Psychosocial Alterations NCLEX Questions

A client who has expressed suicidal ideation in the past says to the nurse while shuffling several documents in an effort to organize them, "Well I'm feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney." Which response by the nurse is most appropriate? A. "You talk about getting organized. Are you thinking of killing yourself?" B. "Good grief! You don't look organized to me." C. "If you keep behaving like this you know that I'll have to tell the HCP, and we'll have to seclude you." D. "Okay, what are you up to today? Your behavior is not appropriate."

A

A client who is undergoing psychiatric counseling calls a nurse in a hotline, crying, and states, "My priest assaulted me when I was an altar boy, and my dad just found out. He's got a gum, and he's driving over to the church rectory. I don't know what to do." Which response by the nurse is most initially appropriate? A. "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police." B. "Call the police immediately and then call the priest to warn him that your dad has a gun." C. "How did your dad learn of your abuse by clergy?" D. "You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened."A

A

A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than his older brother when the were growing up. Now he's had another relapse and we can't understand why he stopped his medication." Which response by the nurse is appropriate? A. Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?" B. Telling the parents, "Medication noncompliance is the most frequent reason that people with their diagnosis relapse." C. Telling the parents, "Well, if its his decision to take his medicine, but it's yours to have him live with you if he stops the medication." D. Saying to the parents, "Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication."

A

A client with schizophrenia attending a support group help by a clinic nurse says to the nurse and the group, "I've been laid off from my job at the factory, and so have 300 other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be the most therapeutic response? A. "Have other people in the group been feeling the job crunch this week? When changes occur, it's best to increase your number of appointments with me for a short time." B. "How do people feel about this loss of employment? Does anyone in the group who experienced this have advice?" C. "I'm sorry to hear that you've lost your job. Why not make an appointment to come in and talk with me this week?" D. "It seems that the stock market is responsible for mass unemployment in our factory-based city."

A

A client with schizophrenia exhibits confused and unintelligible speech. Which nursing statement would be the most therapeutic? A. "This morning you are participating in the tree-decorating ceremony for the unit." B. "I can't understand what you're saying. You have to talk more clearly." C. "I can't understand you. Are you asking me to stay with you while you eat your supper?" D. "Got it. The 'blinks' are taking over the bumpers.

A

A client with schizophrenia in the psychiatric inpatient unit is yelling, "The CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." Based on the client's statement, which clinical manifestation should the nurse document in client record? A. Evidence of persecutory delusions B. Demonstrates paranoia C. Evidence of ideas of somatic delusions D. Exhibits ideas of reference

A

A furious and aggressive client is put in restraints and told that the restraints will be removed once she regains control. At which of the following times is the removal of the restraints by the nurse appropriate? A. When no acts of aggression are observed in the hour following the release of two extremity restraints B. When medication that has been administered has taken effect C. When the client apologizes and tells the nurse that it will never happen again D. When the nurse explores with the client the reasons for the angry and aggressive behavior

A

A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relation are poor. He then tells the nurse that the symptoms started after his best friend was killed in a terrorist attack at the World Trade Center. The nurse plans the client's care, as the client is likely experiencing which disorder? A. PTSD B. OCD C. Social phobia D. Panic disorder

A

The client who is an alcoholic, has been admitted to the mental health unit states to the nurse, "The judge made me come in here. My BAC was only 0.2% when the cop pulled me over in my car." Which statement by the nurse is most appropriate? A. "The level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgement would have been impaired, but you seem to feel that the judge was unreasonable for sending you here." B. "Did you ask the judge to clarify his decision to make you come here?" C. "This limit means that you had consumed enough alcohol to put you close to the legal limit. You were lucky because you just missed that level." D. "Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don't you agree?

A

The nurse caring for a client with schizophrenia is assessing the client's ability to control distorted thought processes. Which finding indicates a positive outcome? A. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations B. The client can describe the hallucinations and delusions in detail and is able to interact with others and share in their delusional systems. C. The client can describe in detail the frequency and context of the hallucinatory and delusional behavior D. The client is able to identify when hallucinations or delusions are real

A

The nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially? A. Making a "no suicide" contract with the client B. Telling the client that anger should be suppressed C. Helping the client control expression of feelings D. Providing a peaceful place for the client to meditate

A

A client with schizophrenia arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client's hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be the most appropriate? A. Asking, "Will you voluntarily admit yourself for a couple of days so that you can straighten out your medication and thinking?" B. Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?" C. Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit. D. Saying nothing and contacting the psychiatrist to sign a commitment order

B

A person who has overdosed on heroin is brought into the ER. The client is having seizures, and the nurse notes that his pupils are constricted. Which intervention does the nurse anticipate the ER HCP will prescribe? A. Ammonium chloride B. Naloxone C. IV fluid D. Gastric lavage

B

A student calls the campus crisis hotline and tells the nurse, "I went out to a sorority party last week and drank too much. Someone raped me, but when I told my parents about it, the acted like it was my fault. I feel so dirty and used." What statement by the nurse is the most therapeutic? A. "Would you come in to talk with me in the strictest confidence?" B. "You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me in more detail about it?" C. "I believe that you can feel a lot better about yourself. Won't you come in to see me tomorrow?" D. "Parents always feel that their daughters could never be raped. I could talk to them for you, if you'll let me."

B

An acutely ill client with schizophrenia says to the nurse "He keeps saying that he likes you and I keep telling him you're married but he won't listen and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be the most appropriate statement? A. "I think that you're trying to share your own feelings towards me but you're shy." B. "Try not to listen to the voices right now so that I can talk with you." C. "Tell him I said to mind his P's and Q's or I'll call the police on him." D. "I think that you can help him stop his behavior if you concentrate."

B

The mother of a child who is taking methylphenidate hydrochloride (HCL) tells the schools nurse that she is administering an OTC cough syrup to her son. Which response by the nurse would be the most appropriate? A. "You may administer a small amount of OTC cough syrup without a problem, but not for more than 3 days." B. "I think that you should stop giving this medicine to your son until I can check its contents with the pharmacy." C. "His cough could be a side effect of methylphenidate HCL." D. "Your son should never take any medicine, even if it's OTC."

B

The nurse brings a meal tray to a client with psychosis in his hospital room. The client refuses the meal and says, "I'm not eating any more poisoned food while I'm vacationing here. I'm starting to fast to stay healthy and alive." Which nursing intervention would be the most appropriate initially? A. Taking the tray away and canceling all meals until further notice B. Having the client eat with other clients in the community dining room C. Eating some of the client's food to prove it's not poisoned D. Telling the client that the psychiatrist will be called for a prescription for a tube feeding

B

The nurse collects data from an older client and monitors him for signs of abuse. Which psychological factor does the nurse recognize as placing the client at risk for abuse? A. The client is independent B. The client is completely dependent on family members for food and medicine C. The client lives alone D. The client shows symptoms of depression

B

The nurse employed in a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided? A. Day shift B. Weekends C. 7 to 10 a.m. D. Weekdays

B

The nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. The nurse is likely to note which aspect of the disorder? A. The client is not concerned about food and meal planning B. Personal relationships tend to become more superficial and distant. C. Social contracts are important. D. The client with anorexia will usually keep his or her weight near normal weight.

B

The nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client? A. Providing hope and reassurance that the crisis is temporary B. Providing authority and action C. Displaying an attitude of detachment and efficiency D. Demonstrating confidence in the client's ability to deal with the crisis

B

The nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client makes which statement? A. "I want to be alone for a while in my own room." B. "I'm no longer a threat to myself or others." C. "I can't breathe in here. The walls are closing in on me" D. "I need to go to the bathroom."

B

The nurse is preparing to admit a client with OCD to the mental health unit observes the client for certain characteristic behaviors. Which characteristic behavior will the nurse likely observe? A. Extreme fear B. Inflexibility C. Adaptability D. Hostility

B

The nurse is preparing to provide nursing unit information to a client who does not speak English who is being admitted to the mental health unit. Which action is best by the nurse to take to ensure that the client understands the information? A. Asking a hospitalized client who speaks the same language as the client to translate. B. Obtaining a hospital interpreter to communicate with the client C. Providing the client with a pamphlet that explains the nursing unit information in the client's language D. Asking a family member to translate for the client

B

A client is scheduled to undergo ECT. Which client concern is of the highest priority? A. Anxiety B. Fear C. Risk for impaired breathing D. Distorted body image

C

A client says to the nurse, "I'm worried about my husband. He's talking about ending it all since his law practice dropped off and his son died of a drug overdose; but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is appropriate? A. "Most people who talk about ending it all are just looking for attention." B. "I'm not sure. I don't know him that well." C. "Your husband is displaying behaviors that indicate a risk for self-harm." D. "Yes, he's too intelligent to end it all."

C

A client with mania who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite." Which statement by the nurse would be the most therapeutic? A. "Do threats and name-calling usually work out for you? Do people tend to listen to you and do as you order them to?" B. "Just get your anger out with me, because we're not going to allow you to be discharged until you calm down." C. "I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in a half hour." D. "When you can speak to me without yelling and being aggressive, I'll be happy to speak with you."

C

A client with schizophrenia is seen seemingly talking to someone who isn't there. Which nursing statement would be the most therapeutic initially? A. "Today is my birthday. Would you like to go on an outing with my family?" B. "You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?" C. "I've noticed your eyes darting back and fourth, and I wondered whether you might be hearing voices." D. "You need to wash up and get ready to go to supper in the cafeteria with the other clients now."

C

A client with schizophrenia says, "I feel like I'm rotting away inside and all of my organs are rusting." Which type of delusion does the nurse identify in the client's statement? A. Jealousy B. Idea of reference C. Somatic D. Persecution

C

An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad told me he had to marry my Mom because she got pregnant." Which response by the nurse would be the most therapeutic? A. "You feel that you were a burden and not wanted? Let's talk with your parents to see whether you're right." B. "Let's speak with your parents about what you've just told me. Let' ask whether you were fully unwanted." C. "You're feeling that your folks didn't want you, but they chose to marry and have you." D. "Sounds like your father was very inappropriate, but I'm certain that he didn't mean that you were a burden to him."

C

The home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic antidepressant lying near the client. What action must the nurse take immediately? A. Administered syrup of ipecac B. Counting the pills remaining in the bottle C. Calling an ambulance D. Inducing vomiting

C

The nurse is providing information to a group of nursing staff members about caring for suicidal clients. What should the nurse tell the group? A. When a person make suicide threats, the only thing the person wants is attention B. Those clients who talk about suicide never actually try it C. Discussing suicide with a client is not harmful D. Depressed clients are the only people who commit suicide

C

The nurse observes that a client is pacing back and fourth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels "Out of control!" Which intervention is the most appropriate initially to maintain a safe environment? A. Restraining the client B. Continuing to monitor the client C. Moving the client to a quiet room and talking about her feelings D. Placing the client in seclusion

C

The nurse working with the survivor of sexual assualt, is developing a plan of care for the client. Which short-term initial goal is most appropriate? A. The client will identify an appropriate treatment plan B. The client will resolve feelings of fear and anxiety related to rape trauma C. The client will verbalize her feelings about the event. D. The client will care for her own physical wounds

C

Which step should be included in the care of a 13-year-old hospitalized child who has been abused? A. Encouraging the child to avoid the abuser B. Having the child identify the abuser if that person should visit when the child is hospitalized C. Providing a caring environment that fosters the development of trust. D. Teaching the child to make intelligent decision when confronted with an abusive situation

C

A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention should the nurse implement? A. Placing the client in a private room and removing all knives and glass from the client's meal tray B. Placing the client in a private room and locking the client's closets and bathroom C. Allowing the client to go out on pass as long as the client is accompanied by a responsible adult. D. Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times

D

A client says to the nurse "I've ruined my life, I left college with only a few credits to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for the rest of my life." Which response by the nurse is therapeutic? A. "What are you saying? Sounds like you need to pull yourself together and go back to school." B. "Having faith in yourself is one thing, but looking at your alternatives realistically is another." C. "Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get." D. "You seem to be saying that your choices are final and that you've lost any other opportunities."

D

A client who is experiencing suicidal thought says to the nurse, "It just doesn't seem worth it anymore. Why shouldn't I just end it?" Which statement should the nurse use to gather additional data from the client? A. "I know you've had a stressful night." B. "Did you sleep at all last night?" C. "I'm sure that your family is worried about you." D. "Tell me what you mean by that."

D

A client with schizophrenia says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my HCP told me to." Which intervention would the nurse suggest as a distraction technique? A. "Pretend that you're on the phone and talk to the voices." B. "The next time this happens, try telling the voices to go away." C. "Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening." D. "Have you tried to count back from 100 or listen to music?"

D

A nurse notices a client's glaring eyes during a conversation with a client. The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be beneficial? A. Allowing the client to pace B. Changing the conversation to a less threatening subject C. Escorting the client to a quite room D. Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings

D

A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, "The voice in my head is telling me that you're cheating." Which response by the nurse is therapeutic? A. "It isn't possible for people to hear voices in their head." B. "Is the voice telling you to do anything?" C. "I don't believe that you are having voices." D. "I do not hear any voices. Has the voice said anything else to you?"

D

A woman is brought to the ED after an assualt. She presents w/ complaints of dizziness, dyspnea, visual disturbances, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client's presentation? A. Moderate B. Mild C. Panic D. Severe

D

An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic? A. "If the milk thistle is so effective. I wonder why the liquor industry isn't lobbying to put it in alcohol?" B. "Milk thistle is used in Europe this way, but research findings are limited, so I'd stop drinking if I had a problem like you do." C. "Milk thistle aside, you need to stop using alcohol. You have a severe drinking problem." D. "Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."

D

Family members awaiting the outcome of a suicide attempt are tearful. Which response by the nurse would be the most therapeutic to the family at this time? A. "You can see your loved one soon." B. "You have nothing to worry about." C. "Everything possible is being done." D. "I can see that you are worried."

D

The nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic? A. "What are you doing? How much are you drinking, and how long has this been going on?" B.. "Do you think your wife would want you to behave like this?" C. "I can see that this isn't a good time to visit." D. "You seem to be having a very difficult time."

D

The nurse is caring for a client who has been identified as a survivor of physical abuse by a family member. Which action is the priority as the nurse plans care for the client? A. Notifying the caseworker of the situation B. Obtaining treatment for the abusing family member C. Adhering to the mandatory abuse reporting laws D. Removing the client from any immediate danger

D

The nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the client's discharge outcomes, the most positive outcome is that the client states that he or she will perform which action? A. Take a painting class B. Continue to attend AA meeting C. Start and exercise program D. Learn to play tennis

D

The nurse is teaching a group of new employees ways to deescalate aggressive behavior exhibited by a client with schizophrenia. After the course employees state several actions they would take if a client with schizophrenia becomes increasingly aggressive. Which comment causes the nurse to realizes further instruction is required? A. Negotiating options with the client B. Maintaining a nonaggressive posture C. Being assertive with the client D. Standing close to the client and telling him the client that the behaviors is unacceptable

D

The nurse is working with a new nurse employee who has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. The new nurse employee has developed a plan of care for the client. The nurse realizes the new nurse employee requires additional instruction when what is included in the plan of care? A. Acknowledging the client behavior B. Maintaining a safe distance with the client C. Assisting the client to an area that is quiet D. Initiating confinement measures

D

The nurse is working with a new nurse employee who is creating a care plan for an adolescent returning home after an acute psychiatric hospitalization for a suicide attempt. The nurse should suggest a revision of the care plan if the new nurse includes which intervention? A. Offering and providing the family options and resources B. Identifying thee family's strengths and weaknesses C. Encouraging the sharing of feelings D. Suggesting that the client's mother quit her job

D

The nurse is working with an older client who has been hospitalized and the client's family to formulate a plan for discharge. In guiding the discussion with the client and the family, which living arrangement should the nurse promote? A. Long-term care facility B. Alone C. With their children D. Independently but close to their children

D

The nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. What action should the nurse take? A. Informing the client that everything is alright B. Explaining to the nursing assistant that yelling in the client's room is only tolerated if the client is talking loudly C. Speaking to the CNA immediately, while in the client's room, to solve the problem D. Determining that the client is safe, calmly asking the CNA to join you outside the room, and informing the CNA of the observation

D

The nurse working in a mental health unit reads a client's medical records and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of which disorder? A. Depression B. OCD C. Schizophrenia D. PTSD

D

A client with a diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The nurse plans care knowing that this condition is referring to which aspect of the disorder? A. Pressured speech B. Mutism C. Poverty of speech D. Verbigeration

B

An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement interventions, knowing that this situation is characteristic of what type of crisis? A. An individual crisis B. A situational crisis C. A maturational crisis D. An adventitious crisis

C

A client arrives in the ED in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on which client factor? A. The physical condition of the client B. The client's coping mechanisms C. Sources of support D. The object of the crisis

A

A client brought to the ED by the police after being mugged is extremely agitated, trembling, and hyperventilating. What is the most appropriate initial nurse action? A. Staying with the client B. Asking the client questions about the mugging C. Teaching the client how to relax D. Allowing the client to be alone in a room at the end of the ED, where it is quiet

A

A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't know how in the world I would do it." Based on the client's statement, what does the nurse determine? A. The risk for suicide exists and continued assessment is needed B. Suicide has been attempted unsuccessfully C. There is a minimal suicide risk D. There is no suicide risk

A

The nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should have what focus? A. Contracts and immediate available crisis resources B. Encouraging the family to always be with the client C. Follow-up appointments D. Providing the hospice phone number

A

A client with OCD who continually cleans her room with paper towels becomes enraged with her roommate for throwing a package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which action by the nurse would be done first? A. Removing both clients to safe locations B. Restraining the client C. Filling out an incident report D. Calling the hospital's risk-management department

A

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action? A. Allowing increased in-room activities B. Increasing the level of suicide precautions C. Suggesting a reduction of medication D. Allowing the client off-unit privileges as necessary

B

The nurse is working in the ER is performing an initial assessment on a client, and notes many physical injuries. The nurse suspects family violence. Which finding is specific to this type of violence? A The client relies on neighbors and friends for transportation to and from appointments. B. The client lives with one of their children and requires extensive assistance with activities of daily living C. The client is financially dependent on him or herself D. The client lives in an assisted living facility

B

The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern? A. "What is suicide going to do for me except excommunicate me from the church?" B. "No, I wasn't, but I am now, thanks to you." C. "Of course not, but there are days when I think I should be." D. "I hadn't thought about that, but I can see that you are."

B

The nurse plans outcomes for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment> A. Use of directive communication with the client B. Keeping the client active with hobbies, exercise, and work C. Administration of acute psychotropic medications D. Evaluation of neurological status

B

A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I can't stand it." Which statement by the nurse is most important? A. "Do you think that something physically wrong is causing your baby to cry?" B. "Have you been having any thoughts of hurting your baby?" C. "You say that he doesn't seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?" D. "Do you think that your baby cries so frequently because he's not getting enough nourishment from breastfeeding?"

B

A client who has attempted suicide twice says, "If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do." Which response by the nurse is appropriate? A. "Sounds to me like you're angry with people for caring enough about you to try to keep you from hurting yourself." B. "You've tried to end your live twice, yet you feel that everyone should let you do what you want to do?" C. "Of course you can't be left alone to get on with what you want to do." D. "Okay, go ahead and do whatever you want to do. Human being have free will."

B

A client and her newborn have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time? A. Describe the stages of and treatments for HIV B. Listen quietly while the mother talks and cries C. Discuss with the mother how she might have gotten HIV D. Call an HIV counselor and make an appointment for the woman

B

A client is admitted to the psychiatric unit and suicide precautions are instituted. Which intervention should the nurse implement? A. Placing flowers brought to the client in a small glass vase and putting them in the client's room B. Removing perfume, shampoo, and other toiletries from the client's room C. Restricting visitors D. Placing the client in a private room and locking the bathroom door

B

A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In the report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time? A. Informing the HCP of the client's depression and requesting medication to assist the client in coping with the diagnosis. B. Reflecting back to the client that he appears upset C. Reminding the client that the injury was a result of an alcohol abuse incident and referring him for counseling D. Letting the client have some time alone to grieve the impending loss of the limb

B

A client says to the nurse, "I don't do anything right. I'm such a loser." What is the appropriate response? A. "Everything will get better." B. "You don't do anything right?" C. "You are not a loser, you are sick." D. "You do things right all the time."

B

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this? I'm the one who's dying." Which response by the nurse would be the most therapeutic? A. "Well It sounds like you're being pretty pessimistic." B. "You're feeling angry that your family continues to hope for you to be cured." C. "Have you shared your feeling with your family?" D. "I think we should talk more about your anger with your family."

B

A client says to the nurse, "It's over for me, the whole thing is over." Which response be the nurse would be therapeutic? A. "Over? Well, that sounds pretty drastic to me. Let's discuss this in the strictest confidence." B. "Let's talk more about your feeling that the whole thing is over for you. This is important, and I man need to share your feelings with other staff members." C. "What do you mean, "The whole thing is over?" D. "Can you tell me more about why it's over for you? I'll keep your thoughts strictly confidential."

B

A client tells the nurse "I am a queen I'm mean, and I gleam." The nurse recognizes this as an example of which speech pattern? A. Loosened associations B. Clang associations C. Echolalia D. Tangential speech

B

A client with schizophrenia says, "I'm away for the day, but I don't thing we should play or do we have feet of clay?" Which alteration in the client's speech does the nurse document? A. Neologism B. Clang associations C. Associative looseness D. Word Salad

B

A client in a mental health unit gets into a fight with another client over the use of the public telephone in the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which intervention by the nurse would be the most therapeutic? A. Saying to the clients, "Okay, this is the last straw. Neither of you may use the telephone until tomorrow, and then only when your nurse is timing you." B. Taking telephone privilege's away from both client for the day and giving them time-outs in their room C. Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you agree by my decision?" D. Saying to the clients, "Go to your rooms, both of you. I don't want to hear anything more about the telephone on this unit for at least 2 hours."

C

A client in skeletal traction says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my call light. Last night one of them told me that she had other patient besides me! I'm very sick, but the nurses don't care! Which response by the nurse would be therapeutic? A. "I can hear your anger. The nurse had not right to speak to you that way. I will report her to our director. It will not happen again." B. "You poor thing! I'm so sorry this happened to you. That nurse should be reported!" C. "It's hard to be in bed and have to ask for help. You call for a nurse that never seems to come?" D. "I think you're being very impatient. The nurses work very hard and come as quickly as they can."

C

A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. What is the priority nursing intervention? A. Place the client in a seclusion room from which all potentially dangerous articles have been removed B. Request that a family member remain with the client at all times C. Remain with the client at all times D. Remove the client's clothing and dress the client in a hospital gown

C

A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I have been through." Which statement by the nurse would be the most therapeutic? A. "This must be very distressing to you. Can you tell me more about the voices?" B. "The voices will disappear in a few weeks as your hormones stabilize." C. "You will want to tell the HCP about them when you visit him next week. He is very interested in these voices and will want to help you with them." D. "It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices."

D

A 2-year-old client has injuries consistent with child abuse and the nurse is interviewing the child's parent. Which statement by the parent indicates the possibility of child abuse? A. "I can expect my child to talk using some words at this age." B. "I expect my child to try and do some things without my help." C. "My child can't be expected to learn everything at once." D. "When I tell my child to do something, I don't expect to have to repeat myself."

D

A 24-year-old with schizophrenia says, "I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester." Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client's return to college? A. Compliance with treatment, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and socialization with one important friend B. Limiting college attendance to commuter status to maintain a supportive family group and avoiding alcohol, drugs, and the strain of socialization C. Telling all friends about the illness so that they support the client's avoidance of alcohol and drugs and help the client maintain a balanced lifestyle D. Compliance with the treatment regimens, immediate reporting of relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle

D

A resident of a long-term care facility who has Alzheimer's disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which should the nurse consider when approaching the client about this behavior? A. This resident probably had an unfortunate experience while singing and dancing in his own youth. B. Individuals with Alzheimer's disease are likely to be child molesters. C. This resident is a dangerous individual D. Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine

D

A client experiencing homelessness, with an antisocial disorder, is brought to the ER by the police after disturbing customers in a department store. The client says to the nurse, "I need to be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which nursing intervention would be therapeutic? A. Sending the client to a shelter the will provide temporary housing if he signs a contract agreeing not to attempt suicide B. Asking the police to pick up the client and arrest him for vagrancy, as they should have done immediately C. Sending the client to the psychiatric hospital intake center immediately for evaluation D. Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up

A

A client in a retirement center rings the night alarm and says to the nurse, "Look at this old man! He keeps breaking into my apartment! You've go to get him to stay out of here so I can sleep." Which statement by the nurse would be the most therapeutic? A. "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest." B. "Why not just throw him out yourself and lock up once and for all?" C. "Now, you know that you're always seeing things and people at night who aren't there." D. "I;m sure you're very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he'll leave your apartment."

A

A client in halo traction says to the nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which response by the nurse is therapeutic? A. "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move." B. "If I were you, I'd have the surgery rather than suffer like this." C. "No one ever gets used to that thing! It's horrible." D. "Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don't you think?

A

A client says to the nurse, "I'm really phobic about flying, so my husband and I always drove or took the train everywhere. Now he's been offered a big job in Europe, and if I don't get over this and fly with him, he says we're done. I'll be left to bring up our three children by myself." Which statement by the nurse is most therapeutic? A. "I can teach you strategies to help master your panic. An antianxiety medication would also help you." B. "I'm interested that it took his threat of leaving you to motivate you to seek help." C. "No problem. You can be hypnotized to sleep through your trip." D. "You seem more anxious and afraid of raising three children alone than of flying."

A

The nurse instructor enters a classroom to begin class and finds two students yelling and physically assualting each other. Which intervention by the instructor would be the most appropriate? A. Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop and take their seats. B. Telling the class, "Take a break, I'll come and get you to restart class as soon as I can.", then closing the door, refusing to let anyone else in, and asking a passing instructor to get security. C. Getting the class to leave with her and sending everyone to the nursing laboratory, then calling security to the classroom and reentering to observe what is happening with the two students. D. Walking out of the classroom and asking the secretary to call security, then telling all of the students to leave and go to the nursing laboratory.

A

The nurse is caring for an older adult client who says, "I don't want to talk with you; you're only a nurse. I'll wait for my HCP." Which response by the nurse would be therapeutic? A. "So you're saying that you want to talk to your HCP?" B. "I'll leave you now and call your HCP." C. "I'm assigned to work with you. Your HCP placed you in my hands." D. "I'm so angry with the way you dismissed me. I am your nurse."

A

The nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which finding indicates that the client is at high risk for suicide? A. The client has an immediate plan for a suicide attempt. B. The client is impulsive C. The client has a history of suicide attempts D. The client is disorganized

A

The mental health nurse is conducting the initial assessment of a client who is obese. The client confides that she was sexually molested at the age of 7 and began putting on weight thereafter. The nurse determines that the client's symptoms are compatible with a somatization disorder and recalls obesity for this client most likely represents which? A. A form of functional coping B. Long-term lack of compliance with weight programs C. Protection from the risk of intimacy D. Satisfaction with self

C

The nurse employed in an ED is assisting in caring for an adult client who is a survivor of family violence. Which priority instruction does the nurse include in the discharge plan? A. Self-defense classes B. Calling the police C. The locations of shelters D. The importance of leaving the violent situation

C

The nurse is explaining the plan of care to family members of an older client with a diagnosis of depression. Which explanation should the nurse provide to the client and family members? A. Older adult clients do not commit suicide B. Depression in an older adult person is never treatable C. Indications of dementia may be present in an older client with depression D. Depression in an older person will not cause physical manifestations

C

The nurse is preparing a care plan for a client with OCD? What should the nurses primary focus be? A. The client's medical diagnosis B. Group therapy C. Goals and objectives D. Recreational therapy

C

A client who has just been admitted to the mental health unit with a diagnosis of OCD. The nurse observes the client for compulsive behavior involving which repetitive element? A. Thoughts B. Fear C. Delusions D. Actions

D

Which client is at the highest risk for suicide? A. A 24-year-old man who is angry with his family B. A 71-year-old man with mild depression and social withdrawal C. A 30-year-old newly divorced woman who has custody of her children D. A 75-year-old woman with severe depression and debilitating arthritis

D

Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective? A. "I went out to lunch today with my cousin." B. "I'll eat until I don't feel hungry." C. "I no longer have to lose weight." D. "I won't starve myself anymore."

A

A client with major depression says to the nurse, "I should have died, I've always been a failure." Which response by the nurse is therapeutic? A. "Feeling like a failure is part of your illness." B. "You still have a great deal to live for." C. "You've been feeling like a failure for some time now?" D. "I see a lot of positive things in you."

C

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse planning care for this client to understand that the client is afflicted with which disorder? A. Paranoia B. Depression C. Schizophrenia D. Somatization disorder

D

A client says to the nurse, "I came in to see you because I've been off my medication for 4 years but I feel as though I may be getting depressed again. I've been despondent again and thinking I should have ended it. That's why I'm here to get help." Which response by the nurse would be therapeutic? A. "Well it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening again?" B. "Well, you really have had a good long drug-free time, but it sounds as if the HCP needs to reorder your medication at once." C. "Well it's similar to when a client is battered; things have to boil over before the police can act; so you need to be suicidal to get admitted to a hospital or hurt yourself before the HCP can restart the medication." D. "If you've been able to be drug-free all this time, you probably don't need to restart the medicine. You probably just need some therapy to help you manage your stress."

A

The nurse in the ER is helping care for a young female survivor of sexual assualt. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors as which type of reaction? A. Common reactions to a devastating event B. Indicative of the need for hospital admission C. Evidence that the client is at high risk for suicide D. Signs of depression

A

A client with schizophrenia is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations. Which problem does the nurse expect the client is experiencing? A. Sensory perception alterations B. Defensive coping C. Inability to communicate effectively D. Inability to cope effectively

C