Psychiatric/Mental Health Assignment Exam Hesi Practice

A male client is brought to the emergency department by a police officer, who reports the client was "disturbing the peace" by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary committment? (Choose all that apply.) A. Threats to kill his friend. B. Disruptive behaviors in a community setting. C. Hears voices telling him to kill himself. D. Reports he has not needed a bath in 4 months. E. Created extensive private property damage. F. Says he has not eaten in 3 days.

ANS: A, C, D, F A. Threats to kill his friend. C. Hears voices telling him to kill himself. D. Reports he has not needed a bath in 4 months. F. Says he has not eaten in 3 days. Most states provide for emergency involuntary hospitalization or civil commitment for a specified period to prevent dangerous behavior that is likely to cause harm to self or others. Police officers and healthcare providers may be designated by statute to authorize the detention of persons who are a danger to themselves or others or who are unable to provide for their own basic needs due to mental illness. The other behaviors are civil issues, not factors related to involuntary commitment.

An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement? A. Administer acetylcysteine (Mucocyst). B. Monitor cardiac rhythm for flat T waves. C. Check both serum AST and ALT levels. D. Prepare to administer Syrup of Ipecac.

ANS: A. Administer acetylcysteine (Mucocyst). Tylenol overdose is treated with immediate administration of Mucomyst to prevent hepatic insult. The other actions are not indicated.

At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first? A. Ask a group member to seek help. B. Obtain the client's blood pressure. C. Position in a recovery position. D. Assess the client's level of orientation.

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

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

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

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

ANS: Reevaluate the client's blood pressure in an hour. The client is irritable and pacing, which can contribute to the elevated BP. A reevaluation of the client's BP in an hour allows time for the excitement and stress of the admission process to abate. The other actions are not indicated at this time.

The nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client? A. Coping skills. B. Physical exercise. C. Grief management. D. Social support.

ANS: A. Coping skills. Ineffective coping skills are characteristic of depression, and based on this client's symptoms, group therapy that focuses on coping skills is likely to be most beneficial. The other groups processes are less likely to be beneficial.

A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? A. Ask the family if they would like to see and hold the infant after birth. B. Inquire if the parents want a picture taken after the infant is born. C. Discuss with the parents which funeral home should be notified. D. Find out if the client has a special outfit for the infant after the birth.

ANS: A. Ask the family if they would like to see and hold the infant after birth. Interventions and support from the nursing staff during a prenatal loss are extremely important in the grief process and healing of the parents. Research had shown it is most helpful for a mother and father to see and hold their deceased infant after delivery, so the parents should be given this opportunity initially after birth. The other actions should be done after determining the parents' wishes and providing the opportunity for bonding and closure with their infant.

The client with depression asks the nurse, " What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain." What information should the nurse use to support an explanation of neurotransmitters? A. Chemical messengers that cause brain cells to turn on or off. B. Areas of the brain that are responsible for controlling emotions. C. Clumps of cells that alert the other brain cells to receive messages. D. Web-like structures that provide connections among parts of the brain.

ANS: A. Chemical messengers that cause brain cells to turn on or off. Neurotransmitters are chemicals manufactured in the brain that are responsible for exciting or inhibiting brain cells to produce an action. The other explanations address functions of neural structures and specific areas of the brain.

A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain? A. Drugs taken in last 7 days. B. Family history of suicide. C. Usual coping mechanisms. D. Frequency of anxiety attacks.

ANS: A. Drugs taken in last 7 days. Use of prescribed, over-the-counter, and illicit drugs are the most important information to obtain when planning care because drugs are likely to influence the client's behavior and ability to cope with stressful situations. The other assessment findings are not the priority at this time.

Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit? A. Establish rapport in each phase of the nurse-client relationship. B. Determine the client's ability to communicate effectively. C. Reflect on previous psychiatric interviews the nurse has performed. D. Ensure data is collected and recorded in a systematic sequence.

ANS: A. Establish rapport in each phase of the nurse-client relationship. A client with whom the nurse establishes rapport during the initial interview and in each phase of the nurse-client relationship feels understood by the nurse and is more likely to cooperate and provide feedback during the admission process. The other actions not always needed to establish rapport or maintain the therapeutic self in a therapeutic relationship.

The nurse is caring for a female client who is admitted for depression with the nursing diagno sis, "Self-esteem, chronic low." Which client response indicates to the nurse that the client has improved self-esteem? A. Identifies own strengths. B. Stops crying during every session. C. Talks with other clients about marital advice. D. Asks the nurse if her behavior has improved.

ANS: A. Identifies own strengths. Identifying one's personal strengths is an important part of increasing self-esteem. The other client behaviors do not indicate an improved self-esteem or self-confidence.

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

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

A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will always be this way and that there's no hope for me." What information should the nurse provide? A. Panic disorder is treatable in a number of different ways, including medication. B. Understanding the fact that a cure is not attainable helps the client learn to adjust. C. This disorder is a biologically determined hereditary disease that has no cure. D. Evidence based practice indicates that neuroleptic drugs can be used prophylactically.

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

The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care? A. Search the client's personal belongings. B. Introduce the client to others on the unit. C. Ask the client about recent stressful events. D. Move to a room that allows close observation.

ANS: A. Search the client's personal belongings. To safeguard that the client dose not have some means to inflict self harm, a routine search of personal belongings, which is a common safety policy, should be implemented until the client stabilizes and suicidal ideations abate. The other interventions are components of the plan of care that ensure a therapeutic milieu but are not the priority in ensuring safety from self-harm.

A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because my husband told me I will be deported if my depression is not cured." What information should the nurse report to the healthcare provider? A. The client's consent may have been coerced. B. All the elements of informed consent were met. C. The woman may not fully understand the risks and benefits. D. The client is not competent to sign permission for treatment.

ANS: A. The client's consent may have been coerced. Informed consent requires that the choice is freely given. Although the staff acted ethically and observed the client's right to give informed consent, the decision may have been coerced based on family pressure, which may require further interventions. The other information is inaccurate.

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

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

The community health nurse facilitates a substance abuse prevention group for a homeless population. Which statement demonstrates that a client has a realistic understanding of the recovery process? A. I do OK as long as I can get methadone from the clinic regularly. B. By learning what led to my latest relapse, I know what to do in the future. C. A 12-step program is the only treatment approach that is proven effective. D. I know now that I wasn't ready to make a change until I hit rock bottom.

ANS: B. By learning what led to my latest relapse, I know what to do in the future. Recovery is a lifelong process in which clients must constantly learn and apply new behaviors to replace ineffective ones. Long-term recovery improves when a client acquires new coping skills that are successful, so those who learn from their relapses and triggers demonstrate an understanding of the process. The other statements do not necessarily indicate a client who is addicted will maintain recovery.

The daughter of an older male client tells the nurse that her father is becoming increasingly forgetful. Which finding indicates that the client needs further evaluation of cognitive function? A. Repeats the same stories to different family members or friends. B. Cannot mentally retrace objects that were recently misplaced. C. Cannot remember instructions to program an electronic device. D. Forgets a planned event, then remembers the event a short while later.

ANS: B. Cannot mentally retrace objects that were recently misplaced. Inability to retrace misplaced objects is an indicator of possible cognitive impairment that requires further assessment. The other examples are common in benign forgetfulness.

A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement? A. Tell the client to quiet down. B. Escort the client to a quieter place. C. Ask the group to reconsider the suggestion. D. Ignore the client's manic outbursts.

ANS: B. Escort the client to a quieter place. A client in the manic phase has an inflated ego, feelings of grandiosity, and is unlikely to respond to limit-setting. To curtail further escalation and disruption, the client should be escorted to a less stimulating environment. The other actions are not indicated and are ineffective for a client in the manic phase who often is unable to control their behavior.

A school-aged girl with severe birth defects and mental retardation is brought to the emergency room because of a possible broken arm. The caregiver reports that the girl sustained the injury when she fell from her wheelchair. Which intervention should the nurse implement? A. Prepare the child for cast placement. B. Evaluate the intellectual functioning of the child. C. Evaluate the child for other injuries. D. Ask the child to explain the accident.

ANS: B. Evaluate the child for other injuries. The nurse should evaluate the child for other injuries because this child with a low-level fall that results in a fracture should be considered a possible victim of child abuse, until unproven otherwise. The other interventions are not indicated.

A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation. What action should the nurse implement? A. Encourage him to share his feelings more appropriately. B. Express concern over his disappointment. C. Arrange to have a clergy person visit. D. Administer a PRN prescription for an antianxiety drug.

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

The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider? A. Restlessness, anxiety, and difficulty sleeping. B. Global confusion and inability to recognize family members. C. Agitation, vomiting, and visual and auditory hallucinations. D. Low-grade fever, diaphoresis, hypertension, and tachycardia

ANS: B. Global confusion and inability to recognize family members. Delirium tremens (DT), or alcohol withdrawal delirium,usually peaks 2 to 3 days (48 to 72 hours or later) after cessation or reduction of intake and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal manifested as global confusion and an inability to recognize family members is life-threatening and requires emergency medical intervention. The other signs of withdrawal can occur within hours after cessation or reduction of alcohol intake and may require treatment to minimize risk of progression to DTs.

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

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

A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take? A. Assist the client in verbalizing distress about the disease. B. Inquire about emotional factors affecting the client's present condition. C. Assess priorities to be set for the client's overall nursing care plan. D. Encourage the client to emotionally accept the chronicity of the disease.

ANS: B. Inquire about emotional factors affecting the client's present condition. Holistic care considers biological, psychological, and sociocultural factors that influences one's health status. The client is giving clues to psychological distress, so assessment for emotional factors that have impacted the client's present condition should be made. The other actions are not the priority.

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

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

The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first? A. Offer oral fluids. B. Monitor vital signs. C. Evaluate ECT effectiveness. D. Encourage group participation.

ANS: B. Monitor vital signs. Sedatives, muscle relaxants, and an anticholinergic agent are often prescribed for a client during ECT. Vital signs should be monitored during recovery after the ECT procedure. The other actions are not indicated immediately post ECT.

A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the nurse to implement? A. Leave the room without saying a word. B. Provide information about infection prevention. C. Allow the client to change the dressing himself. D. Explain the healthcare provider's prescriptio

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

Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? A. Context. B. Self-analysis. C. Counter transference. D. Therapeutic self-disclosure.

ANS: B. Self-analysis. Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs. The nurse's primary tool is self-analysis and use of the therapeutic self to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. The other techniques may occur in a nurse-client relationship, but do not contribute to establishing a therapeutic relationship.

What nursing assessment is the priority focus for a client with major depression? A. Mood and affect. B. Suicidal ideation. C. Nutritional status. D. Fluid and electrolyte balance.

ANS: B. Suicidal ideation. Suicidal ideations are a major risk factor in a client with major depression. Although mood and affect are assessed while determining if the client has suicidal ideations, the client's risk for self-injury is the priority. The other assessments are not indicated at this time.

A client who abuses alcohol says to the nurse, "I am glad I went in for treatment. Now my problems with alcohol are all behind me." Which response is best for the nurse to provide? A. Yes, but do you know that the treatment program you attended has an excellent success profile? B. Tell me more about what you mean when you say that your problems with alcohol are now behind you. C. You are likely to have a difficult time staying sober if you think that problems with alcohol are behind you. D. Do you know what "one day at a time" means for those who have problems with alcohol?

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

Which client outcome during hospitalization indicates improvement for a client who is admitted with auditory hallucinations? A. Argues with the voices. B. Tells when voices decrease. C. Follows what the voices say. D. Tells the nurse what the voices say.

ANS: B. Tells when voices decrease. Hallucinations are defined as false sensory perceptions. The goal of nursing interventions with clients who are hallucinating is to help them to increase awareness of symptoms and distinguish between the world of psychosis and reality. The client outcome that shows improvement is the client can tell when the voices decrease. The other client behaviors do not indicate improvement towards a client outcome.

While assessing an older male client, a nurse working in the outpatient clinic notices bruises on the client's chest. The client admits that his daughter, who is his caregiver, becomes frustrated and sometimes hits him. What is the priority outcome for the client who is experience physical abuse at home? A. The client will verbalize an acceptance of his health status and dependency. B. The client will report feeling safe with his daughter's care at home. C. The client will report the frequency of abuse has decreased. D. The client will describes the potential danger of his situation.

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

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? A. Ready the client for discharge. B. Notify pastoral care to offer the client a blessing. C. Ask the client what name she had picked out for the infant. D. Inquire if the client would like to see what was obtained from her D&C.

ANS: C. Ask the client what name she had picked out for the infant. The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name provides an opportunity to offer support. The other actions are not indicated.

A client with substance abuse is admitted to the mental health unit. Which action should be implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)? A. Provide menus for dietary selections. B. Clarify visiting hours and telephone usage. C. Collect a complete substance abuse history. D. Obtain vital signs and orient the client to the unit.

ANS: C. Collect a complete substance abuse history. As part of a comprehensive assessment, the nurse should assess the client for past and present alcohol, tobacco, prescription drug, over-the-counter drug, and illicit drug use. The nurse can delegate the other basic skills to the UAP.

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

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

A client is responding to auditory hallucinations and shakes a fist at a nurse and says, "Back off, witch!" The nurse follows the client to the unit's day room. What action should the nurse implement? A. Sit down in a chair near the client. B. Position self within an arm's length of the client. C. Ensure that there is physical space between the nurse and client. D. Move to a position that allows the client to be closest to the room's door.

ANS: C. Ensure that there is physical space between the nurse and client. Personal space should increase when a client feels anxious and threatened. An adequate social space (4 to 12 feet) between the nurse and the client should be maintained to minimize the client's escalation and physical contact with the nurse. The other positions increase the risk for injury if the client becomes aggressive.

A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first? A. Secure samples of vaginal hair combings. B. Offer prophylactic antibiotic medication. C. Explain the rape protocol to the client. D. Implement crisis intervention counseling.

ANS: C. Explain the rape protocol to the client. Impact reactions of the acute phase of the rape-trauma syndrome include shock, emotional numbness, confusion, disbelief, restless, and agitated motor activity. First, the nurse should provide the client with an explanation of the forensic rape protocol and ask her permission to proceed with examination to minimize additional trauma during assessment and collection of evidence. After the collection of evidence, prophylactic antibiotic medication is provided and then crisis intervention counseling initiated.

During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client? A. On a scale of 1 to 10 how do you rate your anxiety level? B. How would you describe your mood right now? C. Have you had any thoughts of hurting yourself? D. What medications have you taken in the last 24 hours?

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

An adult female who is married and works full-time in a factory has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question should the nurse use? A. Do you drink excessively? B. Did your husband beat you? C. How did this happen to you? D. What did you do to deserve this?

ANS: C. How did this happen to you? Domestic violence can present in several forms, including sexual, physical, mental, and neglect. The victim of spousal abuse is often frightened or may feel at fault about the abuse, so a therapeutic relationship should be established with the client using nonjudgmental, open-ended questions so that the client is comfortable to disclose details about the injury, if abuse is suspected. The other questions are close-ended questions that can be answered with "yes" or "no" answers and are not therapeutic.

Which client statement should the nurse identify as most typical of a client with mania? A. I can't do anything anymore. B. I can't understand where all our money goes. C. I manage our finances great because I buy in big quantities. D. I wonder why my wife is so upset that I spend money easily.

ANS: C. I manage our finances great because I buy in big quantities. A client with bipolar disorder, mania, characteristically demonstrates thoughts of inflate self-esteem, grandiosity, and a tendency for excessiveness, such as excessive spending. The other client statements do not support a client's lack of insight, poor judgment, and inflated self view that is typically seen in mania.

An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately? A. Increased serum creatinine level. B. Positive rapid plasma reagin (RPR). C. Increased thyroid stimulating hormone (TSH). D. Elevated serum calcium level.

ANS: C. Increased thyroid stimulating hormone (TSH). The healthcare provider should be notified of TSH levels immediately. An increased TSH suggests a low thyroxine level because TSH is being secreted to stimulate thyroxine production, which is the pathophysiology of hypothyroidism that may present as depression. The other results should be evaluated but do not have the priority relative to the admission diagnosis.

An adolescent female client is admitted to the Emergency Department because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room. What action should the nurse implement? A. Reassure client that the male UAP is a staff member who wants to help her. B. Tell the client that her fear is understandable under these circumstances. C. Reassign an all-female healthcare team to the client until her fear subsides. D. Ask her mother to please stay with her throughout the assessment procedures.

ANS: C. Reassign an all-female healthcare team to the client until her fear subsides. An adolescent female who has been physically violated and emotionally traumatized needs a non-threatening environment, and reassigning this client to all-female personnel is best to reduce her fear and anxiety related to rape. The other actions do not specifically address the client's fear of the male UAP.

A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond? A. Images indicate the presence of tumors and scars. B. The scan clearly outlined structures of the brain. C. Results show activity in various portions of the brain. D. PET shows biochemical levels of neurotransmitters.

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

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

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

A client is pacing in the hall near the nurses' station and swearing loudly. What response is best for the nurse to provide? A. Hey, what's going on? B. Others are being distracted. Please, quiet down. C. You seem pretty upset. Tell me about it. D. Please go to your room to get control of yourself.

ANS: C. You seem pretty upset. Tell me about it. A client who is distressed and acting out angrily should be assessed for additional information about what may be causing a change in the client's behavior. Therapeutic responses to disruptive behavior or language should begin with the nurse's reflective interpretation of the client's distress, and followed with an open-ended statement. The other responses are not client-centered.

Which client should the nurse identify as the highest risk for the onset of stress-related problems? A. A man whose new business is growing slowly, who plans to adopt a child with his wife, and says, "I think I'm in control of my destiny." B. A woman who is graduating from college, getting married in one month, and states, "I'm anticipating the changes these events will make in my life." C. A client who is passed over for promotion, quits a job to start a new business, and states, "This is just one of a series of challenges I've faced in my life." D. A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless."

ANS: D. A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless." A client who is dealing with two stressful life events and expresses a cognitive appraisal of loss and helplessness is at the highest risk for a stress-related health problem. The other persons are coping with change using healthy strategies.

A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse? A. Collect a specimen for a blood alcohol level (BAL). B. Do nothing because the time for BAL determination is passed. C. Review the results of a Breathalyzer obtained in the emergency department upon admission. D. Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.

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

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

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

A nurse is teaching about women's health with a female client who is in a homosexual relationship. Which topic is the most important for the nurse to address? A. Sexually transmitted diseases. B. Annual gynecologic examination. C. Monthly breast self-examination. D. Domestic violence interventions.

ANS: D. Domestic violence interventions. Since all women, regardless of sexual orientation, are at risk for domestic violence that can be potentially lethal, this is the most important topic for the nurse to address and is a policy that should be included in the nursing interview. The other topics should be included, but determining the presence of domestic violence is a life threatening priority.

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

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

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

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

The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing problem? A. Impaired mobility. B. Ineffective individual coping. C. Impaired verbal communication. D. High risk for fluid and electrolyte imbalance.

ANS: D. High risk for fluid and electrolyte imbalance. Maintaining physiological stability by first addressing basic physiological needs is the priority. A client who is in a catatonic or stuporous state is at risk for malnutrition and dehydration. Fluid and electrolyte imbalance is the priority nursing problem for this client at this time. The other problems are not life-threatening.

A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement? A. Keep this information confidential until the client's release. B. Immediately contact the the client's spouse and the lover. C. File oral and written reports with the local police department. D. Inform the healthcare provider and document the plan in the record.

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

Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? A. Tell them there is nothing to fear. B. Insist that they hold infant so they can grieve. C. Respect their wishes and release the body to the morgue. D. Keep the body available for a few hours in case they change their minds.

ANS: D. Keep the body available for a few hours in case they change their minds. Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours in the event they change their mind after the initial shock. The other actions are not indicated.

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

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

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

ANS: D. Psychoanalytical. The psychoanalytical model uses concepts that interpret and focus on working through feelings and behaviors related to previously unresolved conflicts. The other are related to other theoretical frameworks and treatments.

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

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

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

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

A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the priority nursing intervention? A. Notify the local police of a suspected spousal abuse situation. B. Ask the hospital security to remove the husband from the treatment room. C. Reassure the husband that his wife will be treated well while he is in the waiting area. D. Require the husband to leave the cubicle while the client is being treated.

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

A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention should the nurse take at this time? A. Arrange for emergency admission to a detoxification unit. B. Talk to the spouse about strategies to limit the client's drinking. C. Have the client admitted to the inpatient psychiatric unit. D. Tell the client that therapy cannot take place while she is intoxicated.

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

A client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able to kick this habit." How should the nurse respond? A. The goal of the individual is one of growth, health, autonomy, and self-actualization. B. All people have the right to an equal opportunity for adequate health care. C. Dependence on an extensive support system is needed to overcome any addiction. D. The client must participate in making decisions about one's own physical and mental health.

ANS: D. The client must participate in making decisions about one's own physical and mental health. The client has the right to self-determination and the responsibility to make a decision to pursue health or illness, so the client must actively participate, which the nurse should clarify with the client. The other responses are components in addcition recovery, but do not indicate the client's responsibility and primary commitment for decision-making about self care and health.