PSYCH II

A nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? Strong desire to improve her body image Close, supportive mother-daughter relationship Satisfaction with and desire to maintain her current weight Low level of achievement in school and little concern for grades

Strong desire to improve her body image Clients with anorexia nervosa[1][2] have a disturbed self-image and always see themselves as fat and needing further weight loss. The mother-daughter relationship is usually not supportive; it is disturbed. Usually there is dissatisfaction with one's weight and a desire to lose more. Usually the client is a high achiever who is concerned about grades.

A client believes that doorknobs are contaminated and refuses to touch them except with a paper tissue. What nursing intervention will be most therapeutic for this client?

Supplying the client with tissues to maintain function until the anxiety eases

A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client?

Helping the client learn to trust the staff through selected experiences

A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. How should the nurse plan to meet this client's nutritional needs?

Stay with the client during meals

A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be?

Staying physically close to the client

What is the best nursing intervention during the working phase of the therapeutic relationship with which to meet the needs of individuals who demonstrate obsessive-compulsive behavior?

Supporting rituals while setting realistic limits

A 7-year-old boy is brought to the clinic by the mother, who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in schoolwork since she and her husband separated 6 months ago. The mother reports that lately her child has not been eating dinner, and she often hears him crying when he is alone. What basis for these behaviors should the nurse consider?

The child may be blaming himself for his parents' breakup.

A nurse enters a client's room and notes that the client appears preoccupied. Turning to the nurse, the client says, "They're saying terrible things about me. Can't you hear them?" What is the most therapeutic response by the nurse?

"I don't hear anyone else talking, but I can see that you're upset."

A daycare environment is recommended for a client with incapacitating behaviors resulting from an obsessive-compulsive personality disorder. The client's partner asks the nurse why this approach is necessary. What is the best response by the nurse? "This environment limits time to carry out the rituals." "A neutral atmosphere facilitates the working through of conflicts." "A location that requires no decision-making will resolve feelings of anxiety." "The daycare setting allows the staff to exert control over unacceptable behaviors."

"A neutral atmosphere facilitates the working through of conflicts." These clients can better work through their underlying problems when the environment is structured, demands are reduced, and the routine is simple. Preventing these clients from carrying out rituals may precipitate panic reactions. Although eliminating the necessity to make decisions may decrease anxiety, simple decision-making should be encouraged. The intention of therapy should be to help the client gain control, not to enable others to do the controlling.

An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit?

"Around 2:30 in the afternoon is the best time to visit."

An older adult, accompanied by family members, is admitted to a long-term care facility with symptoms of dementia. During the admission procedure the initial statement by the nurse most helpful to this client is:

"Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you."

A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.)

"Every time I turn around the kid is falling over something." "I can't understand it. He didn't have a problem using the stairs without my help before this."

A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." The best response response by the nurse is:

"Everyone has a bed. This one is yours."

A client in the outpatient clinic is denying that he is addicted to alcohol. He tells the nurse that he is not an alcoholic and that it is his nagging wife who causes him to drink. What is the most therapeutic response by the nurse?

"Everyone is responsible for his own actions."

An occupational health nurse is meeting with a new employee to obtain a health history and schedule an appointment with the nurse practitioner for a physical examination. How can the occupational nurse best respond when the new employee exhibits a moderate level of anxiety and verbalizes extreme nervousness about starting the new job? "It's common to feel a little nervous." "You'll be less nervous when you get used to the job." "I felt the same way when I first started working here." "Feeling upset about starting a new job can be difficult.""

"Feeling upset about starting a new job can be difficult."" The response "Feeling upset about starting a new job can be difficult" focuses on the employee's feelings and demonstrates understanding and empathy. The response "It's common to feel a little nervous" negates the employee's feelings and is not therapeutic. The response "You'll be less nervous when you get used to the job" negates the employee's feelings and provides false reassurance. The response "I felt the same way when I first started working here" focuses on the nurse's, rather than the employee's, feelings.

A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test?

"Have you ever felt bad or guilty about your drinking?"

A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test? "Do you feel that you are a normal drinker?" "Have you ever felt bad or guilty about your drinking?" "Are you always able to stop drinking when you want to?" "How often did you have a drink containing alcohol in the past year?"

"Have you ever felt bad or guilty about your drinking?" The CAGE screening test for alcoholism contains four questions, corresponding to the letters CAGE: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (as an " Eye-opener") to steady your nerves or get rid of a hangover? "How often did you have a drink containing alcohol in the past year?" is one of the 10 questions on the Alcohol Use Disorders Identification Test (AUDIT). "Do you feel that you are a normal drinker?" and "Are you always able to stop drinking when you want to?" are two of the 26 questions on the Michigan Alcohol Screening Test (MAST).

A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?

"How will you manage the next time your problems start piling up?"

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse?

"I didn't hear anyone talking; come with me to your room."

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? "I didn't hear anyone talking; come with me to your room." "What you heard was in your head; it was your imagination." "Come to the dayroom and watch television; you'll feel better." "God wouldn't tell you to lie there in the hall. God wants you to behave reasonably."

"I didn't hear anyone talking; come with me to your room." The nurse is focusing on reality and trying to distract and refocus the client's attention. "What you heard was in your head; it was your imagination" is too blunt and belittling; this approach rarely is effective. "Come to the dayroom and watch television; you'll feel better" is false reassurance; the nurse does not know that the client will feel better. "God wouldn't tell you to lie in the hall; God wants you to behave reasonably" may be interpreted as belittling or an attempt to convince the client that the behavior is irrational, which is usually ineffective.

A client has been on the psychiatric unit for several days. The client arouses anxiety and frustration in the staff and manipulates them so well that staff members are afraid to approach the client. One morning the client shouts at the nurse, "You've worked it so I can't go for a walk with the group today. You're as cunning as a fox. I hate you! Get out, or I'll hit you!" What is the best response by the nurse?

"I don't like hearing your threats, but tell me more about your feelings."

A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The statement that best describes how clients with obsessive-compulsive behavior view this disorder is:

"I know there's no reason to do these things, but I can't help myself."

A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped, and I don't want to be bothered." What is the best response by the nurse?

"I know you don't feel like getting up, but you might feel better if you did. Let me help you get started."

A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse?

"I understand that these voices are real to you, but I want you to know that I don't hear them."

The practitioner prescribes a diet high in vitamin B 1 (thiamine) for a client with a long history of alcohol abuse. The nurse concludes that the client understands the teaching about foods high in thiamine when the client makes which statement? "I'll choose fish, aged cheese, and breads." "I'll choose lean beef, organ meat, and nuts." "I'll choose poultry, milk products, and eggs." "I'll choose green vegetables, lentils, and citrus fruits."

"I'll choose lean beef, organ meat, and nuts." Lean beef, organ meats, and nuts all provide high levels of thiamine; other sources include legumes, whole and enriched grains, and lean pork. Of fish, aged cheese, and bread, only fish is considered a source of thiamine. Of poultry, milk products, and eggs, only eggs are considered a source of thiamine; this list contains sources of protein. Of green vegetables, lentils, and citrus fruits, only lentils (legumes) are considered a source of thiamine; most vegetables contain only traces of thiamine, and citrus fruits provide vitamin C.

A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower?

"I'll help you take your shower now."

A 17-year-old teenager is found to have leukemia. Which statements by the teenager reflect Piaget's cognitive processes associated with adolescence? (Select all that apply.)

"I'm going to do my best to fight this awful disease." "Now I can't go to the prom because I have this stupid disease." "This illness is serious, but with treatment I think I have a chance to get better."

A confused hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse?

"It can be frightening to feel that way."

A clinically depressed young mother whose husband has been killed tells the nurse that she sees no purpose in life and feels like ending it all. What is the best response by the nurse? "How much consideration have you given to the method you'd use to kill yourself?" "Death is hard on everyone, but people make it through every day. You'll see; things will get better." "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now." "You feel that way now, but you still have your whole life ahead of you. Why don't you try to make a new start?"

"It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now." The response "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now" validates the client's experience and opens a channel of communication for further exploration; empathy helps build trust. Asking how much consideration the client has given to the method she would use to kill herself is premature; the nurse should first explore the client's feelings before discussing thoughts and plans. Telling the client that death is hard on everyone but people make it through every day and that things will get better is false reassurance; it invalidates the client's experience. Telling the client that she has her whole life ahead of her and advising her to make a new start is false reassurance; it invalidates the client's experience.

The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse?

"It must be frustrating to deal with your child's behavior."

The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? "It must be frustrating to deal with your child's behavior." "Have you considered any alternatives to using medication?" "Perhaps you're looking for an easy solution to the problem." "Let me teach you about the side effects of medications used for ADHD."

"It must be frustrating to deal with your child's behavior." Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.

A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk?

"It's time for you to go for a walk now."

During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be?

"Let's discuss this concern a little more."

The nurse is interviewing a female adolescent with anorexia nervosa who is malnourished and severely underweight. The nurse concludes that the client is experiencing secondary gains from her behavior when she says: "I'm as big as a house." "I get straight A's in school." "My mother keeps trying to get me to eat." "My hair is beginning to fall out in clumps."

"My mother keeps trying to get me to eat." The client's behavior has gotten attention for her; it provides a sense of power and control. "I'm as big as a house" reflects a disturbed perception about her body. Although clients with anorexia nervosa are concerned about social acceptance, perfectionism, and achievement and may obtain high grades in school, good grades are not a secondary gain related to the eating behaviors associated with anorexia nervosa. Hair falling out in clumps is a result of starvation, not a secondary gain.

The nurse notes that a client has been experiencing a somatic delusion. Which statement led to this conclusion?

"My stomach has disintegrated." A somatic delusion is a false belief that one has a disease or a physical defect. A delusion about being a person of importance is a grandiose delusion. A delusion about death is a nihilistic delusion. A delusion that others are out to cause personal harm is a paranoid delusion.

A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse's initial reply?

"No, I don't see any bugs."

A client with a mood disorder is being discharged from a psychiatric hospital after agreeing to continue follow-up visits with a therapist. During the last interview with the nurse before discharge, the client says, "I've told you a lot about my life and my problems, but there are a few things that bother me that I've told no one." What is the most therapeutic response by the nurse once it has been determined that the client is not at risk for harming herself or others? "The purpose of our getting together is to discuss your problems." "Do you want to work on those during the few minutes we have left?" "What kind of problem have you not shared with me during our time together?" "One purpose of continuing counseling is to allow you to discuss things that bother you."

"One purpose of continuing counseling is to allow you to discuss things that bother you." Clients may introduce new topics during the last session to avoid termination; the nurse should encourage them to discuss these problems as outpatients. Two purposes of the last interview are to summarize and terminate, not to begin discussion of new problems. The last minutes of the last interview are not the appropriate time to introduce new problems.

An adolescent female with an antisocial personality disorder plans to live with her parents after discharge. The parents request advice on how to respond to their daughter's unruly behavior. What is the most therapeutic response by the nurse?

"Set clear limits, explain the consequences if she disregards them, and firmly and consistently apply them."

A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent?

"Tell me again how your child fell down the stairs."

A client is admitted to the surgical unit with superficial wounds of both wrists, the result of a suicide attempt. When the nurse enters the room, the client says, "I suppose you're going to ask me about my suicide attempt." What is the best response by the nurse?

"Tell me how you feel about it."

The parents of an overweight 12-year-old bring their child to the mental health clinic. One parent says, "You've got to do something to help us—just look how huge he is." The child tells the nurse, "I hate school. The other kids tease me about my weight. I'm always last when they pick teams in gym." What is the most therapeutic response by the nurse?

"That hurts a lot when you want to be liked."

A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. What is the best response by the nurse?

"The medication will increase your appetite and make you feel better."

Certain questions are applicable in determining nursing negligence. (Select all that apply.)

"Was reasonable care provided?" "Was there a breach of nursing duty?" "Was there an act of omission that resulted in harm? "Except for the nurse's action, would the injury have occurred?"

A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit of the local community hospital. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After evaluating the client, what should the nurse ask?

"What emotion were you feeling before you felt the weakness?"

A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse?

"What were you doing yesterday when you first noticed the feeling?"

One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I'm a devil." What is the best response by the nurse?

"When I look at you I see a person, not a devil."

A delusional client has refused to eat for the past 24 hours because, he says, "the food is poisoned." How should the nurse respond?

"You feel worried that someone wants to poison you?"

A client with the diagnosis of borderline personality disorder is manipulative and uses this behavior to get cigarettes from other clients. One day the client begins to badger another client. What should the nurse say while removing the client from the area? "You must leave people alone; this behavior is unacceptable." "There will be consequences if you do not stop annoying people," "Tell me how you feel when you are exerting control over people." "I'm surprised that you're still bothering people; you seemed to have improved lately."

"You must leave people alone; this behavior is unacceptable." Limits must be set when the client's behavior physically or emotionally imposes on other clients. The response "There will be consequences if you do not stop annoying people" is a threat and is contraindicated. Although the response "Tell me how you feel when you are exerting control over people" is an exploration of feelings, which is important, the priority at this time is to set limits and protect the other clients. The response "I'm surprised you're still bothering people; you seemed to have improved lately" devalues the client and may precipitate feelings of guilt.

One morning a client with the diagnosis of acute depression says to the nurse, "God is punishing me for my past sins." What is the best response by the nurse?

"You really seem to be upset about this."

One morning a client with the diagnosis of acute depression says to the nurse, "God is punishing me for my past sins." What is the best response by the nurse? "Why do you think that?" "God is punishing you for your sins?" "You really seem to be upset about this." "If you feel this way, you should talk to a member of the clergy."

"You really seem to be upset about this." "You really seem to be upset about this" focuses on the client's feelings rather than on the statement and serves to open a channel of communication. "Why do you think that?" asks the client to decide what is causing the feelings; most people are unable to explain why they feel as they do. Although paraphrasing may stimulate further communication, the statement does not focus on feelings. "If you feel this way, you should talk to a member of the clergy" does nothing to stimulate further communication; in fact, it tells the client to talk about feelings with someone else.

A hospitalized client with a mood disorder begins to be less hyperactive. One day the client says to the nurse, "My husband and I have problems getting along sometimes. We see things differently." Which response is nontherapeutic? "What do you normally do when this happens?" "Tell me what you mean by 'see things differently'." "Not getting along with your spouse can be upsetting." "You seem calmer today than you have been the last several days."

"You seem calmer today than you have been the last several days." The nurse changes the subject in this response; in this situation it is better to continue discussing the same subject. "Tell me what you mean by 'see things differently'" is a therapeutic response that asks the client to clarify and elaborate. "Not getting along with your spouse can be upsetting" is an acceptable response because it focuses on the client's implied feelings. "What do you normally do when this happens?" is a therapeutic response because it allows the nurse to explore coping techniques with the client.

An older widower who is sitting by himself in a lounge in the nursing home, says, "I'm all alone; no one has any use for me." Which response by the nurse is most therapeutic?

"You seem upset. Let's talk about what's bothering you."

A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse?

"You sound upset about not being able to have an erection."

An adult client charged with molesting a child is admitted for psychiatric evaluation. When a nurse invites the client to come to dinner, the client refuses and says, "I don't want anyone to see me. Leave me alone." What is the best response by the nurse?

"You sound upset; let's talk about it."

A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse?

"You would rather not live."

One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client begs, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic?

"You're frightened. Come with me to your room, and we can talk about it."

One day while shaving, a male client with the diagnosis of bipolar disorder tells the nurse, "I've hidden a razor blade, and tonight I'm going to kill myself." What is the best reply by the nurse?

"You're going to kill yourself?"

A nurse is evaluating a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident?

2 years

A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 2 years 6 years 6 months 1 to 3 months

2 years By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.

A monoamine oxidase inhibitor (MAOI) is prescribed. What should the nurse instruct the client to avoid while taking this drug?

Aged cheeses

A client with phobias about elevators and large crowds comes to the clinic for help because of feelings of depression related to these fears. What is an appropriate short-term goal for this client?

Describing the thoughts and feelings experienced in terrifying situations

a (Rationale Cyclothymic disorder involves a mood range from moderate depression to hypomania. Bipolar I disorder is characterized by a single manic episode with no past major depressive episodes. Seasonal affective disorder is a form of depression occurring in the fall and winter.)

A client in an outpatient mental health clinic is diagnosed with cyclothymic disorder. Which statement about cyclothymic disorder is​ true? a It involves a mood range from moderate depression to hypomania. b It involves a single manic episode. c It is a form of depression that occurs in the fall and winter. d It is a mood disorder similar to major​ depression, but of mild to moderate severity.

d (Rationale It takes 10 -21 days to achieve a lithium level within the therapeutic range. During an acute manic​ episode, the normal therapeutic range is 0.8 -1.2 ​mEq/L. At higher​ dosages, the client would be exhibiting signs and symptoms of toxicity.)

A client who has bipolar disorder and is in a manic phase has been taking lithium carbonate 600 mg orally 3 times per day for 14 days. What serum lithium level does the nurse note is​ therapeutic? a 3.3 -4.0 ​mEq/L b 2.6 -3.2 ​mEq/L c 0.6 -1.6 ​mEq/L d 0.8 -1.2 ​mEq/L

5,2

A depressive state is characterized by _____ or more symptoms in a​ ___-week period that demonstrate either a depressed mood or a decrease in pleasure or interest in daily activities.

A 5-foot 5-inch (165 cm) 15-year-old girl who weighs 80 lb (36.3 kg) is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes what factor as the most likely cause of her problem? A desire to control her life The wish to be accepted by her peers The media's emphasis on the beauty of thinness A delusion in which she believes that she must be thin

A desire to control her life Eating and weight loss become the means of control to decrease anxiety related to perfectionist thinking. Controlling one's self within the family seems to be more important than peer group acceptance. Although it is true that the media celebrates thinness, the response of the client with anorexia nervosa falls outside the usual range. Although fear of weight gain in the client with anorexia nervosa sometimes reaches delusional proportions, it is based on a belief that being fat is the problem that must be controlled.

A nurse in a community therapeutic recreation program is working with a client with dysthymia. The treatment plan suggests group activities when possible for this client. What is the priority rationale for this intervention?

A group can offer increased support.

A female accountant comes to the health clinic for a preemployment physical. During the health history the new employee frequently states, "I feel so nervous about starting this job." She is able to connect with her feelings, thoughts, and actions but constantly focuses her attention on starting the new job. What does the nurse determine that the client is exhibiting? A moderate level of job-related anxiety A severe level of anxiety related to new situations An inappropriate response to handling new situations An ineffective coping mechanism in handling job-related stress

A moderate level of job-related anxiety The ability to connect feelings, thoughts, and actions, plus inattention to all but the anxiety-causing subject, is associated with a moderate level of anxiety. Severe anxiety is related to dissociation, selective inattention, and an inability to connect feelings, thoughts, and actions. The development of mild or moderate anxiety is common in new situations because of apprehension related to the unknown. There is insufficient information for the nurse to come to the conclusion that the client is exhibiting an ineffective coping mechanism in handling job-related stress.

a,b,c,d (Rationale Appropriate nursing diagnoses for a client with bipolar disease who is displaying mania​ include: Impaired knowledge about the disease​ process; potential for appropriate medication​ management; risk for altered nutritional​ status; and impaired coping mechanisms. The client with mania who has overdosed on medication has an impaired knowledge about his or her disease and has a potential for appropriate medication management. The client with mania is also at risk for altered nutritional status due to the decreased need for eating. The client with mania who overdoses on medication has impaired coping mechanisms. It is not known if the client has alterations in interpersonal relationships. This information may be obtained in a psychosocial assessment.)

A nurse is caring for a client with bipolar disorder who is admitted to the hospital after an accidental overdose of sleeping medication. What are appropriate nursing diagnoses for this​ client? Select all that apply. a Risk for altered nutritional status b Potential for appropriate medication management c Impaired knowledge about the disease process d Impaired coping mechanisms e Alterations in interpersonal relationships

a (Rationale Edema of the lower extremities may indicate lithium carbonate toxicity. The nurse should notify the healthcare provider immediately. The other answer choices are not appropriate as the best response.)

A nurse is caring for a client with bipolar disorder who is being treated for this condition with lithium carbonate. Upon​ assessment, the nurse notes that the client​'s lower extremities appear swollen. What is the nurse​'s best response to this clinical​ finding? a Notify the healthcare provider immediately. b Continue to monitor the client. c Document the client findings in the clinical chart. d Elevate the client​'s extremities above the heart.

d (Rationale The nurse must assess the client for suicidal ideations. The client is expressing thoughts of​ worthlessness, which may indicate the client is suicidal. The other aspects are important for the nurse to assess during the psychosocial​ assessment; however, these are not the most important in this client at this time.)

A nurse is caring for a client with bipolar disorder with a depressive episode. The client tells the​ nurse, "I don​'t know why I even try anymore. I always fail at everything in my life. I should just give up. " What aspect of the psychosocial history during the nursing exam is most important at this time for this​ client? a Interpersonal relationship assessment b Hallucination assessment ​c Self-esteem assessment d Suicide assessment

a,b (Rationale Olanzapine​ (Zyprexa) is an antipsychotic mood stabilizer that is often taken with an anticonvulsant mood​ stabilizer, not an anxiolytic. Lithium​ carbonate, not​ Zyprexa, must be monitored with a blood test.)

A nurse is caring for a client with bipolar disorder. The healthcare provider has prescribed olanzapine​ (Zyprexa) for the collaborative treatment of the client​'s condition. What information will the nurse include in the client teaching regarding this​ medication? Select all that apply. a "This medication is often taken with an anticonvulsant mood stabilizer. b "This medication is called an antipsychotic mood stabilizer. " c "This medication is often taken with an anxiolytic. d "This medication is called an anxiolytic. " e "This medication must be monitored with a blood test.

a,b,d,e (Rationale ​Nausea, vomiting, and diarrhea —not constipation —are symptoms of lithium toxicity. Lithium carbonate should not be used in pregnant clients and may be used in combination with antipsychotic mood stabilizers. Lab work is needed to monitor the therapeutic level of this medication.)

A nurse is caring for a female client with bipolar disorder. The healthcare provider has prescribed lithium carbonate for the collaborative treatment of the client​'s condition. What information will the nurse include in the client teaching regarding this​ medication? Select all that apply. a "Monitor for nausea and​ vomiting, as this could indicate a lithium toxicity. b "This medication should not be used if you suspect you may be pregnant. c "Monitor for​ constipation, as this could indicate a lithium toxicity. d "This medication may be used with an antipsychotic mood stabilizer. e "Lab work will be needed to monitor the therapeutic level of this medication.

d

A nurse is caring for an adolescent client with bipolar disorder. The nurse understands that this client may also have additional psychosocial alterations. Which condition is most likely complicating the client​'s ​diagnosis? a Personality disorder b Schizophrenia c Anorexia nervosa d Substance abuse

a,b,c,d

A nurse is providing discharge instructions for a client with bipolar disorder who presented to the hospital in a manic state. What instructions will the nurse include in the home care instruction of the client with bipolar​ disorder? Select all that apply. a Seek help when needed. b Learn effective​ self-administration of medications. c Recognize medication side effects. d Recognize the importance of adhering to therapy schedules. e Learn methods to prevent the disorder.

A client with a history of alcohol abuse says to the nurse, "Drinking is a way out of my depression." Which strategy will probably be most effective for the client at this time? A self-help group Psychoanalytical therapy A visit with a religious advisor Talking with an alcoholic friend

A self-help group Members of self-help groups, particularly Alcoholics Anonymous, are living with the problem themselves; therefore problem identification and self-responsibility are emphasized, and manipulation is limited. Long-term therapy tends to increase anxiety until resolution occurs; level of commitment and duration of therapy render it a less desirable choice for substance abusers. Depending on the client's feelings about religion, talking with a religious advisor may or may not be helpful. Whether talking with an alcoholic friend will be useful depends on the friend's drinking status; it may be helpful or harmful. These variables negate the effectiveness of this choice.

b,c,e

ATI: A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? Select all that apply a. provide flexible client behavior expectations b. offer concise explanations c. establish consistent limits d. disregard client complaints e. use a firm approach with communication

Clients with eating disorders often exhibit similar symptoms. What should the nurse expect an adolescent with anorexia nervosa to exhibit? Affective instability Repetitive motor mechanisms Depersonalization and derealization Disheveled and unkempt physical appearance

Affective instability Individuals with anorexia often display irritability, hostility, and a depressed mood. Repetitive motor mechanisms are associated with autism. Depersonalization and derealization are associated with individuals with schizophrenia. Clients with eating disorders are usually meticulous about dress and physical appearance; a disheveled appearance is associated with dementia or depression.

When taking a health history from a client who has a moderate level of cognitive impairment as a result of dementia, the nurse expects the presence of: Hypervigilance Increased inhibition Enhanced intelligence Accentuated premorbid traits

Accentuated premorbid traits A moderate level of cognitive impairment because of dementia is characterized by increasing dependence on environmental and social structure and by increasing psychological rigidity with accentuated previous traits and behaviors. Although paranoid attitudes, which are associated with hypervigilance, may be exhibited, the decrease in cognition, disorientation, and loss of memory usually do not lead to hypervigilance. With the decrease in impulse control that is associated with dementia, decreased, not increased, inhibition occurs. Enhancement of intelligence does not occur with dementia, but initially intellectual deterioration is subtle.

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention?

Accepting that the client is unable to control this behavior and setting appropriate limits

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? Telling the other clients to disregard what the client is saying Ignoring the client's disruptive behavior and waiting for it to subside Restricting the client's contact with other clients until the disruptive behavior ceases Accepting that the client is unable to control this behavior and setting appropriate limits

Accepting that the client is unable to control this behavior and setting appropriate limits Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.

What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client?

Accepting the client's statements as the client's beliefs

A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism?

Active membership in Alcoholics Anonymous

A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism? Daily administration of disulfiram Individual or group psychotherapy Admission to an alcoholic unit in a hospital Active membership in Alcoholics Anonymous

Active membership in Alcoholics Anonymous Members find empathy, patience, and understanding in Alcoholics Anonymous (AA). They are able to have their dependence needs met while helping others who are even more dependent. Individual or group psychotherapy is helpful, but it does not have the success rate of AA. Admission to an alcoholic unit in a hospital is important for the detoxification stage, not for overall therapy. Daily administration of disulfiram may be helpful for some clients, but it does not have the success rate of AA.

Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action?

Administering chlordiazepoxide as indicated by the client's CIWA score

On the third day of hospitalization, a client with a history of heavy drinking begins experiencing delirium alcohol withdrawal syndrome. What is the most appropriate response by the nurse when the client begins experiencing hallucinations? Withholding intervention, because the client may be having vivid dreams Asking the client to describe the hallucinations and explaining that they are not real Administering the prescribed medication to the client to subdue the agitated behavior Pretending to visualize the imaginary things the client is describing to foster acceptance

Administering the prescribed medication to the client to subdue the agitated behavior The nurse must administer the prescribed medication to the client to subdue the agitated behavior in this life-threatening situation. The client's central nervous system (CNS) is overstimulated, and seizures and death can occur. CNS-depressant medications, usually benzodiazepines, are needed to blunt the withdrawal effects. The client needs intervention because the hallucinations are not dreams. Focusing on the sensations associated with the withdrawal syndrome is not therapeutic; it is not helpful to tell the client that the hallucinations are not real, because they are real to the client. Validation reinforces the client's distorted perceptions of reality, is not helpful, and may be unsafe.

A client is prescribed a monoamine oxidase inhibitor. The nurse teaches the client about what foods to avoid when taking this medication. (Select all that apply.)

Aged cheese Ripe avocados Delicatessen meats

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

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

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing? Alcohol Barbiturates Hallucinogens Multiple drugs

Alcohol The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program?

Alcoholism involves the entire family.

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs?

Allow the client to undress when ready to help maintain identity

A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client?

Ambivalence

A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit for 2 weeks is to be discharged home. The client is vacillating between being happy and sad about going home. What term best describes these conflicting emotions? Double bind Ambivalence Loose association Inappropriate affect

Ambivalence The simultaneous existence of two conflicting emotions, impulses, or desires is known as ambivalence. A single communication containing two conflicting messages is known as a double-bind message. A lack of connections between thoughts is known as loose associations. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.

A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? Slow pulse, mild weight loss, and alopecia Compulsive behaviors, excessive fears, and nausea Amenorrhea, excessive weight loss, and abdominal distention Excessive activity, memory lapses, and an increase in the pulse rate

Amenorrhea, excessive weight loss, and abdominal distention In anorexia nervosa, weight loss is excessive (15% of expected weight); nutritional deficiencies result in amenorrhea and a distended abdomen. Although pulse irregularities and alopecia are associated with anorexia, weight loss is excessive, not mild. Although compulsive behaviors are common, excessive fears and nausea are not associated with anorexia nervosa. Memory lapses are not associated with anorexia nervosa; excessive exercising and pulse irregularities are.

What are the "four As" for which nurses should assess clients with suspected Alzheimer disease? Amnesia, apraxia, agnosia, aphasia Avoidance, aloofness, asocial, asexual Autism, loose association, apathy, affect Aggressive, amoral, ambivalent, attractive

Amnesia, apraxia, agnosia, aphasia Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposeful movements (apraxia), and comprehension of visual, auditory, and other sensations (agnosia). Avoidance, aloofness, asocial, and asexual are characteristics of the schizoid personality. Autism, loose association, apathy, and affect are characteristics of schizophrenia. Aggressive, amoral, ambivalent, and attractive are characteristics of an antisocial personality.

A young adolescent is found to have anorexia nervosa. What does the nurse understand probably precipitated the anorexia nervosa? The acting out of aggressive impulses, resulting in feelings of hopelessness An unconscious wish to punish a parent who tries to dominate the adolescent's life The inability to deal with being the center of attention in the family and a desire for independence An inaccurate perception of hunger stimuli and a struggle between dependence and independence

An inaccurate perception of hunger stimuli and a struggle between dependence and independence Inaccurate perception of hunger stimuli and a struggle between dependence and independence are theoretical explanations for the development of anorexia nervosa[1][2]. Acting-out and the wish to punish a domineering parent do not play a role in the development of anorexia nervosa. The inability to be the center the family's attention has not been correlated with anorexia nervosa.

A nurse is caring for a group of depressed clients. What should the nurse attempt to provide?

An uncomplicated daily schedule

A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel:

Angry

What is a major recognizable difference between anorexia nervosa clients and bulimia nervosa clients? Anorexia nervosa clients tend to be more extroverted than clients with bulimia. Anorexia nervosa clients seek intimate relationships, whereas clients with bulimia avoid them. Anorexia nervosa clients are at greater risk for fluid and electrolyte imbalances than are clients with bulimia. Anorexia nervosa clients deny the problem, whereas clients with bulimia generally recognize that their eating pattern is abnormal.

Anorexia nervosa clients deny the problem, whereas clients with bulimia generally recognize that their eating pattern is abnormal. The client with anorexia nervosa denies the illness; the client with bulimia nervosa hides the behavior because she recognizes that the behavior is a problem. Clients with anorexia nervosa are more introverted and tend to avoid relationships. Clients with bulimia are at a greater risk for fluid and electrolyte problems because of the purging; clients with anorexia nervosa are at greater risk for severe nutritional deficiencies.

A nurse works with school-age children who have conduct disorder, childhood-onset type. The nurse knows that these children are at risk for progression to another disorder during adolescence. For signs of which disorder should the nurse evaluate their current behavior?

Antisocial personality

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder? Anxiety and guilt Anger and hostility Embarrassment and shame Hopelessness and powerlessness

Anxiety and guilt Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.

During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, "Welcome to the funny farm. I'm Jo-Jo, the head yo-yo." Which meaning can the nurse assign to the client's statement?

Anxious over the arrival of new staff members

A nurse is caring for several clients who are going through withdrawal from alcohol. The primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they:

Are dependent on it

An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get the urge to do it, too." What is the most appropriate response by the nurse?

Asking the client, "Have you ever acted on these thoughts?"

A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which action is most appropriate for the nurse to implement?

Assuring the client that the symptoms are part of the withdrawal syndrome

A nurse is assigned to care for a college student who has been talking to unseen people and refusing to get out of bed, go to class, or participate in daily grooming activities. What is the nurse's initial effort toward helping this client?

Attempting to establish a meaningful relationship with the client

The nurse recalls that the major defense mechanism used by an individual with a phobic disorder is:

Avoidance

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention?

Avoiding focusing on the client's physical symptoms

A 19-year-old adolescent is admitted to the emergency department with multiple fractures and potential internal injuries. The client's history reveals multiple drug abuse for the past 8 months. When caring for this client, the nurse determines that the most serious life-threatening responses usually result from withdrawal from: Heroin Methadone Barbiturates Amphetamines

Barbiturates Withdrawal from central nervous system depressants, such as barbiturates, is associated with more severe morbidity and mortality. Symptoms begin with anxiety, shakiness, and insomnia; within 24 hours convulsions, delirium, tachycardia, and death may occur. Withdrawal from heroin or methadone is rarely life threatening, but it does cause severe discomfort, including abdominal cramping and diarrhea. Withdrawal from amphetamines is rarely life threatening, but it causes severe exhaustion and depression.

What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa?

Based on realistic limits

An antipsychotic has been prescribed to be taken three times a day by a client who was admitted to the psychiatric service because of delusions and physical and verbal abuse of others. What client behavior demonstrates a therapeutic response to the medication? Exhibits enthusiasm about the food in the hospital Becomes aware of the behavior and its consequences Begins to get involved with the activities of others on the unit Remains preoccupied with the delusions but is less verbally abusive

Becomes aware of the behavior and its consequences As the therapeutic level is reached and maintained, the client's psychotic symptoms decrease and insight increases. Exhibiting enthusiasm about the food or beginning to get involved with the activities of others on the unit does not indicate that the client is responding therapeutically to the medication. Remaining preoccupied with the delusions but is less verbally abusive is an indication that the client is not responding to the medication.

The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? Being physically immobile Sobbing for no apparent reason Reporting great difficulties falling asleep Startling easily to loud noises and being touched

Being physically immobile Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.

The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? Being physically immobile Sobbing for no apparent reason Reporting great difficulties falling asleep Startling easily to loud noises and being touched

Being physically immobile Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.

What should the nurse identify as the foremost basis for the development of schizophrenia? Seasonal perspective Biological perspective Immunological perspective Psychoanalytical perspective

Biological perspective The biological factors, including genetics, neuroanatomy, and abnormal neurotransmitter-endocrine interactions, prevail as the origin of schizophrenia as a result of studies conducted during the twentieth century. Psychoanalytic perspective no longer is thought of as the primary basis for schizophrenia. A seasonal or immunological perspective is not the primary basis for schizophrenia.

A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors?

Bipolar disorder, manic phase

An adolescent with a major depressive disorder is prescribed venlafaxine (Effexor). What signs or symptoms related to the medication should the nurse communicate immediately to the prescribing provider? (Select all that apply.)

Blurred vision Suicidal ideation Difficult urination

A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence?

Blurs reality

A client with the diagnosis of obsessive-compulsive disorder uses paper towels to open doors to avoid touching dirty doorknobs. How should the nurse respond initially to this behavior?

By allowing the behavior for the time being

How can a nurse minimize agitation in a disturbed client?

By limiting unnecessary interactions with the client

A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary nurse approaches the client, who appears to be listening to voices, and comments, "You seem to be listening to something. Tell me what you hear." The primary nurse requests feedback from the psychiatric clinical specialist regarding this nursing intervention. How should the clinical specialist respond?

By reminding the nurse that once the content is known, there is no need to focus on the hallucinations because doing so reinforces them

A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished?

By visiting frequently for short periods with the client each day

A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? (Select all that apply.)

Calm Matter-of-fact (In their head)

The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive, and appears unaware of her surroundings. What is the best term for the nurse to use to describe these symptoms? Alogia Catatonia Echopraxia Affective flattening

Catatonia Catatonia is the term to describe stupor, rigidity, or extreme flexibility of the limbs; excitability; confusion; and lack of verbal expression. Alogia is a term used to describe an inability to speak or near-absence of speech. Echopraxia is the term for the mimicking or repetition of the actions of another person. Affective flattening is the term for blunted or constricted facial expression.

When a client who has a bipolar mood disorder is hyperactive, it is difficult to entice her to sit still long enough to eat a complete meal. The plan of care states, "Provide finger foods such as carrots, celery, and cheese sticks at 10 am, 2 pm, and 7 pm." Recent assessment of this client indicates that all of the food provided at mealtimes is being eaten but that snacks have been refused. The nursing staff should: Change the plan, depending on evaluation findings. Ask the client whether the finger foods should still be provided. Continue the current plan so the client's nutritional status will improve. Reassess the client's nutritional status in 1 week so changes can be made.

Change the plan, depending on evaluation findings. Because the plan does not meet the client's needs, it should be changed. The client has already let the staff know that finger foods are not wanted. Continuing the plan will be frustrating for the client and the staff because the client's behavior indicates that snacks are not wanted. When the client's needs are not being met, the plan should be changed immediately.

When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? Checking on the client frequently Keeping the client's room lights dim Addressing the client in a loud, clear voice Restraining the client during periods of agitation

Checking on the client frequently During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.

A nurse is teaching a client about side effects of medications. Which drug will cause a heightened skin reaction to sunlight?

Chlorpromazine

What should a nurse consider when planning care for a client who is using ritualistic behavior?

Clients do not want to repeat their rituals but feel compelled to do so.

Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat:

Clinical depression

A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing?

Command hallucination

A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing? Fixed delusion Magical thought Pathological regression Command hallucination

Command hallucination Command hallucinations are auditory hallucinations that give verbal messages to do harm either to the self or others; giving an identity to the hallucinated voice increases the risk of compliance. A delusion is a false belief held to be true even with evidence to the contrary. In magical thinking, the individual believes that thinking about something can make it happen. Magical thinking is common in young children. The data do not indicate that the client has regressed to a prior level of development.

A clinically depressed female client on a psychiatric unit of a local hospital uses embroidery scissors to cut her wrists. After treatment, when the nurse approaches, the client is tearful and silent. What is the best initial intervention by the nurse? Note client's behavior, record it, and notify the practitioner. Sit quietly next to the client and wait until she begins to speak. Say, "You're crying. I guess that means you feel bad about attempting suicide and really want to live."

Comment, "I notice that you seem sad. Tell me what it's like for you and perhaps we can begin to work it out together." Noting that the client seems sad and asking her to describe her feelings so the nurse and client can begin to work it out together recognizes feelings and behavior; it encourages the client to share feelings and promotes trust, which is essential for a therapeutic relationship. Although noting, recording, and notifying the practitioner of the client's behavior are important actions, they are not enough; nursing intervention with the client must be included. Without verbal encouragement, the depressed client will not respond to this intervention. Saying that because the client is crying she must feel bad about attempting suicide and really want to live assumes too much and may be inaccurate; an indirect approach should be used.

A client with a long history of alcohol dependence spends 28 days in an alcohol-rehabilitation unit. What type of referral does the nurse anticipate will be included in the discharge plan?

Community-based self-help group

When assessing the mental status of a 7- or 8-year-old child, it is most important for the nurse to: Listen to the parents' description of the child's behavior. Compare the child's function from one occasion to another. Engage the parents in a discussion about the child's feelings. Determine the child's mental status with the use of direct questions.

Compare the child's function from one occasion to another. Comparison over time is the only way for the nurse to accurately assess the mental status of a child. Listening to the parents' description of the child's behavior may be unrealistic and foster bias. The nurse should consider the parents' description of behavior but should rely on personal assessment and observation over time. The child's ability to discuss feelings is limited. In addition, the child's feelings are subjective symptoms that are known only by the child. Determining the child's mental status with the use of direct questions can be threatening and may precipitate anxiety.

As a nurse enters a room and approaches a client who has schizophrenia, the client shouts, "Get out of here before I hit you! Go away!" The nurse concludes that this aggressive behavior is probably related to the fact that the client felt:

Confined when the nurse walked into the room

A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate?

Confusion immediately after the treatment

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? Seclusion room Four-point restraints Constant one-to-one supervision Removal of unsafe objects from the environment

Constant one-to-one supervision A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.

What is the greatest difficulty for nurses caring for the severely depressed client? Client's lack of energy Negative cognitive processes Contagious quality of depression Client's psychomotor retardation

Contagious quality of depression Depression is contagious; it affects the nurse as well as the client. The client's lack of energy does not make nursing care difficult. Intervening with the client's negative thinking is an expected part of nursing care and does not create special difficulties for the nurse. The client's lack of energy does not make nursing care difficult.

In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting:

Delusional thinking

A 30-year-old woman reports to the mental health clinic on the recommendation of her primary health care provider. She has been unable to carry out everyday activities because of increased pain in her lower back and legs. Numerous neurological and orthopedic workups indicate that her symptoms seem excessive when compared with the physical problems shown on physical examination and repeated MRIs and x-rays. She says that no one understands how difficult it has been to care for her 32-year-old husband, who has an inoperable brain tumor and is undergoing chemotherapy. In light of the history and symptoms, what disorder should the nurse suspect?

Conversion

A nurse is making a home visit to a young male client manifesting chronic symptoms of AIDS. The nurse assesses the client for signs of altered mental health function associated with AIDS. Select all that apply. Delusions Memory loss Hopelessness Hyperactivity Paranoid thinking

Correct 1, 2, 3, 5

For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply. Irritability Tachycardia Hallucinations Increasing anxiety Profuse diaphoresis

Correct 1, 2, 4, 5 Alcohol is a central nervous system depressant; irritability and increasing anxiety reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia and diaphoresis are early signs of withdrawal that result from autonomic overactivity. Hallucinations are not early signs of alcohol withdrawal; they usually do not occur before 48 to 72 hours of abstinence.

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

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

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. Chronic stress Severe anxiety Generalized pain Excessive caffeine Chronic depression Environmental noise/distractors

Correct 1, 4, 6 Acute or primary insomnia is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.

A nurse who is assessing a recently hospitalized client with a diagnosis of opioid addiction should look for signs of withdrawal. What are these signs? Select all that apply. Seizures Yawning Drowsiness Constipation Muscle aches

Correct 2 5 Yawning and muscle aches are clinical manifestations of opioid withdrawal, which occurs after cessation or reduction of prolonged moderate or heavy use of opioids. Seizures do not occur with opioid withdrawal. Insomnia, not drowsiness, occurs with opioid withdrawal. Diarrhea, not constipation, occurs with opioid withdrawal

A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? Select all that apply. Discuss how others can precipitate anxiety. Provide physical outlets for aggressive feelings. Establish a contract regarding manipulative behavior. Develop activities that provide opportunities for success. Encourage the client to verbalize negative feelings to others.

Correct 2, 3, 4 Channeling energy to healthy physical activities can decrease violent behavior. A behavioral contract is used to reinforce problem solving and encourage the use of social skills. Successful experiences improve the client's self-esteem and should decrease the manipulative behavior. Clients with conduct disorders tend to generate stress for others, not the other way around. Verbalization of negative feelings to others can often escalate and result in antisocial or acting out behavior.

A nurse is implementing interventions to assist an aggressive client in deescalating the agitated behavior. Select all that apply. Physical contact with the client to show caring Encouraging the client to express his perceived needs Avoiding verbal struggles in an attempt to demonstrate authority Providing the client with clear options to the unacceptable behavior Referring to the client in an authoritarian manner to demonstrate control of the situation Explaining the expected outcomes if the client is unable to control the unacceptable behavior

Correct 2, 3, 4, 6 Encouraging the client to express his perceived needs provides the client with a sense of being heard and respected. Verbal struggling will likely increase the tension and aggressive behavior of the client. Providing options will allow the client to effectively change behaviors if he is capable of doing so. Explaining outcomes for continued unacceptable behavior allows the client to make a decision to change behaviors if he is capable of doing so. Touching the client will likely be viewed as aggressive and lead to an increase in the client's agitation. It is important to present a calm, firm persona but avoid being authoritarian because this will likely lead to a power struggle.

The nurse can identify the most commonly demonstrated comorbid disorders associated with generalized anxiety disorder (GAD) by assessing the client for which of the following? Select all that apply. Obesity Signs of alcohol withdrawal Phobias Impaired cognitive function Suicidal ideations

Correct 2, 3, 5 The most frequent comorbid conditions associated with GAD include alcohol abuse, simple phobias, and major depression. Obesity and impaired cognitive function generally are not identified as being comorbid conditions associated with GAD.

2

Cyclothymic disorder is characterized by at least ___years of chronic fluctuating periods of hypomanic and depressive behaviors.

A woman who has severe rheumatoid arthritis becomes depressed and is admitted to the psychiatric unit. The nurse begins to work with her in one-on-one sessions to help her cope with her depressive episode. The best long-term goal for this client is that she will: Eat at least two meals per day with other clients. Maintain self-care and attend structured activities. Make a positive verbal comment to another client daily. Decrease negative thinking about herself, others, and life.

Decrease negative thinking about herself, others, and life. The best long-term goal is that the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has been effective and the client may be discharged. Eating at least two meals per day with other clients is a short-term goal associated with a therapeutic milieu. Maintaining self-care and attending structured activities is a short-term goal and an expected behavior on an inpatient unit. Making a positive verbal comment to another client daily is an intermediate goal that helps the client focus on others; this goal is a step toward achieving long-term goals.

A client is admitted to the mental health hospital with the diagnosis of major depression. What is a common problem that clients experience with this diagnosis? Loss of faith in God Visual hallucinations Decreased social interaction Feelings about the future are absent

Decreased social interaction Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy. They tend to withdraw, speak in monosyllables, and avoid contact with others. Loss of faith and visual hallucinations are not commonly associated with the diagnosis of major depression. Hallucinations are associated with schizophrenic disorders. Depressed clients are commonly negative and pessimistic, especially regarding their future.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? Increase in serotonin Deficiency of thiamine Reduction in iron intake Malabsorption of riboflavin

Deficiency of thiamine Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1(thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to evaluate?

Dehydration

Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing?

Delusion

Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing? Illusion Delusion Confabulation Hallucination

Delusion A delusion is a fixed false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client's attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.

A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing?

Delusion of grandeur

A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing?

Delusion of persecution

During a one-on-one interaction with a client with paranoid-type schizophrenia, the client says to the nurse, "I've figured out how foreign agents have infiltrated the news media. They want to shut me up before I spill the beans." How should the nurse describe this statement when documenting this client's response? Nihilistic delusion Delusions of persecution Delusions of control Delusions of grandeur

Delusions of persecution Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).

An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. A specific outcome criterion unique to adolescents with this problem is:

Demonstration of respect for the rights of others

An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. What specific outcome criterion is unique to adolescents with this problem? Increased impulse control Identification of two positive personal attributes Demonstration of respect for the rights of others Age-appropriate play activities with at least one peer

Demonstration of respect for the rights of others Demonstrating respect for the rights of others is a specific outcome criterion for children with a risk for violence directed at others; children with the diagnosis of conduct disorder typically present with a repetitive and persistent pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules. Increased impulse control is a short-term goal for children with a variety of mental disorders of childhood such as attention deficit-hyperactivity disorder and oppositional defiant disorder. Identifying two positive personal attributes is a short-term goal for children who have disturbed self-esteem. Using age-appropriate play activities with at least one peer is a short-term goal for children who have impaired social interaction.

An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." The nurse identifies the defense mechanism known as:

Denial

When planning nursing care for clients who are grieving the potential death of a family member, it is helpful to draw on the understanding of the five stages of grieving identified and described by Elisabeth Kübler-Ross. Place these stages in order of progression from first to last.

Denial Anger Bargaining Depression Acceptance

People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? (Select all that apply.)

Denial Confusion Helplessness

A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual?

Denial of this activity may precipitate a panic level of anxiety.

A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual?

Denying this activity may precipitate an increased level of anxiety.

A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of:

Dependence versus independence

A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? Depressed mood Paranoia Euphoria Satisfaction

Depressed mood A sense of being out of control accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one's self. Paranoia is associated with paranoid schizophrenia, not with bulimia nervosa. After bingeing, a person with bulimia nervosa usually feels depressed rather than euphoric or satisfied and an awareness that the eating pattern is abnormal.

When a client is expressing severe anxiety by sobbing in the fetal position on her bed, the nurse's priority is:

Ensuring a safe therapeutic milieu

A client has a diagnosis of schizoid personality disorder. During the assessment the nurse should expect the client's behavior to be: Rigid and controlling Dependent and submissive Detached and socially distant Superstitious and socially anxious

Detached and socially distant Clients with the diagnosis of schizoid personality disorder neither desire nor enjoy close relationships, prefer solitary activities, and demonstrate emotional coldness, detachment, and a flattened affect. Rigid and controlling behavior is typical of clients with the diagnosis of obsessive-compulsive personality disorder. Dependent and submissive behavior is typical of clients with the diagnosis of dependent personality disorder. Superstitious and socially anxious behavior is typical of clients with the diagnosis of schizotypal personality disorder.

What is the most difficult initial task in the development of a nurse-client relationship?

Developing an awareness of self and the professional role in the relationship

A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that apply.)

Diaphoresis Tachycardia Hypertension

A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status?

Difficulty recalling recent events related to cerebral hypoxia

A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis?

Disordered thinking

A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? Chronic confusion Disordered thinking Defined personal boundaries Violence directed toward others

Disordered thinking The schizophrenic individual has neurobiological changes that cause disorders in thought process and perceiving reality. Chronic confusion and disorientation are not usually associated with this disorder. Illogical thinking and impaired judgment are associated with schizophrenia. Individuals with the diagnosis of schizophrenia often have personal boundary difficulties. They lack a sense of where their bodies end in relation to where others begin. Loss of ego boundaries can result in depersonalization and derealization. Most clients with schizophrenic disorders are not violent.

A nurse in an outpatient mental health setting has been assigned to care for a new client who has been found to have an antisocial personality disorder. What does the nurse expect to observe in the client during the assessment? Pays great attention to detail and demonstrates a high level of anxiety Has scars from self-mutilation and a history of many negative relationships Displays charm, has an above-average intelligence, and tends to manipulate others Demonstrates suspiciousness, avoids eye contact, and engages in limited conversation

Displays charm, has an above-average intelligence, and tends to manipulate others A client with an antisocial personality disorder is charming on first contact, but this charm is a manipulative ploy. These clients usually are bright and use their intelligence for self-gain. Paying great attention to detail and demonstrating a high level of anxiety are traits of an individual with an obsessive-compulsive personality disorder. The client with a borderline personality disorder self-mutilates when under stress; there is a fear of abandonment so that any relationship is better than no relationship. Demonstrating suspiciousness, avoiding eye contact, and engaging in limited conversation resembles the behavior of an individual with a paranoid personality, which includes suspiciousness and lack of trust.

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem?

Disruptions in cerebral blood flow, resulting in thrombi or emboli

A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example?

Dissociation

A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place the following interventions in priority order, from the least to the most restrictive.

Diversional activities Limit-setting Medication administration Seclusion Restraints

A client's history demonstrates a pervasive pattern of unstable and intense relationships, impulsiveness, inappropriate anger, manipulation, offensive behavior, and hostility. The admitting diagnosis is borderline personality disorder. What does the nurse anticipate that this client may attempt to do?

Divide the staff into opposing factions to gain self-esteem

A practitioner prescribes divalproex (Depakote) for a client with the diagnosis of bipolar I disorder, manic episode. What side effects of this medication might the client report during a follow-up visit? Dizziness, nausea, and vomiting Photosensitivity, agitation, and restlessness Abdominal cramps, tremor, and muscle weakness Weight gain, drowsiness, and diminished concentration

Dizziness, nausea, and vomiting Divalproex (Depakote), an anticonvulsant, causes gastric irritation and should be taken with food; it is available in an enteric-coated form. It may cause nausea, vomiting, indigestion, hypersalivation, diarrhea or constipation, anorexia or increased appetite, dizziness, headache, and confusion. Photosensitivity, agitation, and restlessness are all common side effects of phenothiazines. Abdominal cramps, tremor, and muscle weakness are signs and symptoms of lithium toxicity. Weight gain, drowsiness, and diminished concentration are common side effects of tricyclic antidepressants.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider that clients with OCD:

Do not want to repeat the ritual but feel compelled to do so

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? Are unaware that the ritual serves no purpose Can alter the ritual depending on the situation Should be prevented from performing the ritual Do not want to repeat the ritual but feel compelled to do so

Do not want to repeat the ritual but feel compelled to do so The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.

A parent of a 17-year-old girl who has been hospitalized for extremely disturbed acting-out behavior leaves a gift for the daughter but says, "I'm too busy to visit today." The daughter becomes upset and tearful after being given the message and opening the package. What does the nurse conclude that the parent's actions represent?

Double-bind message

A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD?

Early onset, before 36 months of age

A nurse recalls that language development in the autistic child resembles:

Echolalia

A client with a history of schizophrenia has recently begun reporting symptoms of depression and is now being prescribed a selective serotonin reuptake inhibitor (SSRI). In light of the information in the client's chart, the nurse's priority is: Educating both the client and family on how to identify the early signs of extrapyramidal symptoms Requesting a gastrointestinal consult to identify the cause of the client's need for frequent antacids Stressing the importance of managing the client's diet while taking the prescribed antidepressant Discuss the stressors that have developed since the client moved in with his sister and brother-in-law

Educating both the client and family on how to identify the early signs of extrapyramidal symptoms Extrapyramidal symptoms can result from antipsychotic medication therapy, and the risk is increased when the treatment plan includes an SSRI antidepressant. The cause of the frequent use of antacids should be explored but does not take priority in this situation. A well-balanced diet is always important, but the importance of diet management would still exist if the antidepressant were an MAOI and not an SSRI. Identifying and addressing stressors is important, but it does not take priority in this situation.

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation?

Electroconvulsive therapy

The day after the birth of their baby, the parents are upset to learn that the baby has a heart defect. At this time it is most helpful for the nurse to:

Encourage the expression of their feelings

What therapeutic nursing intervention may redirect a hyperactive, manic client?

Encouraging the client to tear pictures out of magazines for a scrapbook

A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? (Select all that apply.)

Euphoria Agitation Hypervigilance Impaired judgment

Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. The most important intervention for the client who is given a PRN medication and confined to involuntary seclusion is to: Continue intensive nursing interactions. Evaluate the client's progress toward self-control. Determine whether any staff member has been injured. Observe the client for side effects of the medication given to the client.

Evaluate the client's progress toward self-control. For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.

What characteristic of an adolescent girl suggests to the nurse that she has bulimia? History of gastritis Positive self-concept Excessively stained teeth Frequent re-swallowing of food

Excessively stained teeth Dental enamel erosion occurs with repeated self-induced vomiting. History of gastritis is not associated with bulimia. Often body image is disturbed and there is low self-esteem. Habitual regurgitation of small amounts of undigested food (rumination) and re-swallowing of food are not associated with bulimia; emptying of the stomach contents through the mouth (vomiting) is associated with bulimia

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children:

Experience perceptual difficulties that interfere with learning

Risk for assaultive behavior is highest in the mental health client who:

Experiences command hallucinations

Risk for assaultive behavior is highest in the mental health client who: Uses profane language Touches people excessively Exhibits a sudden withdrawal Experiences command hallucinations

Experiences command hallucinations Command hallucinations are dangerous because they may influence the client to engage in behaviors that are dangerous to self or others. Although profane language, excessive touching of others, and withdrawn behavior may all be cause for concern, but none is as dangerous as command hallucinations.

A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. The nurse remembers that the main reason that clients use self-mutilation is to:

Express anger or frustration

A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse's objective for this client be?

Feeling comfortable with the nurse

A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feeling stop." What clinical manifestation is evident?

Feelings of panic

A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feelings stop." What clinical manifestation is evident? Feelings of panic Suicidal tendencies Narcissistic ideation Demanding personality

Feelings of panic The client can no longer control or tolerate these overwhelming feelings and is seeking help. The client has not indicated plans for self-harm. Narcissistic ideation is not typical of a narcissistic personality. The client's behavior does not indicate a demanding personality.

A client is admitted to the psychiatric service with a diagnosis of severe depression. When approached by the nurse, the client says, "You know I'm a sorry, lazy person. I don't deserve a job. I'm just stupid and no good." What does the nurse conclude that the client is experiencing?

Feelings of self-deprecation

What is the most appropriate way for the nurse to help a severely depressed adolescent client accept the realities of daily living?

Helping the client fulfill personal hygiene needs

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates that she is hearing voices. When a nurse begins to walk toward her, the client pulls out a large knife. What is the best approach by the nurse?

Firm

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate? Flight of ideas Ritualistic behaviors Associative looseness Auditory hallucinations

Flight of ideas Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders. Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks?

Fluphenazine

A client is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. The client's anxiety level is approaching a panic level, and the client's ritual is interfering with work and daily living. Which selective serotonin reuptake inhibitor (SSRI) should the nurse anticipate that the health care provider may prescribe?

Fluvoxamine (Luvox)

A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed?

Fluvoxamine (Luvox)

The nurse is caring for a client with Alzheimer's disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, the nurse will instruct staff to monitor the client:

For attempts at eating inedible objects

A client arrives at the mental health clinic complaining about feelings of extreme terror when attempting to ride in an elevator and feelings of uneasiness in large crowds. He reports that these fears are interfering with his concentration at work. What does the nurse identify as the source of these symptoms? Conflict with society, resulting in an obsession Depression about life events, resulting in unreasonable fears Generalized anxiety about conflicts, resulting in unreasonable fears Repression of a terrifying incident in an elevator, resulting in an obsession

Generalized anxiety about conflicts, resulting in unreasonable fears Phobias are specific fears that often serve as a means of coping with generalized anxiety. Conflicts with society do not result in phobias. Although depression is related to phobias, finding a direct connection to life events is difficult.

A client arrives at the mental health clinic complaining about feelings of extreme terror when attempting to ride in an elevator and feelings of uneasiness in large crowds. He reports that these fears are interfering with his concentration at work. What does the nurse identify as the source of these symptoms? Conflict with society, resulting in an obsession Depression about life events, resulting in unreasonable fears Generalized anxiety about conflicts, resulting in unreasonable fears Repression of a terrifying incident in an elevator, resulting in a phobia

Generalized anxiety about conflicts, resulting in unreasonable fears Phobias are specific fears that often serve as a means of coping with generalized anxiety. Conflicts with society do not result in phobias. Although depression is related to phobias, finding a direct connection to life events is difficult. Repression of a terrifying incident in an elevator does not result in a phobia. Repression is utilized as a coping mechanism to protect the client's conscious mind from thoughts or events that will cause them anxiety.

A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? Threats Ideation Gestures Attempts

Gestures A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death

A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? Threats Ideation Gestures Attempts

Gestures A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention?

Giving the client one simple direction at a time in a firm low-pitched voice

A nurse is planning activities for a withdrawn client who is hallucinating. Which activity will be most therapeutic for the client?

Going for a walk with the nurse

A nurse is planning activities for a withdrawn client who is hallucinating. What is the most therapeutic activity for this client? Going for a walk with the nurse Watching a movie with other clients Playing a board game with a group of clients Playing a game of cards alone in the dayroom

Going for a walk with the nurse Walking with the nurse facilitates one-on-one interaction and the development of a trusting relationship. Watching a movie will allow the client to withdraw further. Playing a game with others is beyond the client's ability at this time. Playing cards alone will allow the client to withdraw further.

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of:

Grandeur

What is the prognosis for a normal, productive life for a child with autism? Dependent on an early diagnosis Often related to the child's overall temperament Ensured as long as the child attends a school tailored to meet needs Guarded because of interference with so many parameters of function

Guarded because of interference with so many parameters of function Research studies have shown that the prognosis for normal, productive function in autistic people is guarded, particularly if there are delays in language development. Accurate diagnosis and early interventions have not been shown to promote a normal, productive life; however, early intervention may help individuals maximize their abilities. Although temperament may affect the child's response to treatment, it does not affect prognosis to any extent. Stating that success is ensured as long as the child attends a school tailored to meet needs is false reassurance and is not helpful.

A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing?

Guilt

A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client?

Having a staff member sit with the client in a quiet area during mealtimes

What is an appropriate way for a nurse to help a client ease anxiety?

Help the client acquire skills with which to face stressful events

A nurse plans to give greater responsibility for self-control to clients with a long history of alcohol abuse who are about to enter a detoxification program. What should the nurse plan to do? Tell them about the detoxification program. Help them adopt more healthful coping patterns. Confront them with their history of substance abuse. Administer their medications in accordance with the prescribed schedule.

Help them adopt more healthful coping patterns The client must learn to develop and use more healthful coping mechanisms if drinking is to be stopped; the responsibility lies with the client because the client must do the changing. Telling the clients about the detoxification program will tell them what to expect but will not instill responsibility for change. Confronting them with their history of substance abuse will place clients on the defensive; it usually does not foster the development of a trusting relationship. Medications may decrease withdrawal symptoms, but they do not provide the motivation for change; this must come from within.

A nurse uses behavior modification to foster toilet-training efforts in a cognitively impaired child. What reward should the nurse provide to reinforce appropriate use of the toilet?

Hug with praise

A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms of schizophrenia?

Hyperactivity, auditory hallucinations, loose associations

A client tells the nurse, "That man on the television is talking only to me." What should the nurse document that the client is exhibiting?

Idea of reference

A client with schizophrenia sees a group of visitors sitting together talking. The client tells the nurse, "I know they're talking about me." Which altered thought process should the nurse identify?

Ideas of reference

A college student visits the health center and describes anxiety about having to declare an academic major. What developmental conflict, according to Erikson, is this client still attempting to resolve?

Identity versus role confusion

A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing?

Illusion

A client in the mental health clinic has a phobia about closed spaces. Which desensitization method should the nurse expect to be used successfully with this client?

Imagery

When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic?

Imitating and participating in the child's activities

A widow who is hospitalized for a medical problem has dementia of the Alzheimer type and is no longer able to live alone. The client is to be transferred from the hospital to a long-term care facility. When should the staff begin preparation for the transfer?

Immediately after the client's admission to the hospital

A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? Crying Self-mutilation Immobile posturing Repetitive activities

Immobile posturing Clients with catatonia exhibit rigidity and posturing behaviors. Most clients with catatonic schizophrenia are unable to express feelings. Self-mutilation is associated with depression. Repetitive activities are associated with obsessive-compulsive disorders.

A depressed client is admitted to the mental health unit. What factor should the nurse consider most important when evaluating the client's current risk for suicide?

Impending anniversary of the loss of a loved one

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?

Impulsive

A 4-year-old child is found to have attention deficit-hyperactivity disorder (ADHD). What information about the child's behavior should the nurse expect when obtaining a health history from the parents? (Select all that apply.)

Impulsiveness Excessive talking Playing video games for hours on end Failure to follow through or finish tasks

A client who is to begin a physical therapy regimen after orthopedic surgery expresses anxiety about starting this new therapy. The nurse responds that some of this apprehension can be an asset because it will:

Increase alertness to the environment

How should a nurse expect a client's anxiety to be manifested physiologically?

Increased blood glucose level

A client has been hospitalized for 3 weeks while receiving a tricyclic medication for severe depression. One day the client says to the nurse, "I'm really feeling better; my energy level is up." After the encounter an aide tells the nurse that the client has given away his favorite jacket. What should the nurse conclude that the client's statement indicates?

Increased risk for suicide

A nurse has been caring for a suicidal client for 3 weeks on an inpatient unit. One morning the client greets the nurse cheerfully and states, "Everything is looking up. I'm not going to have problems for very long." What does the client's behavior and statement indicate?

Increased risk of suicide

The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse?

Informing the client in a matter-of-fact tone that everyone must remain with the group

What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client 30 years of age?

Intimacy versus isolation

A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?

Intramuscular injections of thiamine

A client with a history of sleeplessness, lack of interest in eating, and excessive purchases on charge accounts is seen in the mental health clinic. The adaptation that the nurse should expect the client to exhibit is:

Intrusive involvement with environmental activities

A depressed client is very resistive and complains about inabilities and worthlessness. The best nursing approach is to:

Involve the client in activities in which success can be ensured

Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of what symptoms? Irritability and tremors Yawning and convulsions Disorientation and paranoia Fever and profuse diaphoresis

Irritability and tremors Alcohol is a central nervous system depressant; irritability and tremors are the body's neurological adaptation to the withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last ingestion of alcohol. Yawning occurs with heroin withdrawal. Convulsions (delirium tremens, or DTs) are a later sign of severe withdrawal that occurs with alcohol withdrawal delirium. Delirium (paranoia and disorientation) is not an early sign of alcohol withdrawal and occurs 48 to 72 hours after abstinence. Fever and diaphoresis may occur during prolonged periods of delirium and are a result of autonomic overactivity.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating?

Is too busy to take the time to eat

A nurse working on a substance abuse unit knows that the individual uses opioids most commonly for what reason? Desires independence Is trying to reduce stress Wants to fit in with the peer group Enjoys the social interrelationships that occur

Is trying to reduce stress Individuals often take drugs because they cannot deal with the pain of reality; the drug blurs the pain and reduces anxiety. Drugs increase dependency rather than foster independence. Although the individual wanting to fit in with the peer encourages initial use by some adolescents, it is not the most common reason for opioid use. The use of drugs fosters social isolation.

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine (Cogentin) or trihexyphenidyl in conjunction with the phenothiazine derivatives neuroleptic medications?

It combats the extrapyramidal side effects of the other drug.

What should nurses consider when working with depressed young children?

It is important to include the family in the treatment plan.

Clients addicted to alcohol often use the defense mechanism of denial. What is the reason that this defense is so often used? It reduces their feelings of guilt. It creates the appearance of independence. It helps them live up to others' expectations. It makes them look better in the eyes of others.

It reduces their feelings of guilt. Alcoholic clients often use denial as a defense against feelings of guilt; this reduces anxiety and protects the self. Denial may make a client seem more stable to others, not independent. Denial deals more with a client's own expectations. Looking better in the eyes of others may be part of the reason, but the bigger motivating factor is to ease guilt feelings.

A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning and the client no longer talks about suicide. What should the nurse do in response to this client's behavior?

Keep the client under closer observation

A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child?

Keeping the child from inflicting any self-injury

For which clinical indication should a nurse observe a child in whom autism is suspected? Lack of eye contact Crying for attention Catatonia-like rigidity Engaging in parallel play

Lack of eye contact Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation?

Leaving a dim light on in the client's room at night

A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? (Select all that apply.)

Leaving the bedroom when unable to sleep Exercising in the afternoon rather than in the evening Counting backward from 100 to 0 when his mind is racing

When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, the nurse should:

Listen to what the client is saying

A client with dementia has been cared for by the spouse for 5 years. During the last month the client has become agitated and aggressive and is incontinent of urine and feces. What is the priority nursing care while this client is in an inpatient mental health facility?

Managing the behavior

What is the greatest difficulty for nurses caring for the severely depressed client?

quality of depression

A client is admitted to an alcohol rehabilitation center. On the fourth day after admission, the nurse detects a strong odor of alcohol on the client's breath. What is the nurse's first action? Asking where the client got the alcohol Locating and removing the alcoholic substance Conveying the staff's disappointment in this behavior Documenting and notifying the practitioner of the client's drinking

Locating and removing the alcoholic substance The nurse should remove the substance before the client or other clients have an opportunity to consume more alcohol. The primary concern is not where the alcohol was obtained but instead protecting the client from consuming more. Making the client feel guilty could increase the desire for more alcohol. The client may drink the remaining alcohol while the nurse documents the information and notifies the practitioner.

A nurse is interacting with a depressed, suicidal client. What themes in the client's conversation are of most concern to the nurse? (Select all that apply.)

Loneliness Hopelessness

A client with schizophrenia says to the nurse, "I've been here 5 days. There are 5 players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder?

Loose association

A nurse is caring for an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?

Loosened associations and hallucinations

The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is:

Lorazepam (Ativan)

A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem?

Low self-esteem

A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective?

Maintaining a supportive, structured environment

During an interview a 32-year-old man describes symptoms of decreased appetite, insomnia, anhedonia, and feelings of worthlessness that have been present for the past few weeks. He reports having had a few episodes of feeling depressed in the past but says that the feelings subsided. Recently he has felt worse, and he is now concerned that his symptoms are negatively affecting his job performance and fears he may lose his job "if someone doesn't help me soon." The nurse suspects these symptoms are related to which disorder? Schizophrenia Bipolar disorder Dysthymic disorder Major depressive disorder

Major depressive disorder The client is describing symptoms of major depressive disorder. Symptoms include depression that has lasted at least 2 weeks, that has resulted in a change in previous function, and that can impair important areas of function such as work performance. The client does not describe feeling depressed for most of his life. There are no symptoms of paranoia or psychosis that would be present in schizophrenia. For bipolar disorder to be considered, symptoms of mania would need to be included in the findings. With dysthymic disorder, depressive symptoms are chronic and present for 2 years or longer. Because of its chronic nature, dysthymia is difficult to distinguish from the person's usual pattern of function.

A depressed client frequently expresses doubts about living and admits thinking about suicide while denying that he has developed a plan. During this period it is essential that the nurse: Have a staff member stay with the client continuously Plan to involve the client in activities that foster independence Explain in detail to the client how the staff will protect him against self-harm Make frequent unobtrusive observations of the client's moods and his activities

Make frequent unobtrusive observations of the client's moods and his activities It is necessary to assess behavior changes that indicate impending suicidal acting out. Because there is no overt acting out and there is no plan, continuous observation is not necessary. The depressed client has little energy and has difficulty making decisions. Activities that are more structured are needed. Detailed explanations are inappropriate and overwhelming for a depressed client.

A client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol (Haldol) tablets orally to reduce agitation and preoccupation with auditory hallucinations. There has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started. What should the nurse's priority intervention be?

Making certain that the client is swallowing the medication

A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?

Malingering

What should the nurse teach parents about childhood depression? May appear as acting-out behavior Looks almost identical to adult depression Does not respond to conventional treatment Is short in duration and has an early resolution

May appear as acting-out behavior Children have difficulty verbally expressing their feelings; acting-out behaviors, such as temper tantrums, may indicate an underlying depression. Many conventional therapies for adults with depression, including medication, are effective for children with depression. Adult and childhood depression may be manifested in different ways. Childhood depression is not necessarily short and requires treatment.

A nurse is caring for a client with the diagnosis of bulimia nervosa. What does the nurse understand to be the function of food for individuals with bulimia? Gain attention Control others Avoid growing up Meet emotional needs

Meet emotional needs Clients with bulimia[1][2] eat to blunt emotional pain because they frequently feel unloved, inadequate, or unworthy; purging is precipitated to relieve feelings of guilt for bingeing or out of fear of obesity. The bingeing and purging are usually done alone and in secret. Clients with bulimia often feel out of control and perform their behaviors in secret. A protest against growing up is one of the psychodynamic theories regarding anorexia nervosa, not to bulimia nervosa.

A client with a history of substance abuse is brought to the emergency department. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing?

Methamphetamine

A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions?

Mild

A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? Mild Panic Severe Moderate

Mild A person with mild anxiety has a broad perceptual field and increased problem-solving abilities. Panic is characterized by a completely disruptive perceptual field. With severe anxiety, the perceptual field is reduced, as is the ability to focus on details. A moderately anxious person shuts out peripheral events and focuses on central concerns but has a decreased ability to problem solve.

An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? Mild Panic Severe Moderate

Moderate The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety. Mild anxiety is the level at which the individual is cognizant of all aspects of reality but has a "jumpy feeling" and "butterflies in the stomach." Panic is the level at which the individual is no longer in contact with reality, is unable to make decisions, has impaired judgment, and is dysfunctional. Severe anxiety is the level at which individuals lose touch with reality and have a feeling of impending doom, which tends to immobilize them.

What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol?

Motivational readiness

What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol? Motivational readiness Availability of community resources Accepting attitude in the client's family Qualitative level of the client's physical state

Motivational readiness Intrinsic motivation, stimulated from within the learner, is essential if rehabilitation is to be successful. Often clients are most emotionally ready for help when they have "hit bottom." Only then are they ready to face reality and put forth the necessary energy and effort to change behavior. The availability of community resources and the qualitative level of the client's physical state are important factors, but neither is the most important one. An accepting attitude on the part of the client's family is an important factor and a helpful one, but not the most important one.

A delusional client verbalizes the belief that others are out to harm him. A nurse notes the client's worsening pacing and agitation. What is the best nursing intervention?

Moving the client to a quiet place on the unit

The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do?

Prefill a weekly drug box with the medications for the spouse to self-administer

During an assessment interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing? Insomnia Narcolepsy Sleep terror Sleep apnea

Narcolepsy Narcolepsy is overwhelming sleepiness that results in irresistible attacks of sleep, loss of muscle tone (cataplexy), and hallucinations or sleep paralysis at the beginning or end of sleep episodes; the person usually awakens from the sleep feeling refreshed. Insomnia is difficulty initiating or maintaining sleep. Sleep terrors are recurrent episodes of abrupt awakening from sleep accompanied by intense fear, screaming, tachycardia, tachypnea, and diaphoresis with no detailed dream recall. Sleep apnea is a breathing-related sleep disorder caused by disrupted respirations or airway obstruction; sleep is disrupted numerous times throughout the night.

A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The nurse determines that the client is exhibiting:

Neologism

A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" What does the nurse determine that the client is exhibiting? Echolalia Neologism Concretism Perseveration

Neologism Neologisms are words that are invented and understood only by the person using them. Echolalia is the verbal repeating of exactly what is heard. Concretism is a pattern of speech characterized by the absence of abstractions or generalizations. Perseveration is a disturbed system of thinking manifested by repetitive verbalizations or motions or by persistent repetition of the same idea in response to different questions.

A client who attempted suicide by slashing her wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implanted when the client arrives on the unit? (Select all that apply.)

Obtaining vital signs Assessing for suicidal thoughts Instituting continuous monitoring Initiating a therapeutic relationship Inspecting the bandages for bleeding

Personality disorders are identified in the DSM-V in clusters. How should the nurse describe the behaviors of an individual with a cluster A personality disorder? Odd and eccentric Anxious and fearful Dramatic and erratic Hostile and impulsive

Odd and eccentric Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These clients are odd and eccentric and use strange speech, are angry, and have impaired relationships. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. These clients are anxious, fearful, tense, and rigid. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. These clients are dramatic, erratic, labile, impulsive, hostile, and manipulative.

On the fifth day of hospitalization the nurse notes that a depressed client remains lying on her bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat?

Offer to accompany the client to the dining room

How should the nursing staff fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity?

Offering high-calorie snacks frequently that the client can hold

A mother brings her 5-year-old daughter to the children's clinic after teachers report that the girl is disobedient and hostile. The child has a negative attitude and argues often with her teachers. At this time she has not violated the rights of other students. The mother reports that she has also noticed this behavior at home. The nurse suspects that the behavior described is associated with what disorder? Anxiety disorder Conduct disorder Major depressive disorder Oppositional defiant disorder

Oppositional defiant disorder Oppositional defiant disorder usually becomes evident before 8 years of age. Affected children do not violate the rights of others. They do not see themselves as defiant but feel that they are responding to unreasonable demands or situations. Children who are anxious or depressed may exhibit some disobedience during the school day but do not exhibit the argumentative and hostile behavior pattern seen with oppositional defiant disorder. Conduct disorder is characterized by a pattern of behavior in which the rights of others and social norms or rules are violated. There is a lack of guilt or remorse for inappropriate behavior, and blame is placed on others.

A nurse is caring for a client during the manic phase of bipolar disorder. What should the nurse do to best help meet the nutritional needs of this client?

Order foods that the client can hold in the hand to eat while moving around

A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client? Outbursts of anger Focused concentration Preoccupation with delusions Intense interpersonal relationships

Outbursts of anger Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients who have schizophrenia rather than with clients experiencing depression and hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have the physical or emotional energy for intense interpersonal relationships.

A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior?

Passive range-of-motion exercises three times a day for effective joint health

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

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

A nurse concludes that a client has successfully achieved the long-term goal of mobilizing effective coping responses when the client states that when he feels himself getting anxious he will:

Perform a relaxation exercise

A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? Ideas of grandeur Confusing illusions Persecutory delusions Auditory hallucinations

Persecutory delusions The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.

A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? Ideas of grandeur Confusing illusions Persecutory delusions Auditory hallucinations

Persecutory delusions The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.

A client with a diagnosis of bipolar disorder, manic episode, is admitted to the mental health unit. Because the environment is important, what should the nurse do?

Place the client in a private room to provide a quiet atmosphere

A hyperactive, acting-out 9-year-old boy is started on a behavior modification program in which tokens are given for acceptable behavior. When he begins to lose a game he is playing with other children, he begins to kick the other children under the table and call them names. What is the most appropriate behavior modification technique for the nurse to use?

Placing the child in a short time-out

When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. (Select all that apply.)

Planning for future safety Validating the experiences Promoting access to community services

A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child?

Play

b (Feedback Rationale: This response makes an observation, gives some health information about risks, and allows the client to choose. The client experiencing mania does not sleep or eat well, which can cause health problems. The client has stated that sleep is not necessary, so telling the client that the medication will help the client be in good shape tomorrow is meaningless to the client. Reminding the client of the rules is a threat and not acceptable. It is incorrect to state that the medication will potentiate the mood stabilizing medication.)

Prior to bedtime, the nurse offers trazodone (Desyrel) for the client with bipolar disorder who is experiencing mania. The client "declines the medication, stating they do not need sleep. The most therapeutic response by the nurse is the following: a "The medication should help you sleep so you'll be at your best tomorrow." b "You stated that you did not sleep at all last night. That can be tough on your system." c "You'll be in trouble if you break the unit rule that lights are out at 11 p.m." d "This medication will potentiate your mood stabilizer so that you'll be discharged sooner."

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization?

Project involving drawing

An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using?

Projection

The nurse understands that paranoid delusions may be related to the defense mechanism of: Projection Regression Repression Identification

Projection Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within. Regression is the use of a behavioral characteristic appropriate to an earlier level of development. Repression is the involuntary exclusion of painful or conflicting thoughts from awareness. Identification is taking on the thoughts and mannerisms of an individual who is admired or idealized.

Which nursing intervention is indicated for a client with an anxiety disorder?

Promoting verbalization of feelings by the client

A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? (Select all that apply.)

Provide physical outlets for aggressive feelings Establish a contract regarding manipulative behavior Develop activities that provide opportunities for success

What is important when the nurse plans care for a client with paranoid ideation?

Providing the client with opportunities for nonthreatening social interaction

A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify?

Rationalization

What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others?

React to the feeling tone of the client's delusion

A 30-year-old female client asks the nurse to change her room, stating that she hates her roommate and can't stand to be in the same room with her. Just as she finishes speaking, her roommate enters and the client tells her she missed her and has been all over the unit looking for her. The nurse recognizes that the client is using:

Reaction formation

Nursing management of a forgetful, disoriented client who exhibits inappropriate behaviors signifying dementia should be directed toward: Restricting gross motor activity to prevent injury Preventing further deterioration in the client's condition Maintaining scheduled activities through behavior modification Rechanneling the client's energies into more appropriate behaviors

Rechanneling the client's energies into more appropriate behaviors Disoriented clients need assistance in how they direct their energy to limit inappropriate behaviors. The staff cannot prevent all gross motor activity; the client needs to use his muscles, but their use must be controlled. Further deterioration usually cannot be prevented in this disorder. Behavior modification methods do not work well with disoriented, forgetful clients.

A nurse is caring for an adolescent with the diagnosis of anorexia nervosa. The plan of care should include helping the client: Plan nutritious meals. Change attitudes about nutrition. Understand that more food must be eaten. Recognize how the need to control influences behavior.

Recognize how the need to control influences behavior. The client's focus on controlling eating redirects attention away from those areas that are felt to be out of the client's control. This is how addressing life's more difficult problems and challenges are avoided. Planning nutritious meals may not be productive because these clients believe that they are eating nutritious meals. It is not the client's attitudes or beliefs about food but instead the distorted self-image that is the problem. Understanding that more food must be eaten may not be productive because these clients believe that they are eating enough food.

A client who is hallucinating actively approaches the nurse and reports, "I'm hearing voices that are saying bad things about me." What should the nurse do?

Recognizing that the behavior is part of the illness but setting limits on it

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? Write down conversations to facilitate the recall of information. Monopolize conversations about the anxiety being experienced. Redirect the conversation with the nurse to physical symptoms. Start a conversation asking the nurse to recommend palliative care.

Redirect the conversation with the nurse to physical symptoms. Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care.

Many clients who call a crisis hotline are extremely anxious. The nurse answering the hotline phone considers that the characteristic distinguishing posttraumatic stress disorders from other anxiety disorders is:

Reexperiencing the trauma in dreams and flashbacks

A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should:

Refer the mother to the psychiatrist

It is determined that a staff nurse has a drug abuse problem. As an initial intervention the staff nurse should be:

Referred to the employee assistance program

A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member?

Regression

What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?

Regression

What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit? Projection Regression Repression Rationalization

Regression Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid type, in which the delusional system is well systematized. Repression, or unconscious forgetting, is not a major defense used by clients with schizophrenia; if it were, they would not need to break with reality. Rationalization, in which the individual blames others for problems and attempts to justify actions, is seldom used by clients with schizophrenia.

A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use? Projection Repression Regression Conversion

Regression Regression is an unconscious defense mechanism that reduces anxiety by returning to behavior that was successful in earlier years. Regression commonly is used by clients with undifferentiated schizophrenia to reduce anxiety. Projection is the attributing of unacceptable feelings or thoughts to others. It is an organized defense used by clients with paranoid, not undifferentiated, schizophrenia. Clients with undifferentiated schizophrenia have psychotic manifestations that are extreme and do not have thought processes effective enough to use projection. Repression is unintentionally putting disturbing thoughts, feelings, or desires out of the conscious mind. Clients with schizophrenia are not able to do this and therefore have a need to escape from reality. Conversion is an unconscious defense mechanism in which a person develops physical symptoms that have no organic cause. Conversion serves the purpose of reducing anxiety. Conversion is not used by clients with undifferentiated schizophrenia.

What characteristic of anxiety is associated with a diagnosis of conversion disorder? Free-floating Relieved by the symptom Consciously felt by the client Projected onto the environment

Relieved by the symptom The client's anxiety results from being unable to choose psychologically between two conflicting actions. The conversion to a physical disability removes the choice and therefore eases the anxiety. The anxiety is not free floating or diffuse but rather localized and converted to a physical disability. The conversion of the anxiety to a physical disability occurs on an unconscious level; the original anxiety no longer exists, and the client generally is not anxious about the physical disability. The anxiety is internalized into a physical symptom, not projected onto the environment.

What should be the nurse's first intervention in the care of a client with a generalized anxiety disorder?

Removing as many stimuli from the client's environment as possible

A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? (Select all that apply.)

Repetitive activities Self-injurious behaviors Lack of communication with others

A client who is hallucinating actively approaches the nurse and reports, "I'm hearing voices that are saying bad things about me." What should the nurse do?

Reply, "I'll stay with you for a while because you seem frightened."

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. The nurse knows that the defense mechanism being utilized by this woman is:

Repression

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified (autistic disorder). What should the nurse consider most unusual for the child to demonstrate?

Responsiveness to the parents

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate? Interest in music Ritualistic behavior Attachment to odd objects Responsiveness to the parents

Responsiveness to the parents One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.

A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When the client sets outcomes, what need is it important for him to understand? Plan to avoid people who drink. Accept that he is a fragile person. Develop new social drinking skills. Restructure his life without alcohol.

Restructure his life without alcohol. Clients must learn new lifestyles and coping skills[1][2] to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option.

A client who has been experiencing excessive stress is hospitalized because of an inability to walk. After a physiologic cause for the problem is ruled out, a diagnosis of somatoform disorder, conversion type, is made. What does the nurse conclude is the cause of the client's paralysis? Nondisabling illness Way to get attention Loss of contact with reality Result of intrapsychic conflict

Result of intrapsychic conflict In situations in which a client may experience a high level of anxiety and psychic pain, a physical reason for not acting may unconsciously be used to limit negative feelings. Somatoform disorders are disabling; the client truly believes that the symptoms are real. These individuals do not enjoy their illness; their anxiety is relieved by it. These individuals are in contact with reality.

A nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client? Reward healthy behaviors. Explain the treatment plan. Identify various means of coping. Encourage participation in community meetings.

Reward healthy behaviors. By realistically rewarding the healthy behaviors, the nurse provides secondary gains and encourages the continued use of healthy behaviors. Explaining the treatment plan, identifying various means of coping, and encouraging participation in community meetings are important but will do little to increase the client's self-esteem.

A 17-year-old client is admitted to the hospital because of weight loss and malnutrition, and the health care provider diagnoses anorexia nervosa. After the client's physical condition is stabilized, the provider, in conjunction with the client and parents, decides to institute a behavior-modification program. What component of behavior modification verbalized by one of the parents leads the nurse to conclude that the parent has an understanding of the therapy?

Rewarding positive behavior

A constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome is:

Role experimentation

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care?

Routines provide stability for clients with dementia.

A client is admitted to the mental health unit after attempting suicide. When a nurse approaches, the client is tearful and silent. What is the best initial nursing intervention?

Saying, "I see that you're crying. Tell me what's going on in your life, and we can work on helping you."

A 12-year-old child who has a history of school failure and destructive acting out is admitted to a child psychiatric unit with the diagnosis of conduct disorder. The youngest of three children, the child is identified by both the parents and the siblings as the family problem. The nurse recognizes the family's pattern of relating to the child as:

Scapegoating

What childhood problem has legal as well as emotional aspects and cannot be ignored? School phobia Fear of animals Fear of monsters Sleep disturbances

School phobia School phobia is a disorder that cannot legally be ignored for long because children must attend school. It requires intervention to alleviate the separation anxiety and promote the child's increasing independence. Fear of animals and monsters and sleep disturbances all require parents to comfort the child, to reorient the child to reality, and to help the child regain self-control. Legally there are no requirements mandating treatment for these common childhood problems.

A child would be demonstrating outwardly focused anger or aggression in an overt manner when engaging in which behavior? Dominating a class discussion Intentionally forgetting to do homework Scribbling on a classmate's art assignment Crying when told he or she must wait his or her tur

Scribbling on a classmate's art assignment Overt anger is demonstrated obviously or in an unconcealed manner that is hurtful, such as in damaging the artwork of another student. Examples of passive outwardly focused anger would be in dominating conversations or intentionally forgetting to do something that is required. Crying is a demonstration of inwardly focused anger that is objectively displayed.

At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse?

Seeking consensual validation

What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants?

Seizure activity

What is the basic therapeutic tool used by the nurse to foster a client's psychological coping?

Self

On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be?

Stating that this behavior is unacceptable

When interacting with an adolescent client with the diagnosis of anorexia nervosa, it is most important that the nurse: Show empathy. Maintain control. Set and maintain limits. Focus on food and nutrition.

Set and maintain limits. The client's security is increased by limit-setting; guidelines remove responsibility for behavior from the client and increase compliance with the regimen. The client needs limit-setting, not empathy. Simply maintaining control is not therapeutic and increases the power struggle. Emphasis on food and nutrition may establish a power struggle between the client and the nurse.

A mother of a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD) tells the nurse that when she is reading storybooks to her son, about halfway through the story he becomes distracted, fidgets, and stops paying attention. The nurse suggests that the mother:

Shorten the rest of the story

A nurse is caring for several extremely depressed clients. The nurse determines that these clients seem to do best in settings where they have: Multiple stimuli Varied activities Simple daily routines Opportunities for decision-making

Simple daily routines Depression is usually both emotional and physical, so a simple daily routine is the least stressful and least anxiety producing. Too many stimuli increase anxiety in a depressed client. A depressed client has limited interest in any activity; offering many may increase anxiety. An extremely depressed client may be incapable of making even simple decisions.

At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. The nurse, recognizing the client's ambivalence, assists by using:

Simple declarative statements

What is a therapeutic nursing action in the care of a depressed client?

Sitting down next to the client at frequent intervals

A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discussing this therapy with the client?

Sleep will be induced and the treatment will not cause pain.

A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?

Somatic delusion

While a nurse is assisting with morning care for a client with the diagnosis of schizophrenia, the client suddenly throws off the covers and starts shouting, "My body is disintegrating! I'm being pinched." What term best describes the client's behavior? Somatic delusion Paranoid ideation Loose association Ideas of reference

Somatic delusion A somatic delusion is a false feeling about the physical self that is caused by a loss of reality testing. Paranoid ideations are beliefs that the individual is being singled out for unfair treatment. Loose associations are verbalizations that are difficult to understand because the links between thoughts are not apparent. Ideas of reference are false beliefs that the words and actions of others are concerned with or are directed toward the individual.

An anxious client reports experiencing pain in the abdomen and feeling empty and hollow. A diagnostic workup reveals no physical causes of these clinical findings. What term best reflects what the client is experiencing?

Somatization

An acutely ill client with the diagnosis of schizophrenia has just been admitted to the mental health unit. What is the most therapeutic initial nursing intervention?

Spending time with the client to build trust and demonstrate acceptance

A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense is the client using when identifying the other clients thusly?

Splitting

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory?

State three random words mentioned earlier in the exam

A delusional client refuses to eat because she believes that the food is poisoned. What is the most appropriate initial nursing intervention?

Stating that the food is not poisoned

What is a priority nursing intervention in the care of a drug-dependent mother and infant? Supporting the mother's positive responses toward her infant Requesting that family members share responsibility for infant care Keeping the infant separated from the mother until the mother is drug free Helping the mother understand that the infant's problems are a result of her drug intake

Supporting the mother's positive responses toward her infant A nurse should attempt to support the mother-child relationship; the mother is experiencing a developmental crisis while coping with drug addiction and possibly guilt. It is the client's right to decide who will share in the care of her child. The client needs contact with her new infant to facilitate bonding. Helping the mother understand that the infant's problems are a result of her drug intake will make the client feel guilty and will not facilitate positive action at this point.

Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?

Suspicious feelings

A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication?

Switches the user from illicit opioid use to use of a legal drug

A client is responding within an hour of receiving naloxone to combat respiratory depression from an overdose of heroin. Why should a nurse continue to closely monitor this client's status?

Symptoms of the heroin overdose may return after the naloxone is metabolized.

A hyperactive 9-year-old child with a history of attention deficit-hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety?

Talking with the child about the importance of using a seat belt

A client with the diagnosis of bipolar disorder, depressive episode, has been hospitalized on a psychiatric unit for 1 week. What is the most appropriate activity for this client?

Talking with the nurse several times during the day

When implementing a tertiary preventive program for cognitively impaired individuals the nurse should: Teach children how to feed themselves. Encourage the use of birth control by women. Refer children for evaluation if they fail to meet developmental milestones. Use the Denver Developmental Screening Test to evaluate children attending well-child clinics.

Teach children how to feed themselves. Tertiary prevention is focused on interventions that prevent complete disability or reduce the severity of a disorder or its associated disabilities. Referring children for evaluation if they fail to meet developmental milestones is secondary prevention aimed at case-finding and early intervention. Encouraging the use of birth control by women who are cognitively impaired is primary prevention. Using the Denver Developmental Screening Test to evaluate children attending well-child clinics is secondary prevention aimed at case-finding and early intervention.

A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should: Demand that the client stop the behavior immediately. Tell the client firmly that the behavior is unacceptable. Ask the client to identify what is precipitating the behavior. Increase the client's medication or get a prescription for another drug.

Tell the client firmly that the behavior is unacceptable. A firm voice is most effective; the statement tells the client that it is the behavior, not the client, that is upsetting to others. Demanding that the client stop the current behavior is a useless action; the client is out of control and needs external control. The client does not know what is precipitating the behavior, and asking the client will be frustrating for him. The dosage of the client's medication should be increased or a prescription for another drug should be obtained if the client does not respond to firm limit-setting.

A nurse is planning to teach a group of nursing assistants about auditory hallucinations. What portion of the brain should the nurse include that is involved with these hallucinations? Parietal lobe Frontal cortex Occipital lobe Temporal lobe

Temporal lobe The temporal lobe helps individuals focus on environmental events and integrates smell and hearing. The parietal lobe receives and integrates information about taste and touch. The frontal cortex receives input from all areas of the brain and integrates information about body position, memory, arousal states, and emotions. The occipital lobe is involved in the perception of visual input and depth perception.

The nurse refers a client to a self-help group. What does the nurse anticipate that a self-help groups such as Alcoholics Anonymous (AA) will help its members learn?

That their problems are not unique

A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug?

The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks.

An adolescent with anorexia nervosa frequently telephones home just before mealtimes. The client uses the phone calls to avoid eating. What client behavior supports the nurse's conclusion that the nursing plan to set limits on this avoidance behavior has been effective?

The client arrives on time for meals without being told

A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? The client is obese and attempting to lose weight. The client behaves appropriately and looks normal. The client has a distorted body image and sees the body as fat. The client is struggling with a conflict of dependence versus independence.

The client behaves appropriately and looks normal. Bulimic clients hide much of their bingeing and purging behaviors and, unlike clients with anorexia, may have near-ideal body weights. Clients with bulimia nervosa[1][2] are usually not obese. Distorted body image and conflict of dependence versus independence are associated with both anorexic and bulimic clients.

Evaluation of clients with anorexia nervosa requires reassessment of behaviors after admission. Which finding indicates that the therapy is beginning to be effective?

The client has gained 6 lb since admission 3 weeks ago.

A client confides to the nurse, "I've been thinking about suicide lately." What conclusion should the nurse make about the client?

The client is fearful of the impulses and is seeking protection from them.

c (Rationale: Stress can cause the release of neurotransmitters, over time causing more rapid mood swings even though the lithium level is normal. The body does not develop a tolerance to lithium and the sleep cycle is not disturbed. A decreased production of melatonin will cause depression, not mood swings.)

The client, who is on lithium for bipolar disorder, is experiencing more mood swings despite a therapeutic lithium level. What is the cause of these mood swings? a "The shorter days in the fall decreases the production of melatonin, which affects mood." b "The body develops a tolerance to the medication, so a higher dose is needed." c When under constant stress, "The brain releases extra neurotransmitters, causing more rapid mood swings." d "The sleep-wake cycle is disturbed by the medication."

A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client? The illness is very real to the client and requires appropriate nursing care. Although the client believes that there is an illness, there is no cause for concern. There is no physiological basis for the illness; therefore only emotional care is needed. Nursing intervention is needed even though the nurse understands that the client is not ill.

The illness is very real to the client and requires appropriate nursing care. Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.

What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness?

The need to follow the prescribed medication regimen

c (Rationale Bipolar disorders are a group of mood disorders that include manic​ episodes, hypomanic​ episodes, and mixed episodes. Symptoms may include​ euphoria, inability to take time to​ eat, sleep​ disturbances, and possibly sexual disinhibition. Cyclothymic disorder symptoms include fluctuating mood​ disturbances, involving numerous periods of hypomanic symptoms and numerous periods of depressive symptoms. Hypomania is a less extreme form of mania that is not severe enough to markedly impair functioning or require hospitalization. A depressed episode occurs when manic or hypomanic episodes have occurred in the​ past, but the features of the current episode are purely depressive.)

The nurse is assessing a new client on the mental health unit. The client states that she has been overly busy every day most of the time for the past 2 years and is unable to cope with family responsibilities. The nurse suspects that this client is suffering from which type of​ disorder? a Bipolar disorder with depression b Bipolar disorder with hypomania c Bipolar disorder with mania d Cyclothymic disorder

a,b,d,e

The nurse is evaluating the effectiveness of the nursing interventions for a client with bipolar disorder. Which evaluation of outcomes are appropriate for this​ client? Select all that apply. a The client remained in a safe environment and free from injury. b The client was able to demonstrate​ reality-based thinking by making an effective decision. c The client was able to sleep at least 4 hours at night. d The client was able to set appropriate limits in a variety of situations. e The client did not commit violent or harmful acts against self or others.

a,b,c,e (Rationale A goal that states that the client who is currently depressed will have no symptoms of depression is inappropriate. All other answer choices are appropriate choices for the client with bipolar disorder with depression.)

The nurse is planning care for a client with bipolar disorder who is experiencing depression. What outcomes are appropriate for the nurse to include in the client​'s plan of​ care? Select all that apply. a The client will have no suicidal ideations. b The client will maintain a safe environment and remain free from injury. c The client and family will become knowledgeable about the​ disorder, effective​ communication, and problem solving. d The client will have no symptoms of depression. e The client will maintain appropriate personal​ self-care.

b,c,d,e (Rationale A goal that states the client will not experience any additional episodes of mania is​ incorrect, because this is not specific to the client​'s problem right now. The other​ outcomes/goals are appropriate for a client with bipolar disorder experiencing mania.)

The nurse is planning care for a client with bipolar disorder who is experiencing mania. What outcomes are appropriate for the nurse to include in the client​'s plan of​ care? Select all that apply. a The client will not experience any additional episodes of mania. b The client will maintain a safe environment and remain free from injury. c The client will get at least 6 hours of sleep per night. d The client will demonstrate socially appropriate behaviors during interactions with others in a variety of settings. e The client will not commit violent or harmful acts against self or others.

a (Rationale By giving the client​ high-calorie foods that can be eaten while the client is​ active, the nurse facilitates the client​'s nutritional intake. The client​'s metabolic rate is not useful information when the client is experiencing mania. The client will not be able to sit still long enough to focus on what the dietitian is saying during a manic episode or to sit in the dining area to eat.)

The nurse is planning care for a client with bipolar disorder. Which intervention would the nurse implement to maintain adequate nutrition during a manic​ episode? a Give the client foods to be eaten while the client is active. b Have the client interact with a dietitian twice a week. c Make the client sit down for each meal and snack in the dining area. d Determine the client​'s metabolic rate.

a,b,c,d (Rationale Appropriate nursing interventions for the client experiencing mania​ include: Administering medications as​ ordered, maintaining proper client nutritional​ status, assisting with personal hygiene as​ needed, and discussing sleep patterns and methods to promote at least 6 hours of sleep at night. The nurse should not encourage the client with mania to sit while​ eating, as this is very difficult or impossible for the client to do.)

The nurse is writing a plan of care for a client with acute mania. Which nursing interventions are appropriate when caring for this​ client? Select all that apply. a Administer medications as ordered. b Discuss sleep patterns and methods to promote at least 6 hours of sleep at night. c Assist with personal hygiene as needed. d Maintain proper client nutritional status. e Encourage the client to sit down while eating.

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance? Thiamine deficiency A reduced iron intake An increase in serotonin Riboflavin malabsorption

Thiamine deficiency The deficiency of thiamine (vitamin B 1) is thought to be a primary cause of alcohol-induced amnestic disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? Feeling undeserving of the food Too busy to take the time to eat Wishes to avoid others in the dining room Believes that there is no need for food at this time

Too busy to take the time to eat Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment

A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? (Select all that apply.)

Tremors Anorexia

A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Which data are the cause of the nurse's concern? Select all that apply. Tremors in both hands make it difficult for the client to hold a cup. The client's systolic blood pressure has dropped 6 points over last 6 hours. The client was observed falling asleep while talking on the telephone to family. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television.

Tremors in both hands make it difficult for the client to hold a cup. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television. Diaphoresis and tremors are physical characteristics of alcohol withdrawal. Agitation is a psychosocial characteristic of alcohol withdrawal. Systolic blood pressure would rise rather than fall if the client were experiencing alcohol withdrawal. Insomnia, rather than drowsiness, is a physical characteristic of alcohol withdrawal.

When planning care for a client who has just completed withdrawal from multiple-drug abuse, what reality in relation to the client should the nurse take into consideration? Unable to give up drugs Unconcerned with reality Unable to delay gratification Unaware of the danger of drug addiction

Unable to delay gratification A person with an addictive personality is unable to delay gratification; drugs help blur reality and ease frustration. Giving up drugs is possible but not easy; it requires a change in attitude and a deconditioning process. Users of drugs are concerned with reality, and their drug use is an attempt to blur the pains of reality. Intellectually these people may be aware of the dangers of drug addiction, but emotionally they cannot buy into the reality that it can happen to them.

What characteristic uniquely associated with psychophysiological disorders differentiates them from somatoform disorders?

Underlying pathophysiology

What characteristic uniquely associated with psychophysiological disorders differentiates them from somatoform disorders? Emotional cause Feeling of illness Restriction of activities Underlying pathophysiology

Underlying pathophysiology The psychophysiological response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatoform disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.

What is the prognosis for a normal productive life for a child with autism?

Unlikely because of interference with so many parameters of function

For what most common characteristic of autism should a nurse assess a child in whom the disorder is suspected? Responds to any stimulus Responds to physical contact Unresponsiveness to the environment Interacts with children rather than adults

Unresponsiveness to the environment Poor interpersonal relationships, inappropriate behavior, and learning disabilities prevent autistic children from emotionally adapting or responding to the environment even when the intelligence level is high. It is the lack of response to stimuli that is the clue that the child may have autism. Children with autism have an aversion to physical contact; they also have impaired interpersonal relationships regardless of the age of the other person.

A 6-year-old child who has autism exhibits frequent spinning and hand-flapping behaviors. What should the nurse teach the parents to do to limit these actions?

Use another activity to distract the child

A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? (Select all that apply.)

Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress

A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. Describes how others have caused the addiction Verbalizes difficulty identifying personal strengths Expresses uncertainty about meeting with the nurse Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress

Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress Looking at one's strengths in addition to areas that need growth is difficult work, and sharing this difficulty demonstrates that the client is willing to work with the nurse to address personal issues. When he is willing to address cause and effect issues of personal behavior, the client is in the working phase of a therapeutic relationship. When people in a therapeutic relationship are able to address how their behavior affects others, they are taking the first step toward taking responsibility for their actions. The use of projection is a defense from taking responsibility for the addiction; this will impair the effectiveness of a working therapeutic relationship. Ambivalence about working with the nurse usually occurs during the introductory phase of the nurse-client relationship.

What behavior by a client with a long history of alcohol abuse is an indication that the client may be ready for treatment?

Verbalizing an honest desire for help

A client on a psychiatric unit misses breakfast because of an elaborate hand-washing ritual. What is the most important therapeutic intervention during the early period of the client's hospitalization?

Waking the client early so the ritual can be completed before breakfast

A client was recently given a diagnosis of a manic episode of a bipolar I disorder. What activity is most therapeutic for this client at this time? Doing a craft project Playing a game of table tennis Playing cards with another patient Walking around the unit with a nurse

Walking around the unit with a nurse Walking allows the client to burn excess energy in a safe, acceptable activity. A one-on-one activity demonstrates that the nurse cares and may allow the nurse to verbally interact with the client. A quiet activity such as a craft project for a person who is hyperactive is unrealistic and would be frustrating for the client. A game of table tennis would be too stimulating and competitive, both of which may increase anxiety. A hyperactive client does not have the ability to be quiet and focus on a card game.

While watching television in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse?

Walking to the end of the hallway where the client is standing

b,c,e (Psychotherapies that are appropriate for a client diagnosed with bipolar disorder include individual​ therapy, CBT, and family therapy. ECT is not a therapy that is typically used for the treatment of bipolar disorder. Lithium therapy is an appropriate pharmacologic therapy for bipolar​ disorder, but it is not a type of psychotherapy.)

What treatment modalities of psychotherapy are used to treat bipolar​ disorder? Select all that apply. a Electroconvulsive therapy​ (ECT) b Family therapy c Individual therapy d Lithium therapy ​e Cognitive-behavioral therapy​ (CBT)

c,d,e (Psychotherapies that are appropriate for a client diagnosed with bipolar disorder include individual​ therapy, CBT, and family therapy. ECT is not a therapy that is typically used for the treatment of bipolar disorder. Lithium therapy is an appropriate pharmacologic therapy for bipolar​ disorder, but it is not a type of psychotherapy.)

What treatment modalities of psychotherapy are used to treat bipolar​ disorder? Select all that apply. a Lithium therapy b Electroconvulsive therapy​ (ECT) c Individual therapy d Family therapy ​e Cognitive-behavioral therapy​ (CBT)

b,d,e (Rationale: People in the hypomanic state experience a dramatically decreased need for sleep. Clients in a hypomanic state develop emotional attachments rapidly and may engage in impulsive or simultaneous sexual relationships. Clients in a hypomanic state have increased neurotransmission, which leads to racing thoughts and pressured or rapid speech. Anhedonia and guilt are not symptoms of the hypomanic phase.)

What would the nurse expect to observe in a client in the hypomanic phase of bipolar disorder? (Select all that apply.) a Anhedonia b Preoccupation with sex c Guilt d Lack of sleep e Rapid speech

In what situation should a nurse anticipate that a client will experience a phobic reaction?

When coming into contact with the feared object

a (Rationale: This complicated activity requires concentration and a long-attention span. Most bipolar clients in the manic phase have increased sexual desire. The client with bipolar disorder is capable of understanding the disease without treatment. 3 hours of sleep would indicate the client is experiencing the hypomanic phase.)

Which outcome indicates that a client taking lithium is responding effectively to therapy? a The client completes the crossword puzzle in the daily newspaper. b The client reports an increase in sexual desire. c The client verbalizes complete understanding of bipolar disorder. d The client reports feeling refreshed after sleeping for 3 hours at night.

Mania

__________ is an abnormal and persistent period of​ increased, expanded, or irritable mood that is characterized by increased energy for a period of time.