What exactly is schizophrenia? Is my husband all right?" Which response is best for the nurse to provide to this family member? 1. It sounds like you're worried about your husband. Let's sit down and talk. 2. It is a chemical imbalance in the brain that causes disorganized thinking. 3. Your husband will be just fine if he takes his medications regularly. 4. I think you should talk to your husband's psychologist about this question.

ANS: 2. It is a chemical imbalance in the brain that causes disorganized thinking. Rationale: The nurse should answer the client's question with factual information and explain that schizophrenia is a chemical imbalance in the brain. The other responses do not directly answer the question.

When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include? 1. It may take 3 to 4 weeks to achieve therapeutic effects. 2. Keep your dietary salt intake consistent. 3. Avoid eating aged cheese and chicken liver. 4. Eat foods high in fiber such as whole grain breads.

ANS: 2. Keep your dietary salt intake consistent. Rationale: The effectiveness of Lithium is influenced by salt intake, so the client should maintain a consistent amount of salt intake. Too much salt causes more lithium to be excreted, thereby decreasing the effectiveness of the drug. Too little salt causes less lithium to be excreted, potentially resulting in toxicity. The other instructions are not specific to teaching about lithium carbonate (Lithonate).

The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit? 1. Monitor appetite and observe intake at meals. 2. Maintain safety in the client's milieu. 3. Provide ongoing, supportive contact. 4. Encourage participation in activities.

ANS: 2. Maintain safety in the client's milieu. Rationale: A client who is depressed is at risk for suicide. The most important reason for close observation immediately after admission is to maintain safety due to the client's potential risk for self injury. The other interventions are not the priority.

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? 1. Notify the healthcare provider immediately and prepare for administration of an antidote. 2. Notify the healthcare provider of the symptoms prior to the next administration of the drug. 3. Record the symptoms as normal side effects and continue administration of the prescribed dosage. 4. Hold the medication and refuse to administer additional amounts of the drug.

ANS: 2. Notify the healthcare provider of the symptoms prior to the next administration of the drug. Rationale: Early side effects of lithium carbonate that occur with a serum lithium levels below 2.0 mEq/L generally follow a progressive pattern beginning with diarrhea, vomiting, drowsiness, and muscular weakness. The nurse should notify the healthcare provider before giving the next dose, which can contribute to higher serum drug levels that may cause ataxia, tinnitus, blurred vision, and large dilute urine output. The other actions are not indicated.

On admission to a residential care facility, an older female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-fours after admission, the nurse notes that the client is withdrawn and isolated. Which activity should the nurse encourage the client to become involved and participate? 1. Clean the unit kitchen cabinets. 2. Participate in a group quilting project. 3. Watch television in the activity room. 4. Bake a cake for a resident's birthday.

ANS: 2. Participate in a group quilting project. Rationale: Peer interaction in a group activity that is identified by the client has a hobby or diversion helps to engage the client with others, which prevents social isolation and withdrawal. The other activities do not involve peer interaction and may promote social isolation.

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? 1. Leave the room without saying a word. 2. Provide information about infection prevention. 3. Allow the client to change the dressing himself. 4. Explain the healthcare provider's prescription.

ANS: 2. Provide information about infection prevention. Rationale: Several factors impact a client who is angry and providing nursing feedback may help lower the client's anger and impact readiness to accept the nurse's interventions in providing care. Since the dressing change is initiated, making the client aware of why the dressing change is necessary to control infection can be therapeutic in forming a nurse-client relationship. The other actions are not indicated and may only escalate the client's anger if the nurse offers no alternatives to addressing the presenting issues during the dressing change.

A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature 100o F, pulse 100 beats/minute, and blood pressure 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority client problem? 1. Risk for injury related to suicidal ideation. 2. Risk for injury related to alcohol detoxification. 3. Knowledge deficit related to ineffective coping. 4. Health seeking behaviors related to personal crisis.

ANS: 2. Risk for injury related to alcohol detoxification. Rationale: The most important client problem is alcohol detoxification because the client has elevated vital signs, a sign of alcohol detoxification. Maintaining client safety is the priority, and the risk for injury should be addressed after giving the client Ativan for elevated vital signs secondary to alcohol withdrawal. The other problems are not the priority.

A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time? 1. Isolation. 2. Stagnation. 3. Despair. 4. Role confusion.

ANS: 2. Stagnation. Rationale: The client is in Erikson's "Generativity vs. Stagnation" stage (age 24 to 45), and meeting the task includes maintaining intimate relationships and moving toward developing a family. Stagnation occur if an individual is not successfully coping with a psychosocial developmental stage related to age.

A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" Which goal is best for the nurse to include in the client's plan of care? 1. Teach the client to outline methods for managing anger. 2. Suggest actions to control impulsive responses toward self and others. 3. Encourage client to verbalize feelings when anger occurs. 4. Discuss recognizing consequences for behaviors exhibited.

ANS: 2. Suggest actions to control impulsive responses toward self and others. Rationale: Those with bipolar disorder often exhibit poor impulse control, and the most important goal for this client at this time is to learn to control impulsive behavior so that he can avert the social consequences related to such behaviors. The other goals do not address the acute issue of impulse control, which is necessary to minimize the likelihood of self harm and harm to others.

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? 1. Yes, but do you know that the treatment program you attended has an excellent success profile? 2. Tell me more about what you mean when you say that your problems with alcohol are now behind you. 3. You are likely to have a difficult time staying sober if you think that problems with alcohol are behind you. 4. Do you know what "one day at a time" means for those who have problems with alcohol?

ANS: 2. Tell me more about what you mean when you say that your problems with alcohol are now behind you. Rationale: Those who attend alcohol treatment programs and Alcoholics Anonymous never put drinking problems behind them and describe alcoholics as only one step away from a slip with maintaining sobriety. The nurse should use reflection and encourage the client to further describe the feelings. The other responses do not encourage the client to reflect on his recovery.

Physical examination of a school-aged child reveals several bite marks in various locations on the body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that the child is always having accidents. Which initial response is best for the nurse to make? 1. I need to inform the healthcare provider about your child's tendency to be accident prone. 2. Tell me more specifically about your child's accidents. 3. I must report these injuries to the authorities because they do not seem accidental. 4. Boys this age always seem to require more supervision and can be quite accident prone.

ANS: 2. Tell me more specifically about your child's accidents. Rationale: Using an open ended, non-threatening statement is best to seek more information. The other responses are not indicated.

An older female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide? 1. Orient the client to the time, place, and person. 2. Tell the client that the nurse is there and will help her. 3. Remind the client that her mother is no longer living. 4. Explain the seriousness of her injury and need for hospitalization.

ANS: 2. Tell the client that the nurse is there and will help her. Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of "offering self" and "talking to the feelings" to provide reassurance. Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, and the other reponses are not likely to help the client's emotional distress.

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? 1. The client will verbalize an acceptance of his health status and dependency. 2. The client will report feeling safe with his daughter's care at home. 3. The client will report the frequency of abuse has decreased. 4. The client will describes the potential danger of his situation.

ANS: 2. The client will report feeling safe with his daughter's care at home. Rationale: The priority outcome should the client feeling safe and satisfied with his care by his daughter at home. The other statements are not outcomes that are client-centered and measurable.

An adult female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. Which condition is this client likely manifesting? 1. Claustrophobia. 2. Acrophobia. 3. Agoraphobia. 4. Post-traumatic stress disorder.

ANS: 3. Agoraphobia. Rationale: Agoraphobia is the fear of crowds or being in an open place. The other anxiety and phobic conditions are not manifested by a fear of leaving a protected environment, such as home.

Over a period of several weeks, a male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? 1. Talk to the client outside the group about his behavior during group meetings. 2. Remind the client to allow others in the group a chance to talk. 3. Allow the group to handle the problem. 4. Ask the client to join another group.

ANS: 3. Allow the group to handle the problem. Rationale: The phase the group process is in--initial, working, or termination--this will help determine communication styles between the group members. After several weeks, the group is in the working phase and the group members should be allowed to determine the direction of the group. The nurse should ignore the client's comments and allow the group to address the situation.

Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior? 1. Administer a prescribed PRN antianxiety medication. 2. Assist the client to identify stimuli that precipitates the ritualistic activity. 3. Allow time for the ritualistic behavior, then redirect the client to other activities. 4. Teach the client relaxation and thought stopping techniques.

ANS: 3. Allow time for the ritualistic behavior, then redirect the client to other activities. Rationale: Initially, the nurse should allow time for the ritual to prevent anxiety. The other actions may help reduce the client's anxiety, but do not address the ritualistic behavior associated with anxiety and ineffective coping ability.

The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history on admission to the hospital? 1. Determine if the client attends a support group weekly. 2. Hold all antidepressant medications until further notice. 3. Ask the client if he takes St. John's Wort routinely. 4. Have the client describe any recent changes in mood.

ANS: 3. Ask the client if he takes St. John's Wort routinely. Rationale: St. John's Wort, an herbal preparation, is an alternative therapy for depression and may adversely interact with medications used to treat HIV infection. The nurse's top priority upon admission is to determine if the client has been taking this herb concurrently with HIV antiviral drugs, which may explain the rise in the viral load. The other actions are not indicated.

A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take? 1. Reassure the client by telling him that his fear of the admission procedure is to be expected. 2. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place. 3. Assess the content of the hallucinations by asking the client what he is hearing. 4. Ignore the behavior and make no response at all to his delusional statements.

ANS: 3. Assess the content of the hallucinations by asking the client what he is hearing. Rationale: Further assessment is indicated and the nurse should obtain information about what the client believes the voices are telling him--they may be telling him to kill himself or the nurse. The other actions are not indicated.

A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms? 1. Perphenazine (Trilafon). 2. Diphenhydramine (Benadryl). 3. Chlordiazepoxide (Librium). 4. Isocarboxazid (Marplan).

ANS: 3. Chlordiazepoxide (Librium). Rationale: Librium, an antianxiety drug as well as other benzodiazepines, is used in titrated doses to reduce the severity of abrupt benzodiazepine withdrawal. The other medications are not indicated for benzodiazepine withdrawal.

An older male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change and the nurse formulates the client's problem as confusion related to ICU psychosis. Which intervention is most important for the nurse implement? 1. Move all machines away from the client's immediate area. 2. Attempt to allay the client's fears by explaining the etiology of confusion. 3. Cluster care so brief periods of rest can be scheduled during the day. 4. Extend visitation times for family and friends.

ANS: 3. Cluster care so brief periods of rest can be scheduled during the day. Rationale: The critical care environment confronts clients with an environment which is stressful and heightened by treatment modalities that may prove to be lifesaving. These stressors can result in isolation or sensory overload that leads to confusion. The best intervention is to cluster care to provide the client with uninterrupted rest periods. The other actions may not be possible.

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? 1. Occupational therapist. 2. Recreational therapist. 3. Dietician. 4. Physician.

ANS: 3. Dietician. Rationale: The nurse should ask for a referral to the dietician who can assist the client with meal planning for weight reduction. The other members of the healthcare team do not give guidance about meal planning.

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected therapeutic response has the highest priority during pharmacological managment for withdrawal? 1. Client will not demonstrate cross-addiction. 2. Codependent behaviors will be decreased. 3. Excessive CNS stimulation will be reduced. 4. Client's level of consciousness will increase.

ANS: 3. Excessive CNS stimulation will be reduced. Rationale: Substitution therapy with another CNS depressant is intended to decrease excessive CNS stimulation that can occur during benzodiazepine withdrawal. The other effects are not the expected therapeutic response.

An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide? 1. You are in the hospital, and I am the nurse caring for you. 2. It must be difficult for you to control your anxious feelings. 3. Go to occupational therapy and start a project. 4. You are not in a war area now; this is the United States.

ANS: 3. Go to occupational therapy and start a project. Rationale: Delusions, which are often well-fixed, often generate fear and isolation. The nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others. The other responses are not indicated and do not distract the client or reassure that he is in a safe place.

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? 1. On a scale of 1 to 10 how do you rate your anxiety level? 2. How would you describe your mood right now? 3. Have you had any thoughts of hurting yourself? 4. What medications have you taken in the last 24 hours?

ANS: 3. Have you had any thoughts of hurting yourself? Rationale: Assessing for suicidal ideation is most essential. The other assessments should be made, and to ensure client safety, thoughts of self-harm are most important.

A young adult male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage? 1. He ingested the drug 3 hours prior to admission to the emergency center. 2. The family reports that he took an entire bottle of acetaminophen (Tylenol). 3. He is unresponsive to instructions and is unable to cooperate with emetic therapy. 4. Those with repeated suicide attempts desire punishment to relieve their guilt.

ANS: 3. He is unresponsive to instructions and is unable to cooperate with emetic therapy. Rationale: Because the client is unable to follow instructions, emetic therapy would be very difficult to implement, therefore gastric lavage is necessary. The other actions are not the basis for determining if gastric lavage is indicated.

The parents of a 14-year-old boy bring their son to the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills." During initial assessment of the adolescent, what information is most important for the nurse to obtain from the parents? 1. If he has seemed depressed recently. 2. If a drug overdose has ever occurred before. 3. If he might have taken any other drugs. 4. If he has a desire to quit taking drugs.

ANS: 3. If he might have taken any other drugs. Rationale: Knowledge of all substances taken guide further treatment, such as administration of antagonists. The nurse should ask the parents if the adolescent may have taken other drugs. The other assessments are not indicated at this time.

An older female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response should the nurse provide? 1. Anywhere you want to stand as long as you do not get hurt by those in the parade. 2. You are confused because of all the activity in the hall. There is no parade. 3. Let's go back to the activity room and see what is going on in there. 4. Remember I told you that this is a nursing home and I am your nurse.

ANS: 3. Let's go back to the activity room and see what is going on in there. Rationale: It is common for those with Alzheimer's disease (AD) to use the wrong words. Redirecting the client, using an accepting non-judgmental dialogue, to a safer place and familiar activities is most helpful because clients with AD experience short-term memory loss. The other responses dismiss the client's attempt to find order, do not help her relate to the surroundings, and are frustrating which increase anxiety level.

The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority? 1. Excessive work activity. 2. Decreased need for sleep. 3. Medication management. 4. Inflated self-esteem.

ANS: 3. Medication management. Rationale: The most important nursing problem is medication management to help prevent hospitalization. The other behaviors are evidence of noncompliance with medication management.

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." Which assessment findi ng should the nurse reference when initiating a referral? 1. Altered thought processes. 2. Moderate levels of anxiety. 3. Inadequate social support. 4. Altered health maintenance.

ANS: 3. Moderate levels of anxiety. Rationale: The nurse should initiate a referral based on anxiety levels and feelings of nervousness that the client described as interfering with sleep, appetite, and the inability to solve problems. The other findings are not indicated based on the client's reported symptoms.

The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge? 1. Crickets are a good source of protein. 2. I have not heard any voices for a week. 3. Only my belief in God can help me. 4. Sometimes I have a hard time sitting still.

ANS: 3. Only my belief in God can help me. Rationale: The most frequent cause of increased symptoms in clients who are psychotic is noncompliance with the medication regimen. If the client believes that "God alone" can help, which may be a delusion and not faith-based, the client may discontinue the prescribed medication. The other client statements do not pose the greatest threat to the client's prognosis.

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make? 1. Did you really believe you were Jesus Christ? 2. I think you're getting well. 3. Others have had similar thoughts when under stress. 4. Why did you think you were Jesus Christ?

ANS: 3. Others have had similar thoughts when under stress. Rationale: The nurse should offer support by assuring the client that others have suffered as he has. The other responses are not therapeutic and not indicated.

A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best behavioral interpretation of the mother's statements? 1. Regressing to an earlier behavior pattern. 2. Sublimating anger. 3. Projecting feelings onto the nurse. 4. Suppressing fear.

ANS: 3. Projecting feelings onto the nurse. Rationale: Projection is attributing one's own thoughts, impulses, or behaviors onto another--it may be the mother who might be harming the child and she is attributing her actions to the nurse. The other evaluations are not the most likely based on the child's history of previous injuries.

A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond? 1. I would be very upset and mad if my best friend did that to me. 2. You must feel betrayed, but maybe you might have led him on? 3. Rape is not limited to strangers and frequently occurs by someone who is known to the victim. 4. This does not sound like rape. Did you change your mind about having sex after the fact?

ANS: 3. Rape is not limited to strangers and frequently occurs by someone who is known to the victim. Rationale: A victim of date rape, or acquaintance rape, is less prone to recognize what is happening when the incident involves persons who know each other, so the dynamics are different than rape by a stranger. Explaining that rape can and often occurs by a perpetrator that the victim frequently knows and trusts provides confrontation for the client's denial. The other responses are not therapeutic and are not indicated.

A client with bipolar disorder on the mental health unit becomes loud, and shouts at one of the nurses, "You fat tub of lard! Get something done around here!" What is the best initial action for the nurse to take? 1. Have the orderly escort the client to his room. 2. Tell the client his healthcare provider will be notified if he continues to be verbally abusive. 3. Redirect the client's energy by asking him to tidy the recreation room. 4. Call the healthcare provider to obtain a prescription for a sedative. Submit

ANS: 3. Redirect the client's energy by asking him to tidy the recreation room. Rationale: Distracting the client, or redirecting his energy, prevents further escalation of the inappropriate behavior. The other actions are not indicated at this time and could escalate the abuse unnecessarily.

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? 1. Images indicate the presence of tumors and scars. 2. The scan clearly outlined structures of the brain. 3. Results show activity in various portions of the brain. 4. PET shows biochemical levels of neurotransmitters. Submit

ANS: 3. Results show activity in various portions of the brain. Rationale: The result of a PET scan, which is used to detect cerebral activity in depression, schizophrenia, and Alzheimer's disease, shows brightly colored cerebral areas where an accumulation of a radioactively tagged glucose is used as a tracer to visualize brain activity, blood flow, and glucose metabolism. The other responses do not explain PET scanning.

The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome? 1. Dementia. 2. Depression. 3. Schizophrenia. 4. Chronic brain syndrome.

ANS: 3. Schizophrenia. Rationale: The client is demonstrating disorganized speech that may include word salad using both real and imaginary words in no logical order, incoherent speech, and clanging (rhyming), which are positive symptoms of schizophrenia. The other syndromes are not manifested by word salad, clanging, or neologisms.

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? 1. Reflection. 2. Clarification. 3. Self-Awareness. 4. Focusing.

ANS: 3. Self-Awareness. Rationale: Self-awareness describes awareness of the nurse's own feelings while empathizing with the client. The other mechanisms are therapuetic communication skills that the nurse uses to allow a client to open up about experiences and feelings.

A young adult female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take? 1. Encourage the client's self-motivation by asking her to pass trays for the rest of the week. 2. Provide an additional challenge by asking the client to help feed the older clients. 3. Suggest another way for this client to participate in the unit's activities. 4. Tell the client that hospital guidelines allow only staff to pass the trays.

ANS: 3. Suggest another way for this client to participate in the unit's activities. Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit activities. The nurse should redirect the client's request and encourage the client to participate in another unit activity. The other responses are not indicated.

Based on noncompliance with the medication regimen, an adult client with a diagnosis of substance abuse and schizophrenia recently had a change in prescriptions from oral fluphenazine HCl (Prolixin) to fluphenazine decanoate (Prolixin IM). What is most important to teach the client and family about this change in medication regimen? 1. Signs and symptoms of extrapyramidal effects (EPS). 2. Information about substance abuse and schizophrenia. 3. The effects of alcohol and drug interaction. 4. The availability of support groups for those with dual diagnoses.

ANS: 3. The effects of alcohol and drug interaction. Rationale: Alcohol enhances the extrapyramidal side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin IM is 2 to 4 weeks. Drinking alcohol can be more severe when the client drinks alcohol after taking the long-acting Prolixin IM. The other information should be included in client teaching, but are not the priority with Prolixin.

A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? 1. The nurse should obtain objective data such as x-rays before reporting suspicions to the authorities. 2. The nurse should confirm any suspicions of child abuse with the healthcare provider before reporting to the authorities. 3. The nurse should report any case of suspected child abuse to the nurse in charge. 4. The nurse should note in the client's record any suspicions of child abuse so that a history of such suspicions can be tracked. Submit

ANS: 3. The nurse should report any case of suspected child abuse to the nurse in charge. Rationale: It is the nurse's legal responsibility to report all suspected cases of child abuse. Notifying the charge nurse starts the legal reporting process.

A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to which client assessment finding? 1. early childhood experiences involving authority issues. 2. anger about being hospitalized. 3. erroneous interpretation of reality. 4. phobic fear of food.

ANS: 3. erroneous interpretation of reality. Rationale: Psychotic clients have difficulty with trust and interpreting reality. Nursing care should be directed at building trust and promoting an accurate reality. Activities with limited concentration and no competition should be encouraged in order to build self-esteem. The other assessment findings are not specifically related to the development of delusions.

The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up? 1. Menstruation onset at age 9. 2. Contraceptive method includes condoms only. 3. Menstrual cycle occurs every 35 days. 4. "Black-out" after one drink last night on a date.

ANS: 4. "Black-out" after one drink last night on a date. Rationale: A "black-out" typically occurs after ingestion of alcohol beverages that the client has no recall of experiences or one's behavior and is indicative of high blood alcohol levels. The client's experience of a "black-out" after one drink is suspicious of the client receiving a "date rape" drug, such as flunitrazepam ("Rohypnol"), and needs additional follow-up. The other findings do not need follow-up at this time.

The nurse is assessing a client who is admitted with a diagnosis of depression. Which findings is characteristic of depression? 1. Grandiose ideation. 2. Self-destructive thoughts. 3. Suspiciousness of others. 4. A negative view of self and the future.

ANS: 4. A negative view of self and the future. Rationale: Negative self-image and feelings of hopelessness about the future are specific findings in depression. The other findings are not the underlying manifestations in depression.

An anxious client expressing a fear of people and open places is admitted to the psychiatric unit. What is the most effective way for the nurse to assist this client? 1. Plan an outing with the peer group within the first week of admission. 2. Distract the client whenever discomfort about being with others is expressed.. 3. Confront fears and discuss the possible causes of these fears with the client. 4. Accompany the client outside for an increasing amount of time each day.

ANS: 4. Accompany the client outside for an increasing amount of time each day. Rationale: The process of gradual desensitization by controlled exposure to the situation which is feared, is the treatment of choice in phobic reactions. The other options are not indicated in the initial phase of desensitization.

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? 1. Collect a specimen for a blood alcohol level (BAL). 2. Do nothing because the time for BAL determination is passed. 3. Review the results of a Breathalyzer obtained in the emergency department upon admission. 4. Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.

ANS: 4. Ask the client about the quantity, frequency, and time the last alcohol drink was ingested. Rationale: The priority assessment is to determine the client's risk for alcohol withdrawal, which can appear within 48 hours since the ingestion of the last alcoholic drink. The nurse should ask the client about quantity, frequency, and time of last drink. The other actions are not indicated at this time.

A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach should the nurse take? 1. Call a staff member to escort the client to his room. 2. Tell the client to talk to his healthcare provider about his privileges. 3. Remind the client of the unit rules. 4. Calmly address the client's inappropriate behavior.

ANS: 4. Calmly address the client's inappropriate behavior. Rationale: Calmly addressing inappropriate behavior minimizes escalation of the issue, specifically that the behavior is unacceptable. The other approaches are not indicated.

At a support meeting for parents of a teenager with polysubstance dependency, a parent states, "Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide." The nurse's response should be based on which information? 1. Addiction is a chronic, incurable disease. 2. Tolerance to the effects of drugs causes feelings of depression. 3. Feelings of depression frequently lead to drug abuse and addiction. 4. Careful monitoring should be provided during withdrawal from the drugs.

ANS: 4. Careful monitoring should be provided during withdrawal from the drugs. Rationale: The priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide. The other responses are not indicated.

The nurse is leading a "current events group" with client who have chronic psychiatric illnesses. One group member states, "Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me." Which response is best for the nurse to make? 1. Clara Barton was not your nurse. 2. What did she do to you that was so mean? 3. I didn't know that Clara Barton was a nurse. 4. Clara Barton started the American Red Cross.

ANS: 4. Clara Barton started the American Red Cross. Rationale: The historical fact that Clara Barton was a nurse during the Civil War is referencing the concept of universality in this group therapy discussion. Stating the original role of Clara Barton in nursing should be presented, which is the reality in nursing and the American culture. The other responses are not indicated.

An adult female client has been increasingly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? 1. No one is after you, you're safe here. 2. You'll feel better after you have rested. 3. I know you must feel lonely and frightened. 4. Come with me to your room and I will sit with you.

ANS: 4. Come with me to your room and I will sit with you. Rationale: The best response offers support without judgment or demands. The other responses are not therapeutic communication for a client who is hallucinating or experiencing a delusion, which are perceive by this client as a crisis.

The nurse is assessing a client with a history of borderline personality disorder. Which question should the nurse include in the assessment? 1. At what age did you begin to exhibit symptoms? 2. Do you have a family history of borderline disorder? 3. How often do you drink alcoholic beverages? 4. Do you frequently have temper tantrums?

ANS: 4. Do you frequently have temper tantrums? Rationale: A client with borderline personality disorder often has a history of intense outbursts of anger. The other questions may provide worthwhile information, but do not provide specific information about the client's symptomatology of borderline personality disorder.

The nurse should withhold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding? 1. Dizziness when standing. 2. Shuffling gait and hand tremors. 3. Urinary retention. 4. Fever of 102 F.

ANS: 4. Fever of 102 F. Rationale: A fever may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. The other findings are adverse effects of Haldol which are not life threatening.

A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is characteristic of a client with schizophrenia? 1. Mood swings. 2. Extreme sadness. 3. Manipulative behavior. 4. Flat affect.

ANS: 4. Flat affect. Rationale: Disinterest, and diminished or lack of facial expression is characteristic of schizophrenia and is referred to as a flat affect. The other findings are not associated with schizophrenia.

The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include in the plan of care? 1. Emphasize the client's strengths and assets. 2. Teach the importance of medication compliance. 3. Offer the client psychoeducational materials to read. 4. Focus on the client's positive or negative feelings toward the nurse.

ANS: 4. Focus on the client's positive or negative feelings toward the nurse. Rationale: Interactions and interventions that focus on the client's positive or negative feelings toward the nurse are based on the psychoanalytical model of mental health care. The other interventions are not associated with the psychoanalytical model.

Which action should the nurse implement during the termination phase of the nurse-client relationship? 1. Identify new problem areas. 2. Confront changes not completed. 3. Explore the client's past in depth. 4. Help summarize accomplishments.

ANS: 4. Help summarize accomplishments. Rationale: By noting the client's accomplishments, the client's progress and self-confidence can be summarized. The other phases of the nurse-client relationship focus on assessment, problem identification, confronting necessary changes.

The nurse plans to help an 18-year-old female intellectually disabled client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make? 1. Your healthcare provider has prescribed ambulation on the first postoperative day. 2. You must ambulate to avoid complications which could cause more discomfort than ambulating. 3. I know how you feel. You're angry about having to ambulate, but this will help you get well. 4. I'll be back in 30 minutes to help you get out of bed and walk around the room.

ANS: 4. I'll be back in 30 minutes to help you get out of bed and walk around the room. Rationale: Telling the adolescent that the nurse will be back in 30 minutes provides a "cooling off" period, is firm, direct, non-threatening, and avoids arguing with the client. The other responses are not therapeutic.

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? 1. Keep this information confidential until the client's release. 2. Immediately contact the the client's spouse and the lover. 3. File oral and written reports with the local police department. 4. Inform the healthcare provider and document the plan in the record.

ANS: 4. Inform the healthcare provider and document the plan in the record. Rationale: The Tarasoff decision gives mental health professionals a duty to warn prospective victims, but the extent and discharge of the duty may vary from state to state. The healthcare provider should be notified, and the information documented in the client's record. The other actions are not indicated.

Which action should the nurse implement first for a client experiencing alcohol withdrawal? 1. Apply vest or extremity restraints. 2. Give an alpha-adrenergic blocker. 3. Provide a diet high in protein and calories. 4. Prepare the environment to prevent self-injury.

ANS: 4. Prepare the environment to prevent self-injury. Rationale: During alcohol withdrawal, self-destructive or violent behavior can occur due to agitation and hallucinations and cause a potentially immediate and life-threatening risk to the client and others. The nurse should first provide a safe environment by removing any potential objects that could inflict self-injury. Secondary prevention strategies, administration of medications, and nutrition needs are then indicated.

An adult female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care? 1. Schedule her to attend various group activities. 2. Reinforce her ability to make her own decisions. 3. Encourage her to identify feelings of anger. 4. Provide a structured environment with little stimuli.

ANS: 4. Provide a structured environment with little stimuli. Rationale: Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment. Planning noncompetitive activities that can be carried out alone help to reduce stimuli. Impulsive decision-making is characteristic of clients with bipolar disorder and require the nurse to intervene when a client is making decisions. Anger is often repressed during depression, not mania.

On admission, a client who is highly anxious describes a delusion. The nurse understands that delusions are most likely to occur with which class of disorder? 1. Neurotic. 2. Personality. 3. Anxiety. 4. Psychotic.

ANS: 4. Psychotic. Rationale: Delusions are false beliefs associated with psychotic behavior that is not in touch with reality. The other mental health disorders are not associated with hallucinations (false sensations such as hearing, or seeing) or delusions (false beliefs), which are a break in reality.

During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, "I look around to see who's talking to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found out they were my imagination. The voices you hear aren't real either." Which phenomenon, common to groups, is exemplified in this interchange? 1. Catharsis. 2. Ventilation. 3. Universality. 4. Reality testing.

ANS: 4. Reality testing. Rationale: Reality testing is a process in which an individual validates one's perception of reality. Group members can provide reality testing by monitoring each member's reactions and behaviors and providing feedback in an open and nonthreatening manner. The other experiences occur during group sessions and not related to validating psychotic phenomena, as in this situation.

A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care? 1. Reassure the client that no one will harm her while she is in the hospital. 2. Ask the healthcare provider to give the client the medication. 3. Explain that the diabetic medication is important to take. 4. Reassess client's mental status for thought processes and content.

ANS: 4. Reassess client's mental status for thought processes and content. Rationale: The most important intervention is to reassess the client's mental status and to take further action based on the findings of this assessment. The other interventions are not likely to help a client who is having false beliefs.

What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable? 1. Do nothing and remember the client's rights. 2. Express doubt that the goal can be achieved. 3. Tell the client that the goal is unrealistic. 4. Reflect the client's behavior and its consequences.

ANS: 4. Reflect the client's behavior and its consequences. Rationale: A client who is psychotic is unable to visualizing the consequences of proposed goals. The use of reflection about the client's behavior and its consequences is a therapeutic response. The other responses halt therapeutic communication.

A 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? 1. Notify the local police of a suspected spousal abuse situation. 2. Ask the hospital security to remove the husband from the treatment room. 3. Reassure the husband that his wife will be treated well while he is in the waiting area. 4. Require the husband to leave the cubicle while the client is being treated.

ANS: 4. Require the husband to leave the cubicle while the client is being treated. Rationale: This client should be questioned about the possibility of spousal abuse and cannot answer truthfully in the presence of the perpetrator, so separating the couple is a priority. The nurse should require the husband to leave the cubicle while the client is being treated. The other interventions are not the priority.

Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen? 1. Hamburger, French fries, and chocolate milkshake. 2. Liver and onions, broccoli, and decaffeinated coffee. 3. Pepperoni and cheese pizza, tossed salad, and a soft drink. 4. Roast beef, baked potato with butter, and iced tea.

ANS: 4. Roast beef, baked potato with butter, and iced tea. Rationale: Foods with tyramine interact with MAOI antidepressant, such as Parnate, and can cause a hypertensive crisis that is life-threatening. Roast beef, potatoes, butter, and tea do not contain tyramine. The other selections contain tyramine and should be avoided by the client who is taking Parnate.

A client who reports feeling depressed tells the nurse on admitted , "I want to feel normal again." How should the nurse respond? 1. How long have you felt this way? 2. We are all here to help you get better. 3. What do you think the hospital can do for you? 4. Tell me more about how things are with you.

ANS: 4. Tell me more about how things are with you. Rationale: When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings. The other responses do not allow the client to vent and is not therapeutic.

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? 1. Arrange for emergency admission to a detoxification unit. 2. Talk to the spouse about strategies to limit the client's drinking. 3. Have the client admitted to the inpatient psychiatric unit. 4. Tell the client that therapy cannot take place while she is intoxicated. Submit

ANS: 4. Tell the client that therapy cannot take place while she is intoxicated. Rationale: Therapy sessions are designed to confront the issues that the client with alcohol dependence may be experiencing. If the client presents inebriated, a therapeutic and confrontational meeting cannot occur because the client's judgment is altered. The other interventions are not necessary.

The nurse suspects child abuse when assessing a 3-year-old boy with several small, round burns on his legs and trunk that appear to be the result of cigarette burns. Which parental behavior provides the greatest validation for such interpretation? 1. The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred. 2. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem. 3. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation. 4. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

ANS: 4. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn. Rationale: Disparity in the parental reports and objective findings of a child's injury provides the most validation. A child's explanation of an injury is often influenced by age, fear, or imagination. The other observations of the parents are not conclusive of child abuse.

Which statement about contemporary mental health nursing practice is accurate? 1. There is one approved theoretical framework for psychiatric nursing practice. 2. Psychiatric nursing has yet to be recognized as a core mental health discipline. 3. Contemporary practice of psychiatric nursing is primarily focused on inpatient care. 4. The psychiatric nursing client may be an individual, family, group, organization, or community.

ANS: 4. The psychiatric nursing client may be an individual, family, group, organization, or community. Rationale: Mental health nursing is not only concerned with one-on-one interactions. Mental health stressors can impact and be reflected in the overall direction, activities, behaviors, and responses involving families, groups, and entire communities. The other statements are not consistent with mental health nursing.

A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response? 1. Can your case manager take you to your appointments? 2. Take your medication for anxiety before you ride the bus. 3. Let's talk about what happens when you feel very anxious. 4. What are some ways that you can cope with your anxiety?

ANS: 4. What are some ways that you can cope with your anxiety? Rationale: An open-ended question that assists the client in problem-solving ways to cope with the anxiety engages the client in self management. The other responses do not allow the client to explore ways to cope with anxiety.