Psychosocial Integrity

The nurse is caring for a client who is severely depressed and has an extremely low energy level. The client answers questions by using one or two words, and makes no eye contact. Which intervention is most appropriate for this client? 1. Ask the client to go to the group session with you. 2. Remind the client to interact with the nurse today. 3. Sit with the client and make no demands. 4. Allow the client to decide when to talk with the nurse.

3. Correct: The client is severely depressed and does not wish to have one on one interaction. Sitting with the client without demands demonstrates that the client is worthy of your time. The silence may also encourage the client to talk with you. 1. Incorrect: The client's energy level is low, so the client would not respond positively to this request. Depressed clients may speak slowly and have slowed comprehension. Group therapy would not be appropriate at this time. 2. Incorrect: The client may not have adequate energy for spontaneous interaction today. Also, reminding the client to interact is not therapeutic. The client may view this as the nurse thinking they are worthless. 4. Incorrect: When clients are extremely depressed, they cannot make decisions independently. Extreme fatigue interferes with social activities and relationships.

A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? 1. "Could you have overheard the staff talking at the desk?" 2. "I will get you some medication for anxiety." 3. "What did the voice tell you? " 4. "You do not have to worry about this. You are safe."

3. Correct: The most important thing the nurse needs to find out is what the voice was telling the client. This is a safety issue. The nurse needs to know if the voice was telling the client to harm themselves or others. 1. Incorrect: In this question, this is not the priority response. This is voicing doubt and also presenting reality. This response could come later in the interaction. 2. Incorrect: This is changing the subject, which is non-therapeutic. The nurse needs to do something prior to giving medicine. 4. Incorrect: This is giving reassurance, which can be a non-therapeutic response. However, it could be used later in the interaction if the nurse finds out the client is safe. This statement does not address the voice heard by the client.

A client has been admitted to Hospice Care. The hospice nurse is reviewing the nursing care plan for interventions to promote comfort for the terminally ill client. Which nursing interventions for the terminally ill client would the nurse implement? Select all that apply 1. Provide oral care every 2 hours. 2. Provide supportive environment. 3. Encourage 3 meals a day. 4. Administer optical lubricants as needed. 5. Encourage client to ambulate every 4 hours.

1.,2., & 4. Correct: Breathing through the mouth causes the mucous membranes and tongue in the mouth and lips to become dry. Oral care should be initiated every 2- 4 hours to increase oral integrity. As the client becomes progressively weaker the nurse should assist with oral hygiene. By creating a supportive environment, the dying client will experience less anxiety. Reducing the noise level and glare in the room will also create a supportive environment. Other ways to maintain a supportive environment are keeping the linen loose and clean. The client's eyes may become dry due to dehydration and less blinking of the eyelids. Optical lubricant should be applied to the eyes to decrease the burning and itching in the eyes. 3. Incorrect: The dying client should be offered 6 small feedings instead of 3 meals a day. The dying client is weak and is also losing their appetite. 5. Incorrect: The client's activity should be encouraged according to the client's energy level. Metabolic demands, disease status, weakness and fatigue will directly affect the client's ability to ambulate.

A psychiatric client calmly approaches the day nurse stating, "I almost died in my sleep." What response by the nurse would be most therapeutic for the client? 1. "How do you know what happened in your sleep?" 2. "Tell me how you felt when that situation occurred." 3. "You seem to have recovered very well since then." 4. "Are you sure it wasn't just a really bad dream?"

2. CORRECT: The nurse is seeking to clarify what occurred to the client, including any feelings or emotions regarding the event. Because the client is presently calm in appearance does not mean the situation is resolved. Though a nurse should not feed into client delusions, note this statement focuses on client feelings. 1. INCORRECT: This question by the nurse is sarcastic and even accusatory by confronting the client's claim that an incident occurred while asleep. Such a question is unprofessional and non-therapeutic. 3. INCORRECT: The nurse is acknowledging the client's appearance but in a non-therapeutic manner. This remark makes fun of the client and is a closed-ended comment. 4. INCORRECT: The nurse is inferring the client imagined or dreamed whatever situation may have occurred during the night. With no further data provided by the client, the nurse's assumption does not address the client's feelings.

The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would be the best indication of the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables.

3. Correct: An adolescent reporting a fear of gaining weight may indicate the beginning of an eating disorder. This is the best indicator of an eating disorder. 1. Incorrect: A decrease in clothing size does not indicate a problem. It may be an indicator of an eating disorder but in itself does not mean there is an eating disorder.2. Incorrect: A client with an eating disorder may eat alone, or not at all. Eating with peers shows the feeling of acceptance which is not usually present with an eating disorder. 4. Incorrect: Eating snacks of fruit and vegetables is a healthy behavior. This alone does not contribute to an eating disorder. Also, it says the diet is "mostly" fruit and vegetables.

An Asian client, who cannot speak or comprehend English, is brought to the emergency department by family. One family member is able to understand simple sentences of English. How would the nurse best explain how to obtain a clean catch urine to the client? 1. Have the family member repeat the nurse's explanation to the client. 2. Contact Social Services to find an authorized interpreter. 3. Use simple hand motions to explain the procedure to the client. 4. Draw a diagram to demonstrate the use of the sterile cup when obtaining the specimen.

2. CORRECT. Hospitals must have a means of communicating with a variety of non-English speaking clients, as well as deaf clients. It is vital to have interpreters that are capable of translating medical terms or instructions correctly and also to relay the client's specific concerns back to medical staff. Because of the importance of accuracy, only trained and qualified interpreters should be used when communicating with those who do not understand English. 1.INCORRECT. Although the family is present and may be able to translate information from the nurse to the client, the accuracy of that information cannot be guaranteed since the family member has a limited understanding of English and no medical knowledge. It is vital that the procedure be clearly explained to the client, since test results will be affected if the specimen is not correctly collected. 3. INCORRECT. The use of hand motions does not ensure that the client will understand the procedure correctly, and in this particular situation, demonstrating some of the steps could be embarrassing to this client. Hand motions do not provide a means for the client to ask questions about anything that is not clearly understood. 4. INCORRECT. Although there may be circumstances in which a nurse can use alternative methods of communication, such as picture boards or hand gestures, this situation calls for clear instructions on the proper method for obtaining a clean catch urine so that test results are accurate. Additionally, a picture does not allow the client to confirm understanding of the process.

The nurse overhears this client responding on the phone when their boss asks them to work an extra night shift. Which statement by the client demonstrates assertive communication? 1. "I know you are joking! I have already worked an extra night shift." 2. "I do not want to work an extra night shift. I have already worked an extra shift this week." 3. "Umm, well, okay. I guess I will work an extra night shift." 4. "Okay, I'll work an extra night shift." Then they say to another client. "The nerve of my boss to ask me to work another extra shift."

2. Correct: This is an example of assertive communication, the best response. Assertiveness is asking for what one wants or acting to get what one wants in a way that respects the rights and feelings of other people. 1. Incorrect: This response is aggressive behavior. This response is delivered in a forceful manner. 3. Incorrect: This response is nonassertive. This statement is giving into the boss, even though the client really doesn't want to work. Keywords are "umm, well and okay" 4. Incorrect: This response is Passive-Aggressive. It is the indirect expression of anger.

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? 1. Anger 2. Acceptance 3. Bargaining 4. Depression

3. Correct: This is the 3rd stage of grief. At this stage, the individual attempts to strike a bargain with God for a second chance, or for more time. The person acknowledges the loss, or impending loss, but holds out hope for additional alternatives. 1. Incorrect: The 2nd stage of grief is when reality sets in. Feelings include sadness, guilt, shame, helplessness, and hopelessness. Self-blame or blaming of others may lead to feelings of anger toward self and others. 2. Incorrect: The fifth and last stage of grief. At this time, the person has worked through the behaviors associated with the other stages and either accepts or is resigned to the loss. Anxiety decreases, and methods of coping with the loss have been established. 4. Incorrect: The 4th stage of grief. The individual mourns that which has been or will be lost. This is a very painful stage, during which the person must confront feelings associated with having lost someone or something of value.

A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack occurs. What would be the nurse's best response to the client? 1. "I understand that you feel anxious. But you must stop this behavior." 2. "The feelings that you described can occur in individuals with asthma. You may find that learning relaxation exercises may help." 3. "I am concerned that feeling anxious during an asthma attack means you need more education about asthma." 4. "Everyone with asthma experiences tough times with their symptoms. You are learning to manage your asthma."

2. Correct: This statement acknowledges the client's feelings and then provides a suggested strategy that has been found to be useful in clients with anxiety and fear associated with asthma. 1. Incorrect: The nurse states understanding but then tells the client to stop the behavior without providing any helpful suggestions. 3. Incorrect: This response is disagreeing with the client's feelings and psychosocial response by stating that more education about asthma will prevent anxiety during an asthma attack. 4. Incorrect: This response dismisses and belittles the client's feelings and psychosocial response associated with asthma. By stating "everyone with asthma", the nurse is making a stereotypical response. This does not promote expressions of feelings by the client.

The nurse is preparing to initiate postmortem care. Which postmortem care interventions would the nurse implement? 1. Identify the client by the name on the client's armband. 2. Remove tubes and indwelling lines after cleansing the body. 3. Insert the dentures after the family has viewed the body. 4. Maintain body preparation according to the client's religious beliefs.

4. Correct: Care of the body after death should be reflective of the client's personal, religious, or cultural practices. 1. Incorrect: The client should be identified by 2 identifiers such as the name and birthday, name and medical record number. 2. Incorrect: The tubes and indwelling lines should be removed prior to cleansing the body. Safety standard precautions should be initiated during the removal procedure. 3. Incorrect: After cleansing the body the dentures should be inserted to maintain facial shape. The family can view the body after the dentures are inserted.

A new nurse is anxious about being assigned to a a client with violent episodes. Which statement by the charge nurse would address the new nurse's anxiety? 1. "What you really mean is that you fear a client with violent episodes." 2. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." 3. "I will instruct the staff to monitor the client's behavior for any signs of violent behavior." 4. "You attended an in-service during orientation on dealing with the client with violent behavior."

2. Correct: This response focuses both on the client's and the staff's response to the client. This is an example of the therapeutic communication of restating. The safety of the client, other clients, and the health care team is also a priority. The aggression by the client may be physical, verbal or both. The nurse should remain calm and firm. This approach will assist the client to return to their pre-crisis state. 1.Incorrect: The charge nurse is concluding the meaning of what the new nurse is saying. This is an example of the nontherapeutic communication of interpreting. The charge nurse stated that the new nurse is scared. This response may block further discussions with the new nurse about nursing care for potentially violent clients. The client, other clients, and the healthcare team's safety can also be placed at risk. 3. Incorrect: The charge nurse is changing the subject by stating that the staff members will be directed to monitor the client for violent behavior. This nontherapeutic communication of introducing an unrelated topic allows the charge nurse to control the direction of the conversation. The new nurse is expressing her concerns about caring for a client with violent episodes. The charge nurse is not focusing on the concerns of the new nurse. 4. Incorrect: The charge nurse responds by stating the new nurse attended an in-service during orientation about dealing with a client with violent behavior. The charge nurse does not identify that the new nurse may be uncomfortable dealing with clients with violent behavior. This is the nontherapeutic communication technique of rejecting. The new nurse may stop sharing with the charge nurse because of concern over further rejection.

The client, who recently started college, tells the nurse, "I am having trouble studying for my tests. Every time I try to study, my mind begins to wander." What is the nurse's best response? 1. "Stop making excuses and make a study schedule you will follow." 2. "I wouldn't worry. You are smart enough to pass college." 3. "You are having difficulty concentrating?" 4. "What do you mean you can't study?"

3. Correct: The correct answer demonstrates the therapeutic communication technique of "restating". The main idea is to let the client know whether or not an expressed statement has been understood and gives him or her the chance to continue or clarify if necessary. 1. Incorrect: This response is disapproving and gives advice. It is not therapeutic. The nurse does not know the client is making excuses and should not assume. 2. Incorrect: This response is giving reassurance. This statement seems like the nurse is somewhat "blowing off" the client. It does not address this issue.4. Incorrect: This response is belittling. This statement does not address the client's problem. It also implies that the client should not have problems studying.

A client has delivered a set of premature twins. The neonatal intensive care unit (NICU) notifies the charge nurse on the postpartum floor the death of one infant is expected within the hour. What is the priority action by the charge nurse? 1. Sit quietly with client and allow expression of feelings. 2. Instruct UAP to take mother to the NICU immediately. 3. Request hospital clergy to visit the mother right away. 4. Notify father of the baby about the current situation.

2. Correct: The priority action is to allow the mother to be with the infant and perhaps to hold the infant prior to demise to help in the grieving process. Escorting the mother immediately to the NICU can be accomplished by the UAP while the charge nurse initiates other actions needed by this client. 1. Incorrect: While it is always important to encourage a client to express feelings, at this point the priority need is to facilitate the bonding of mother and infant. The NICU nurses will be with the client and can provide the emotional support needed by the client. 3. Incorrect: The nurse realizes the client is experiencing anticipatory grief and will need a great deal of emotional support. However, the priority need at this time is for the client to be with the dying infant. Additionally, there is no mention of the mother's religious preference, which should be considered prior to involving the hospital clergy. 4. Incorrect: If the father is not already present, the NICU would have already completed this action. However, it is also important to consider any legal issues regarding this family unit and to verify whether the client requests the presence of the father.

A 16 year old female student is escorted to the school nurse after fainting in gym class. The student tells the nurse, "I just got weak from running." Upon examination, the nurse notes poor skin turgor, dry mucous membranes, and erosion of tooth enamel from her front teeth. Height is 5'4" (162.56 cm) and weight is 110 lbs (50 kg). The student reports muscle pain in the legs. Based on this data, what should the nurse suspect? 1. Anorexia Nervosa 2. Bulimia Nervosa 3. Obesity 4. Physical violence

2. Correct: This client is exhibiting the signs of bulimia nervosa. Additionally, the client will binge on excess calories, and then purge through vomiting and the use of laxatives, diuretics, and enemas. Weight fluctuates: usually within normal limits or slightly under or slightly overweight. Tears in the esophageal and gastric mucosa can occur. Due to vomiting, tooth enamel can erode. 1. Incorrect: Gross distortion of body image, refusal to eat, grossly underweight and malnourished. Characteristics of anorexia nervosa. The client is at the low end of the weight range for her height, but not underweight. 3. Incorrect: Obesity occurs from eating more than the body needs. Weight is more than 20% over expected body weight. They do not purge. This client's BMI of 18.9 is normal, not obese. 4. Incorrect: There is no indication that this is physical violence. The client may report headaches, dizziness and accidents such as falls. However, this client does not have any signs and symptoms of battering such as bruises, scars or burns.

The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? 1. A game of Scrabble with peers 2. A group game of basketball. 3. An individual art project. 4. A card game with the nurse.

3. Correct: The client is likely to be most comfortable with solitary activities. When the client is extremely distrustful of others, solitary activities are best. Activities that demand concentration keep the client's attention on reality and minimize hallucinatory and delusional preoccupation. 1. Incorrect: The client is paranoid; therefore, he would not be comfortable within a group. Noisy environments may be perceived as threatening. 2. Incorrect: The client is likely to be very suspicious of the other players, thereby increasing their own anxiety level. The noisy basketball game may be too threatening for the client. Physical games are not the best choice for the paranoid schizophrenic client. 4. Incorrect: As trust builds with the nurse, this may be an appropriate activity, but there is a better answer. The "most" appropriate is an individual art project. The second best answer would be a card game with the nurse.

A client is transported to the emergency department by the police following a sexual assault. What is the nurse's priority intervention? 1. Instruct the client to remove all of her clothes so they can be bagged as evidence. 2. Ask the client to describe what happened . 3. Tell the client she is safe here. 4. Perform a rape kit in order to preserve the evidence .

3. Correct: The client who has been sexually assaulted often experiences great fears and must be reassured of her safety. She may also be overwhelmed with self-doubt and self blame. This statement will instill trust. Remember, safety first! The most helpful things a nurse can do is listen and let the victim talk. 1. Incorrect: This needs to be done, but you must first build trust and establish a feeling of safety with the client. A woman who feels understood is no longer alone. She then feels more in control of the situation to remove her clothes. 2. Incorrect: This may be done, but you must initially build trust and establish with the client that she is safe. Non-judgmental listening provides an avenue for catharsis that the client needs to begin healing. A detailed account may need to be given for legal follow-up. A caring nurse, as a client advocate, may help to lessen the trauma of evidence collection. 4. Incorrect: This needs to be done. But you must build trust and establish the client feels safe initially. The nurse must maintain a nonjudgmental attitude and provide nonjudgmentalcare before the rape kit can be obtained.

A client who is Chinese comes to the clinic for a follow-up appointment following cardiac bypass surgery. The client's father accompanies the client into the examination room. What is the mostappropriate action by the nurse? 1. Ask the client's father if he has any questions regarding his son's condition. 2. Ask the client's father to leave the examination room due to confidentiality. 3. Perform needed assessments and care without interacting with the father. 4. Inform the father of the assessment findings and plan of care.

. Correct: The nurse is responsible for providing culturally sensitive client care. In the Chinese culture, it is important to show respect to the elders of the family. This option respects the client's father by addressing him personally and providing a sense of involvement in the client's health. This option does not ignore the client's father nor does it violate the client's confidentiality. In addition, questions about certain conditions can be answered without direct reference to the client. 2. Incorrect: Asking the father to leave the exam room would be disrespecting not only the father, but also the client who allowed the father to be present. 3. Incorrect: By failing to acknowledge the presence of the father, this demonstrates a lack of respect for the elder of the family. The nurse should not ignore the presence of others in a client room. 4. Incorrect: By providing information of assessment findings and plan of care, this could violate the client's rights to confidentiality. The client would need to provide expressed permission for specific information to be shared in the presence of another individual.

An elderly widower has been admitted to a psychiatric crisis unit with a diagnosis of major depression with agitation. What behaviors would the nurse expect to observe during an initial assessment? Select all that apply 1. Memory loss 2. Difficulty focusing 3. Excessive sleepiness 4. Short-tempered 5. Hand-wringing

2., 4., & 5. Correct: This type of depression is characterized by the added component of agitation. The client experiences difficulty focusing because of racing thoughts and restlessness. Other symptoms include incessant talking along with short-tempered outbursts of anger towards everyone. The inability to sit still is commonly accompanied by fidgeting or hand-wringing, which would be apparent to the nurse during an initial assessment. 1. Incorrect: Despite the client's agitation, racing thoughts and difficulty focusing, there is no actual memory loss at any point during this activity. 3. Incorrect: While excessive sleepiness may be typical of depression, the agitation which accompanies this disorder makes it very difficult to relax or sleep at all.

A woman who is 2 weeks postpartum calls the clinic stating "All I do is cry. I am so exhausted that I can't think clearly. I can't handle this anymore." What would be the most appropriate response by the nurse? 1. "You are being too hard on yourself. Being a mom is hard. Try to cheer up." 2. "It's normal to feel a little down after having a baby. Just give it some time." 3. "Have you had any thoughts of harming yourself or the baby?" 4. "When the baby starts sleeping better and you get some rest, your thinking will get better."

3. Correct: This mother seems to be experiencing more than the baby blues that many new mothers experience. There are clues in the stem of this question that you should recognize as warning signs of something more significant than the baby blues. The mother states that she no longer is thinking clearly and expresses that she can no longer cope with the existing situation. This mother seems to be experiencing postpartum depression that can include more severe symptoms such as suicidal thoughts of thoughts of causing harm to the baby. Therefore, it is crucial that the nurse ask a very straightforward, direct question to the mother to assess if the mother has any thoughts of harming herself or the infant. Failure to do so could put the mother and/or infant's life at risk for harm. 1. Incorrect: This belittles the client's feelings of hopelessness and gives inappropriate advice to correct the problem on her own. The client might not share any further with the nurse and the situation could become much worse, including harm to her or the infant. 2. Incorrect: Although many mothers do experience baby blues in the postpartum period, you would be missing critical signs that this situation is more than the baby blues if you make the statement that many mothers feel a little down and to just give it some time. During that time, this postpartum depression that was not identified could continue to worsen to the point of more severe symptoms and possible harm to herself or the infant. 4. Incorrect: Although a lack of sleep may be a factor, telling the mother that it will get better later will not give this mother the help that she needs now. Never delay care when the health and well-being of the mother and infant could be at risk.

The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability

3. Correct: The perpetrator has completed the acute battering phase and has now likely entered the honeymoon phase with extreme kindness and acts of love. The attacker is now calm after the tension has been released. You may witness remorseful and apologetic behaviors like bringing gifts and promises of love. 1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. This anger building stage is called tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating the client is calm and described as "in shock" or have have amnesia of the event. You also see extreme anger in the escalation/de-escalation stage. 2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This anger building stage is called tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating the client is calm and described as "in shock" or have have amnesia of the event. You also see extreme anger in the escalation/de-escalation stage. 4. Incorrect: Irritability would be demonstrated during the tension-building phase.

Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."

3. Correct: Encourage caregivers to say "yes" when someone offers assistance. It's smart to have a list ready of small tasks that others could easily take care of, such as picking up groceries or driving the person to an appointment. 1. Incorrect: The caregiver should be willing to surrender some control. Delegating is one thing. Trying to control every aspect of care is another. People will be less likely to help if the caregiver micromanages, or insists on doing things their way. 2. Incorrect: The caregiver should spread the responsibility. Get family members involved as much as possible. Even someone who lives far away can help. Encourage the caregiver to divide up caregiving tasks. One person can take care of medical responsibilities, another with finances and bills, and another with groceries and errands. 4. Incorrect: Encourage the caregiver to stay healthy by keeping on top of primary healthcare provider visits. They should not skip annual routine, checkups, or medical appointments.

The family of a client receiving treatment for substance abuse asks why they should get involved in treatment plan. Which statement by the nurse would best explain the rationale for including the family in the treatment plan? 1. "The treatment plan consists of having the family confront the client about the harm substance abuse causes." 2. "Family involvement reduces distress in family relationships to lessen the risk for relapse by the client" 3. "Involving the family helps the family learn ways to protect the client from additional harm." 4. "The family assists in ways to help reduce temptations for substances by the client."

2. Correct: Reducing distress in relationships lessens risk of relapse. 1. Incorrect: The family is not responsible for confronting the client. 3. Incorrect: The client is responsible for consequences related to client's behavior. 4. Incorrect: The family is not responsible for reducing temptations.

The schizophrenic client tells the nurse, "I am Jesus, and I am here to save the world!" The client is reading from the Bible and warning others of hell and damnation. The other clients on the unit are upset and several are beginning to cry. What nursing intervention is most appropriate? 1. Set verbal limits and have the client return to assigned room. 2. Explain to the client that not all people are Christians. 3. Remove the Bible from the client and explain that the client is not Jesus. 4. Ask the client to share with the group how the client is Jesus.

1. Correct: Yes, the nurse must set limits. This is disrupting others and so the client needs to be redirected to their room for a cool down and then another activity shortly thereafter. This client is experiencing delusions of grandeur, which are not reality based, and require intervention that does not reinforce the behavior. 2. Incorrect: No, this will only reinforce the clients thought process of religion. 3. Incorrect: No, don't argue with the client. This is not therapeutic and does nothing to help resolve the disruption to the other clients. 4. Incorrect: This is ridiculing the client and also inflaming the situation. This is not desirable.

How would a tendency toward stereotyping and countertransference affect the nurse's ability to complete a client's cultural assessment? 1. Facilitate the care planning process 2. Promote decisions based on the nurses value system 3. Utilize an open honest approach while responding to the client's concerns 4. Develop an unbiased approach to care.

2. Correct: Both stereotyping and countertransference will decrease the nurse's sensitivity to the client's needs and the culture they represent. Nurses who impose these values upon clients will make decisions based on their attitudes, values and beliefs and not those of the culturally different client. 1. Incorrect: Both stereotyping and countertransference also interfere with the treatment process you can't base your care plan on your general views toward a client's culture. Care plans, must be individualized and not based on stereotypes. 3. Incorrect: The nurse will make automatic responses based on preconceived ideas and expectations. The nurse is unable to be open and honest about client concerns. Remember, stereotyped behavior is based on the assumption that all people in a similar cultural, racial or ethical group think and act alike. 4. Incorrect: The nurse's need to maintain an unbiased care is important because the client's needs remain unmet. Value clarification by the nurse will assist in preventing stereotyping and countertransference to other clients. The nurse will never have an unbiased approach to care for clients unless the nurse understands and removes unhealthy values affecting the assessment process.

A nurse asked the charge nurse on the psychiatric unit, "Why did you ask that client to explain the meaning of 'It's raining cats and dogs?'" What is the charge nurse's best response? 1. "I was attempting to get the client to admit to being afraid of cats and dogs." 2. "I am assessing the concreteness of the client's form of thought." 3. "Phrases like this one will help the client improve their abstract thinking ability." 4. "Concrete thinking is a higher form of thinking and means that the client's form of thought is improving."

2. Correct: Concreteness, or literal interpretation of the environment, represents a regression to an earlier level of cognitive development. Abstract thinking is very difficult. The client with schizophrenia would have great difficulty describing the abstract meaning of "It's raining cats and dogs". 1. Incorrect: Asking the meaning of "It's raining cats and dogs" has nothing to do with fear of the animals. 3. Incorrect: The purpose of asking the meaning of "It's raining cats and dogs" is to assess concreteness of the client's form of thought. Explaining the meaning of this phrase will not improve abstract thinking. 4. Incorrect: Abstract thinking is a higher level of thinking. Abstract thinking is the ability to conceptualize ideas.

A client admitted in the manic phase of bipolar disorder approaches the nursing station in the middle of the night, demanding the therapist be called immediately. What response by the nurse is appropriate? 1. "Calm down first, and then I will call your therapist." 2. "It's against the rules to call in the middle of the night." 3. "You must be distressed to want to talk at this late hour." 4. "That's a valid request, but it must wait until morning."

3. CORRECT: Regardless of the client's request, the nurse's response should focus on the client's feelings. Rather than reciting the rules or why the phone call cannot be placed, this therapeutic acknowledgement by the nurse clearly addresses the client's emotional state. 1. INCORRECT: Bargaining with a client for behavioral compliance is neither supportive nor appropriate by the nurse. In the manic phase, the client is unlikely to be able to comply, even if the goal is something desired by that individual. This is a non-therapeutic approach by the nurse. 2. INCORRECT: The nurse is focusing on facility rules rather than the client's emotional state or feelings. Such a response by the nurse would not resolve the issue here and is certainly not a therapeutic response. The client is likely to become more agitated. 4. INCORRECT: Even though the nurse is acknowledging the client's request, the response focuses on the phone call rather than the client's emotional state. This statement by the nurse may be true but will not resolve the situation.

A client is seen at the clinic two weeks after starting amitriptyline. The client reports improved sleep patterns and appetite, but no change in feelings of sadness or depression. What comment by the nurse is most appropriate? 1. "Would you like me to ask the doctor to increase your dose?" 2. "You might need to be changed to a different medication." 3. "Tell me what type of situations make you feel depressed." 4. "Some medications take a little longer to improve moods."

4. CORRECT. Tricyclic antidepressants such as amitriptyline often take three to four weeks before the client experiences maximum benefit. The medication has already begun to alter some of the client's symptoms as evidenced by reports of better sleep patterns and improved appetite. The nurse is both reassuring and educating the client about the medication. 1. INCORRECT. Asking the client about an increase in medication dosage is not appropriate since the client is not knowledgeable about the drug actions. The nurse should determine what, if anything, to discuss with the primary healthcare provider after client assessment. 2. INCORRECT. The client has only been taking amitriptyline for two weeks and acknowledges some signs of improvement already. It is premature to assume another medication would be needed. 3. INCORRECT. Though the nurse is presenting an open-ended statement regarding the client's on-going symptoms of depression, this comment focuses on the negative rather than the positive effects occurring with this medication.

A client is brought to the after hours clinic with a stab wound to the left leg, reporting it as "accidental". The nurse notes the odor of alcohol and marijuana on the client. The nurse is aware that client privacy rights do not apply to what action? 1. The right to refuse photos of the wound. 2. The right to refuse a blood alcohol test. 3. The right to refuse a tetanus injection. 4. The right to refuse police notification.

4. CORRECT: When an individual sustains a stab wound, even if self-inflicted, medical personnel are required to notify the police or proper authorities in that jurisdiction. Each facility determines the proper procedure for reporting gunshot or stab wounds, but the injury must be reported immediately while the client is still in the clinic. 1. INCORRECT: A client has the right to refuse to have photographs taken by medical personnel, regardless of the circumstances. Even if the primary healthcare provider determines the client is presenting with "a rare disease", pictures remain within the client's right of refusal. This can be an issue, especially in surgical situations, if the client has not given permission prior to the procedure. 2. INCORRECT: A blood alcohol level can be requested by police or legal authorities, but in most cases, the client retains the right to refuse that blood work. However, there may be legal implications of refusing the test, including immediate arrest, so the client needs to be informed of those implications. 3. INCORRECT: Any treatment or procedure, such as a tetanus shot, can be refused by a competent client, no matter how vital that treatment or procedure may be. Note this scenario does not indicate how potentially impaired the client may be, only that the nurse could smell the odor of alcohol and marijuana. It is impossible to determine whether this client would be considered "competent" from the data provided, and therefore the client can refuse a tetanus injection.

Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? Select all that apply 1. Weigh daily. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.

1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale and clothes if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting. 2. Incorrect: The client will work with their primary healthcare provider to create a controlled exercise program. This is usually done once healthy eating habits and some weight gain is achieved. See the word only in this option and think incorrect. 3. Incorrect: Do not argue or bargain with the client who is resistant to treatment. Be matter of fact about which behaviors are unacceptable and how privileges will be restricted for noncompliance. The person who is denying a problem and who also has a weak ego will use manipulation to achieve control.

The nurse is developing the plan of care for a newly admitted client diagnosed with schizophrenia. What goal would the nurse consider a priority for this client? 1. Schedule alone time for client to relax. 2. Frequently reorient the client to surroundings. 3. Encourage participation in all social activities. 4. Assign same staff to provide client care daily.

4. CORRECT. Schizophrenia is a group of psychotic disorders characterized by thought disturbances, bizarre behaviors and social withdrawal. Because of the numerous emotional and psychologic dysfunctions, there are many possible goals. However, the priority objective is to help the client develop a trusting relationship in order to achieve other goals. Assigning the same staff to provide care daily is the first step toward that objective. 1. INCORRECT. Clients with schizophrenia tend to self-isolate due to paranoid thoughts or hallucinations. Social withdrawal is a problem with these individuals and should not be encouraged by the nurse. Relaxation is not a priority goal for this client. 2. INCORRECT. This client was just admitted with schizophrenia. Getting this disorder under control will take some time, requiring both medications and therapy. Reorienting the client to the surroundings frequently is important but not the priority at this time. 3. INCORRECT. During the initial treatment period, the client may display hostility or angry, defensive behaviors which make group activities inappropriate. Eventually the client can be encouraged to participate in reality-based events but not in this early phase.

An elderly male client's wife recently died unexpectedly. During the clinic visit, the client appears tearful, lacks eye contact, and the clothing appears disheveled. What would be a priority nursing assessment for the client? 1. Adaptive and coping skills for dealing with loss 2. Intellectual capacity to make personal decisions 3. Socioeconomic status for independent living 4. Spiritual awareness for emotional comfort.

1. Correct: The unexpected death of a spouse can elicit a wide variety of emotions due to the grief that is being experienced. Individuals who are grieving often find it difficult to seek help, even from close family members. Elderly clients tend to wish to retain their independence. They often do not want to be burdens to the family members, but may find themselves unable to cope effectively. In this case, the signs of ineffective coping is the lack of eye contact and the personal appearance of the client. The nurse should assess the client's ability to adapt and cope with the unexpected loss and work through the grief process. 2. Incorrect: Although intellectual capacity in this elderly client could impact decision making, the priority assessment at this time is the client's ability to adapt to this sudden loss and determine if the client has the needed coping skills to effectively work through the grief process. 3. Incorrect: With the loss of the spouse, there may be a decrease in income. This could create a financial strain on the elderly client. However, this is not the priority assessment at this time. The nurse should focus on the client's ability to work through the grief. 4. Incorrect: Spiritual awareness can be paramount in the life of an individual, and can certainly be important during times of loss. However, this client does not seem to be coping well with the loss of the spouse, so the priority at this time would be focused on assessing the skills that the client possesses to help adapt to the loss and have the ability to cope.

A client is seen in the clinic for recurrent, unexplained, vague stomach pain over the past 5 years. Esophagogastroduodenoscopy (EGD), colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the pain. The client tells the nurse, "the pain is so bad sometimes that I can't function!" What disorder is this client likely experiencing? 1. Conversion disorder 2. Pseudocyesis 3. Somatization disorder 4. Dysmorphic disorder

3. Correct: Somatization disorder is a syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from healthcare professionals. Symptoms are vague, dramatized, or exaggerated in presentation. The disorder impairs social, occupational and other forms of functioning. 1. Incorrect: Conversion disorder is a loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder. This disorder affects voluntary motor or sensory functioning suggestive of a neurological disease. 2. Incorrect: Pseudocyesis is false pregnancy that may represent a strong desire to be pregnant. The client has nearly all the usual signs and symptoms of pregnancy such as enlarged abdomen, weight gain, cessation of menses and morning sickness.. 4. Incorrect: Dysmorphic disorder is characterized by the exaggerated belief that the body is deformed or defective in some way. Most common complaints are slight flaws of face or head, such as thinning hair, acne, wrinkles.

Which nursing intervention should the nurse include when caring for a client with Alzheimer's disease being admitted to a long term care facility? 1. Offer multiple environmental stimuli at the same time to provide distraction. 2. Encourage the client to participate in activities such as board games. 3. Restrain the client in a chair to prevent falls when sundowning occurs. 4. Involve the client in supervised walking as a routine.

4. Correct: A regular routine and physical activity help client's with Alzheimer's disease maintain abilities for a longer period of time. Physical activities promote strength, agility and balance. The client's walking should be supervised for client safety issues. 1. Incorrect: Environmental stimuli should be limited with clients with Alzheimer's Disease. The client can become agitated and/or more disoriented with an increase in environmental stimuli. 2. Incorrect: Board games would not be appropriate due to the client's cognitive and memory impairment. Board games require complex cognitive actions. 3. Incorrect: Restraints should be avoided because they increase agitation. The client may become agitated by the restriction of he restraints. Also the client may perceive the restraints as a threat.

A newly married wife tells the nurse, "I told my husband that I may not know how to cook, but I can sure do the dishes!" Which defense mechanism is the client displaying? 1. Projection 2. Displacement 3. Sublimation 4. Compensation

4. Correct: Compensation is consciously or unconsciously overemphasizing a characteristic to compensate for a real or imagined deficiency. Making up for deficits in one area by excelling in another helps to raise or maintain the client's self-esteem. 1. Incorrect: Projection is attributing one's own thoughts or impulses to another person as if they had originated in the other person. This is unconsiously done and usually includes intolerable wishes and emotional feelings. 2. Incorrect: Displacement is shifting or transferring the emotional element of a situation from a threatening object to a non-threatening object. This could include transferring emotions from a person, object or situation to another person, object or situation. 3. Incorrect: Sublimation is redirecting a socially unacceptable impulse into socially acceptable behavior. Examples include strong aggressive or sexual drives.

A client who was diagnosed with paranoid delusions has been prescribed a chest x-ray. The client refuses the chest x-ray and states "No, they want to kill me with the rays from the x-ray machine." Which nursing response is appropriate? 1. "Do you think people want to kill you with rays?" 2. "You don't have to worry that someone is going to kill you." 3. "I don't want you to talk about the x-ray technicians." 4. "Where did you get the idea that someone was trying to kill you?"

1. Correct: By restating the client's primary idea this reinforces to the client that statement has been heard. This allows the client to clarify the statement or realize that the nurse has understood the comment. This is the therapeutic communication technique of restating. 2. Incorrect: The nurse is using the nontherapeutic communication technique of giving reassurance. The nurse is stating that the client has nothing to worry about. The client may feel the nurse is moderating their intense concern of the possibility of being killed. 3. Incorrect: The nurse is disregarding the client's concern about possibly being killed. The nurse is redirecting the conversation about the client to concern for the x-ray technicians. The nurse is preferring the conversation to be focused on another topic. This is an example of the nontherapeutic communication technique of introducing an unrelated topic. 4. Incorrect: Demanding a reason from the client about their thoughts or feelings is an example of the nontherapeutic communication technique of requesting an explanation. This is a direct question. The client will need to defend their feelings or thought. The client may feel intimidated and stop communicating with the nurse.

The nurse is assigned a group of clients on the inpatient psychiatric unit. Which client presents the greatest risk for violence toward others? 1. 24 year old man with paranoid delusions 2. 62 year old woman with bipolar disorder 3. 72 year old man with major depression 4. 28 year old woman with borderline personality disorder

1. Correct: Clients with paranoid delusions believe that others may harm them. Because they cannot determine what is accurate, they may react in a violent manner. The clients age falls within the range for males who are most likely to present a risk of violence toward others. 2. Incorrect: The client with bipolar disorder may exhibit mood changes from elated to hopeless episodes. This client may be irritable; however, it is not likely that she will present a great risk for violence. Her age does not fall within the range for women that are most likely to present a threat of violence. 3. Incorrect: This client is more likely to hurt themselves than others. The client may exhibit sadness, anxiety or exhaustion. 4. Incorrect: The client with borderline disorder may exhibit impulsive and dangerous behavior. This client is more likely to hurt herself, perhaps through self-mutilation.

The home health nurse is assessing a client whose spouse died in a motor vehicle accident 6 months ago. The client says, "I feel all alone now". Which response by the nurse is therapeutic? 1. "You are feeling all alone." 2. "Why do you say you are lonely?" 3. "Your feelings of loneliness will decrease." 4. "I know other people who lost someone feel this way."

1. Correct: The nurse is utilizing the therapeutic communication technique of restating. The central statement by the client is restated. The client is able to identify that their thoughts or feelings have been received correctly. This also allows the client to clarify their thoughts or feelings if needed. 2. Incorrect: The nurse is requesting an explanation from the client. This is a nontherapeutic communication technique which can cause the client to have to defend their behavior or feelings. 3. Incorrect: The nurse is conveying to the client that their feelings of loneliness will decrease. This response is nontherapeutic communication technique of giving reassurance. The nurse is downplaying the client's feelings of loneliness. 4. Incorrect: The client is expressing their loneliness of losing a spouse. When the nurse states others have experienced loss, the nurse is utilizing the nontherapeutic communication technique of belittling feelings. This response causes the client to question their loneliness.

The nurse routinely screens injury victims for the possibility of intimate partner violence (IPV). Which statement correctly supports the nurse's action? 1. Victims of abuse are likely to report injuries and causes that do not fit the normal profile. 2. IPV is not routinely seen in the upper socioeconomic level. 3. All women should be screened, but men are not routinely screened. 4. Only victims who enter the emergency department alone should be screened for IPV.

1. Correct: Victims of abuse most often report causes of injuries that don't fit with the type of injury observed. For example, a victim may report that a bruised eye came from "running into" a door. The victim may feel the abuse is a personal incident or is afraid of the abuser. 2. Incorrect: Though many IPVs are from low income families IPV occurs across all socioeconomic levels and cultures. All suspected IPV cases should be assessed and reported regardless of their socioeconomic levels and cultures. 3. Incorrect: Men are also victims of IPV, though not as frequently as women. All potential victims should be assessed and reported if needed. 4. Incorrect: Many times the perpetrator will come to the emergency department (ED) with the victim. The victim may be afraid to give an accurate report of the accident with the perpetrator in the ED exam room. If so, more discreet screening is necessary.

The nurse manager is planning a leadership development workshop for new charge nurses. Which components of the communication cycle should the manager include as necessary for effective verbal communication? Select all that apply 1. There is a sender for every message. 2. A clear message is formulated. 3. There is a receiver for every message. 4. The sender and receiver share the same life experiences. 5. There can be incongruence between the verbal and nonverbal message.

1., 2. & 3. Correct: The communication cycle includes the sender, a clear and concise message, the receiver, plus verbal or nonverbal feedback to acknowledge understanding of the message. The sender is the person who delivers the message, and the receiver is the person who receives the message. 4. Incorrect: The sender and receiver may not share the same life experiences; however, therapeutic communication can still be achieved. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another's meaning and respond accordingly. However, this is not required for effective verbal communication. 5. Incorrect: There should be congruence between verbal and nonverbal communication. Incongruency can lead to misunderstanding and miscommunication.

A client is being admitted to the hospital for possible appendicitis. During the admission history and physical, the client reports having fatigue and trouble concentrating. What other client statement during the assessment would lead the nurse to suspect marijuana use? Select all that apply 1. "My eyes have looked bloodshot lately." 2. "I've noticed that my appetite has been decreasing." 3. "I sometimes feel that I am off balance." 4. "I have been losing weight lately." 5. "I don't have the desire to do the things I used to do." 6. "My heart seems to beat fast a lot of the time."

1., 3., 5., & 6 Correct: Red eyes are a classic sign of marijuana use. The red, bloodshot eyes that the client described may be the result of marijuana use, because it can cause vasodilation in the capillaries of the eye, resulting in increased blood flow. Tetrahydrocannabinol (THC), which is the active ingredient in marijuana, can attach to neuron receptors in the brain that disrupt various mental and physical functions. THC can affect pleasure, thinking, memory, concentration, movement, and coordination. That is why this client may feel "off balance" at times. In addition, sensory alterations and problems with time perception may be noted. The statement from the client about not having the desire to do the things that were formerly done may be a sign of marijuana use. Marijuana has been linked to decreasing motivation and diminishing the desire to engage in activities that were formerly rewarding or enjoyable. Another physical sign of marijuana use is increased heart rate, which would correlate with the client's statement about the sensation of the heart beating faster much of the time. 2. Incorrect: The appetite in individuals using marijuana tends to increase, not decrease. This is because the THC activates a part of the brain that is thought to be the reward system. Therefore, marijuana has an effect on the part of the brain that controls the person's response to normal, healthy, pleasurable behaviors such as eating and sex. 4. Incorrect: Not only does the appetite increase, but individuals who use marijuana may also have cravings for snacks. The weight in these individuals tend to increase rather than decrease.

A distraught client arrives at a mental health crisis center following a house fire that also took the life of a young family member. The nurse knows what action is most important when initiating crisis intervention for this client? 1. Assist the client to verbalize feelings of grief. 2. Assess client for any suicidal behaviors. 3. Admit client to general mental health unit. 4. Assign client to a grief counseling group.

2. Correct: Client safety is always the nurse's priority concern where no other life threatening issues exist. A distraught client in crisis from such overwhelming events does not always think or act clearly. The loss of home combined with the death of a family member places the client at potential risk for suicide. Because the client has presented to the mental health crisis center, the nurse must assume the worst and assess for unexpected responses. 1. Incorrect: While it is true that encouraging the client to verbalize feelings is therapeutic in a crisis, that is not the most important initial action by the nurse at this time. Recall the nursing process when considering an irrational action. 3. Incorrect: Arriving at a mental health crisis center does not automatically require admission to the hospital. This client is overwhelmed by circumstances which include the death of a family member; however, ideally the client may respond to counselling or medications without the need for inpatient care. 4. Incorrect: Following evaluation by a primary healthcare provider, this client will definitely receive counseling, perhaps both individualized and in a support group for those under extreme duress. However, this is not the initial concern for the nurse.

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the primary healthcare provider about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. Correct: Initially, the nurse would fulfill the client's urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given to response to physical complaints. Gradual withdrawal of positive reinforcement will discourage repetition of maladaptive behavior. However, all new symptoms should be reported to ensure physician assessment of the complaint. 1. Incorrect: This is a nontherapeutic response. The client's feelings and concerns should not be denied. This will increase the anxiety level of the client. Do not totally ignore the client's complaint. 3. Incorrect: By postponing the group session the nurse is reinforcing the clients somatization disorder. The group session should start on time. 4. Incorrect: The pain is real to the client. This response is not therapeutic communication. The direct ignoring of the client's complaint will increase their anxiety level.

The primary healthcare provider has prescribed hydromorphone 2 mg intravenously (IV) every 4 hours as needed for pain. When should the nurse plan to administer the medication to the client? 1. Only when requested. 2. Prior to onset of intense pain. 3. With reports of acute pain lasting for at least one hour. 4. Continuously every 4 hours to keep the client pain free.

2. Correct: Pain is best managed before acute pain has developed. If the client waits until the pain is intense, the pain medication may not work as effectively or not at all. 1. Incorrect: Clients sometimes need pharmacologic treatment for pain even if not requested. Nurses should monitor the client for physical signs of pain. Vital sign changes and facial grimacing may be signs of pain. The word "only" is too limiting. 3. Incorrect: Clients should be treated for pain before acute pain develops when possible. The client should be educated to report pain prior to experiencing it for at least one hour. 4. Incorrect: The order is as needed, not continuously. Also, the goal of being pain free may be unrealistic. The nurse wants to keep the client's pain at a tolerable level. Always measure pain on a pain scale such as 0-10.

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is most therapeutic at this time? 1. "You look great today, so you must be feeling better." 2. "I see you are wearing a bright blue sweater today." 3. "Has something changed in your life this morning?" 4. "Today must be a very special occasion for you."

2. Correct: The nurse is focusing on the 'here and now' by acknowledging the client's changed appearance without adding any personal comments. This response avoids typical communication blocks such as "you look great", which seems positive but is considered a judgment by the nurse. The nurse's broad statement shares an observation in an open-ended manner. 1. Incorrect: This remark provides false reassurance to the client by assuming change in visual appearance must be based on emotional improvement. This is very misleading and non-therapeutic for the client. 3. Incorrect: Questions can be positive communication tools if presented in an open-ended format. Asking about life changes in this manner could be answered yes or no, which indicates a closed-ended question. A sudden improvement in appearance may be one of the warning signs of suicidal ideations, but the nurse's inquiry would not provide the information needed. 4. Incorrect: The nurse is inferring the client needs a special occasion in order to be clean and well-kempt. Such a comment is presumptuous and judgmental.

The client shares that her husband died 2 months ago. She stays at home at least 3 times per week and cries most of the day. Which interventions for dealing with loss would the nurse initiate? Select all that apply 1. Resume previous social activities right away. 2. Establish a structure of daily activities. 3. Reinforce that dreaming about the loved one is positive. 4. Recommend immediate professional assistance. 5. Encourage communicating feelings during grief process.

2., 3., & 5 Correct: Organizing specific daily activities will give the client a sense of control of their lives. This action will assist the client through the day and promotes self-confidence. Dreaming about the deceased is a symptom of the normal grief process. The client is compensating for the loss by experiencing dreams that include her husband. The stages of grief do not proceed in a systematic process. The client may stay in one stage for a while, skip a stage, or begin the stages again from the beginning. The client should express their feeling as they move through the grief stages. Grief is an individualized process. 1. Incorrect: Due to the change in the marital status of the client, the client may not be comfortable resuming previous activities. The nurse could discuss prior social activities with client utilizing therapeutic communication techniques such as open ended questions to assist the client in deciding which social activities to resume at this time. 4. Incorrect: The client is exhibiting normal grief actions/symptoms. The assessment of the client does not warrant the professional assistance at this time. The word immediate means prompt or rapid. The stem does not indicate a need for immediate action.

The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional assessment findings by the nurse would suggest the client may develop anorexia nervosa? Select all that apply 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure

3. & 5. Correct: This client is reporting symptoms consistent with anorexia nervosa, a serious and potentially life-threatening eating disorder that develops secondary to the type of family or social stress experienced in adolescence. In addition to severe depression and amenorrhea, the nurse has identified brittle, dry nails, and a low blood pressure secondary to weight loss as additional indications of anorexia nervosa. 1. Incorrect: Despite the fact that anorexic clients experience severe weight loss, they continue to view themselves as heavy and generally wear loose fitting clothing to hide what they perceive as an overweight body. 2. Incorrect: Because of skeletal muscle atrophy and poor nutritional intake, anorexic clients display sallow, dry skin with brittle nails and hair. Oily, non-elastic skin would not be noted in a client with anorexia nervosa. 4. Incorrect: Gingival infections and dental caries are typical of clients with bulimia, another eating disorder in which stomach acid from frequent vomiting causes gum infections or dental caries. This is not common in anorexics.

The nurse is working with the interdisciplinary team in developing a plan of care focused on weight gain for an anorexic client. What intervention would be ineffective for reaching that outcome? 1. Refrain from being critical of client during meals. 2. Permit client to make own food selections on menu. 3. Reward the client with private time for a meal completely eaten. 4. Provide positive reinforcement for each pound gained.

3. CORRECT: Anorexic clients believe they are grossly overweight, regardless of their current physical appearance. Therefore, the individual will attempt to get rid of food ingested at a meal by any means necessary, including aggressive exercise and induced vomiting. Rewarding the client time alone would NOT be effective in reaching the goal of weight gain. 1. INCORRECT: Negative comments at any time are counter-productive for clients with low self-esteem, particularly individuals with body dysmorphia. Refraining from critical comments during a meal is a positive action toward the weight-gain goal. However, the scenario asks for a negative goal. 2. INCORRECT: Permitting a client to participate in food selection demonstrates confidence in the individual and encourages personal responsibility for self-care. This action is a positive step toward reaching the client goal. 4. INCORRECT: The ultimate goal for an anorexic client is weight gain. Positive reinforcement is vital for clients with poor self-image. Gaining even one pound is a great achievement for the client and the nurse should acknowledge the effort toward reaching the ultimate goal.

A nurse has received report on a client to be admitted from the surgical suite following an unexpected amputation of the right arm because of a tractor accident. Which action by the nurse would best help the client upon arrival to the unit? 1. Notify hospital social services about adaptive equipment needs. 2. Prepare to change the dressing so the client can see the stump. 3. Ask client's family and hospital chaplain to be present in room. 4. Advise dietary that client will need food precut in small pieces.

3. Correct. This client will be awake from surgery to face the unexpected amputation of an arm, which has long-term physical, psychological, emotional and financial implication. Even clients facing a scheduled limb removal experience distress, anger or depression. Anticipating that the client will need a great deal of emotional support, the nurse is aware that having family and/or the hospital chaplain present after surgery may help the client cope with the bad news. 1. Incorrect. Losing an extremity involves relearning how to complete ADL's in an alternative manner and usually requires using adaptive equipment. This client may be introduced to specialty equipment prior to discharge, and social services will arrange for any home care needs. However, this action is not of primary concern at the time of the clients arrival in the unit. 2. Incorrect. The loss of a limb, particularly unexpectedly, can overwhelm a client and result in feelings of shock, anger, or even denial. Clients can experience a range of emotional responses based on age, beliefs, values or social support. One common behavior among new amputees is the hesitancy to look at the stump. Forcing the client to visualize the wound before being psychologically ready can hinder or delay adaptation. Additionally, the surgeon generally removes the original surgical dressing. 4. Incorrect. This client will need to learn many adaptive skills once the surgical site has healed. However, having food precut into small pieces diminishes self-esteem and discourages client independence, which is important to recovery. An occupational therapist will be consulted regarding special eating utensils and techniques but usually there is little alteration in the preparation of food.

The behavioral health nurse is providing crisis intervention follow-up with a client and is teaching concepts regarding crises. Which statement by the client would best indicate understanding of the teaching? 1. "I must have a type of mental illness because I was not able to cope with the stressful situation." 2. "I will usually not be able to identify a stressor that can cause a crisis in my life." 3. "This crisis has the potential to help me grow psychologically." 4. "Because this situation created a crisis for me, I can expect this crisis to recur for me."

3. Correct: Although a crisis threatens personality organization and the individual is not able to function as usual, it also presents an opportunity for psychological growth. 1. Incorrect: Individuals, other than those with mental illness, can experience crises. These individuals can be mentally healthy, have functioned well in the past, but find themselves in a state of disequilibrium. Being unable to effectively cope during a stressful situation does not mean that a person has a mental illness. 2. Incorrect: The primary cause of a crisis is a traumatic event, which the client could readily identify. 4. Incorrect: Crises are considered acute and time limited, usually lasting approximately 4 to 6 weeks. A goal of crisis intervention is not only to promote the optimal level of functioning, but also to prevent further emotional disruption. Therefore, the client would hopefully gain the needed resources and coping skills needed to prevent future problem situations from occurring.

After the unexpected death of a Jewish teenager, the coroner tells the family that an autopsy has been requested. The teen's mother starts crying hysterically and refuses to allow the autopsy. After calming the mother, what should the nurse do next? 1. Explain that the coroner does not need the family's permission to perform the autopsy. 2. Ask the primary healthcare provider for a sedative for the mother. 3. Notify the coroner that the family is Jewish. 4. Call the rabbi of the family's synagogue to discuss the nature of the autopsy.

3. Correct: Mutilation of the body is forbidden. Autopsy is allowed only when mandated by civil authorities, such as when murder is suspected. If an autopsy is performed, all body parts must be returned for burial. 1. Incorrect: Permission is not needed when foul play is suspected. The keyword is "unexpected". The law can require an autopsy be performed when death is the result of foul play, homicide, suicide or accidental causes such as motor vehicle crashes, falls, the ingestion of drugs or deaths within 24 hours of hospital admission. 2. Incorrect: The nurse has calmed the mother. The sedative is not needed and does not solve this problem. Remember to stay away from medications as long as possible. 4. Incorrect: A rabbi is usually requested at the time of death, but this will not solve the autopsy problem. The rabbi may pray in a minyan, a group of 10 adults over the age of 13.

A hospitalized American Indian elder is actively dying and is surrounded by a large group of family members. The client's spiritual beliefs include burning a tiny amount of incense while chanting softly. The roommate summons the nurse, complaining about the noise and the odor despite the fact the curtain is drawn between the beds. What is the most appropriate action by the nurse? 1. Tell the client's family the noise and odor bothers the roommate. 2. Move the elder to a private room so family can continue ceremony. 3. Offer to move the roommate to another room in a quieter area. 4. Explain the client is dying and the family will soon be leaving.

3. Correct: The most appropriate action in this situation is to move the roommate to a quieter location, allowing the family and dying client privacy while also fulfilling the roommate's request. 1. Incorrect: The client and family are dealing with an impending death and have the right to embrace any cultural or spiritual traditions to ease that situation. This comment by the nurse would insult the family and not solve the situation. 2. Incorrect: Despite the fact that a private room would be ideal for the dying client and family, the stress and chaos of moving to another room would be physically and emotionally overwhelming. In fact, it could even hasten the client's death. 4. Incorrect: Although the roommate may be aware of the client's condition, the nurse has violated HIPAA regulations by revealing information to the roommate. Even when the elder client does pass away, the family may choose to stay in the room for an extended period of time. This action does not solve the problem.

During a treatment team meeting, a client who recently had a mastectomy shares that she can no longer stand to look at herself in the mirror and does not want her husband to see her without clothes. Which statement by the nurse on the team would be most appropriate? 1. "Try looking at yourself in the mirror 5 minutes four times daily until you feel more comfortable." 2. "I'm sure that your husband loves you just the way you are." 3. "Trying to adjust to the change in your body image must be very hard for you." 4. "You look great! Also, when the swelling goes down, you will look even better!"

3. Correct: This response by the nurse first acknowledges the difficulty that the client is experiencing while adjusting to the change in body image following her mastectomy and then encourages the client to further discuss her body image concerns. This exploration of the client's feelings will assist the nurse in addressing the client's concerns. 1. Incorrect: The client is telling you that she cannot stand to look at herself in the mirror at this point. Telling the client to look at herself in the mirror four times a day indicates that you are not listening to what she said and/or you do not care that she is struggling with her body image. You should first help her deal with the feelings that she is experiencing. Later in the process, encouraging the client to look at herself in the mirror may be incorporated into the plan of care. 2. Incorrect: This statement is pacifying and not therapeutic. You do not know that the husband loves her just the way she is. Husbands may also have a difficult time dealing with a wife's mastectomy. This statement does not assist in exploring the client's feelings nor does it assist the client to develop coping skills for dealing with loss and the altered body image. 4. Incorrect: This is a false reassurance. Nurses and healthcare providers are programmed to "fix" the problem. This is absolutely what nurses should do in most situations. However, false reassurance can inadvertently be made by trying to "fix" the client's feelings by using phrases such as "You look great!" or "Don't worry, you will look even better before long!" The client should first be encouraged to express their feelings of loss, altered body image, etc. so that these can be acknowledged and addressed. Later in the treatment plan, the nurse can provide the realistic reassurance that could serve as encouragement for the client.

A client scheduled for an amniocentesis expresses concerns about the procedure to the nurse, despite having signed the consent form. What statement by the nurse would be most appropriate for the client? 1. "Don't worry, it's a very simple procedure." 2. "You have already signed the consent form." 3. "I will tell the doctor you need to talk more." 4. "Can you tell me what most concerns you?"

4. CORRECT: The client is obviously having second thoughts and needs further clarification or discussion. Even though a consent form was signed, the client has the legal right to withdraw that consent at any time. This open-ended question by the nurse is an appropriate approach to encourage the client to express concerns, allowing the nurse to gather further information and formulate a suitable plan to proceed. 1. INCORRECT: A nurse should not use the words "don't worry" to a client. Doing so dismisses both the client's feelings and the right to request further information. This is not a "very simple procedure", and has definite, potentially serious complications. This comment by the nurse does not employ any appropriate therapeutic communication techniques. 2. INCORRECT: This comment by the nurse is not true, since a client can withdraw consent for a procedure at any time, including just before the actual procedure. The client is expressing concerns about the amniocentesis now. "Patient Rights" always assure clients the ability to question any and all proposed treatments at any time. 3. INCORRECT: Since the client needs more information, it would be important to notify the primary healthcare provider. However, it is not appropriate on the NCLEX to transfer care of the client to someone else initially. The client is anxious and worried; therefore, the nurse should use therapeutic communication techniques to encourage the client to talk.

A client being treated for major depressive disorder arrives at group therapy for the first time in a week wearing clean clothes after showering. What response by the nurse would be therapeutic? 1. "Why are you all dressed up for group?" 2. "Maybe you could add makeup tomorrow." 3. "You must feel better after finally showering." 4. "You look really nice in that flowered jacket."

4. CORRECT: When a depressed client has a sudden change in behavior or attitude, the nurse must cautiously evaluate any meaning behind such abrupt behavior. The best way to proceed is to engage the client in an interactive conversation by utilizing therapeutic techniques. This nursing comment provides positive affirmation of the client's actions by drawing attention to the choice of clothing. Open-ended statements provide a safe environment for building rapport and client interaction. 1. INCORRECT: Demanding an explanation for behavior is always non-therapeutic. Most often, the client will have no response or even understanding of the behaviors and can become frustrated trying to respond. Additionally, this question could be interpreted as disapproving of the clothing, causing the client to return to previous behaviors. 2. INCORRECT: The nurse is suggesting the client's attempts to improve self are less successful by inferring that makeup should be applied. This comment is not therapeutic, nor does it acknowledge the positive initial actions taken by the client. Rather than encouraging, such a response by the nurse is negative and not constructive. 3. INCORRECT:. While this statement does acknowledge the client has showered, the word "finally" has a negative connotation, suggesting the client has neglected personal care for an unacceptable amount of time. Such a comment by the nurse is non-therapeutic and discourages communication.

The nurse is caring for a client and the family at a time of impending death for the client. What comment by the nurse would best assist the family to cope with their grief during this time? 1. "Don't cry. Your family member would not want it this way." 2. "Things will be fine. You just need to give yourself some time." 3. "Try not to be upset in front of your family member." 4. "I'm so sorry. This must be very difficult for you."

4. Correct: Nurses can best facilitate the family's expressions of grief by supporting and encouraging them to express themselves. This is the best option that best demonstrates that expressions of grief are acceptable and expected. Here, you are empathizing to provide emotional support during their grief and providing an open ended statement that would promote expression of the family members' grief. 1. Incorrect: Telling grieving family members not to cry is certainly not very therapeutic. They need to feel free to express their emotions of grief at the time of impending death of the loved one. This statement would be a barrier to demonstrating care and concern. 2. Incorrect: Telling the family that things will be fine and to give themselves time are trite assurances and clichés that should be avoided by the nurse. Instead, you should use therapeutic responses that promote the expressions of grief by the family. 3. Incorrect: Again, by telling them to try not being upset in front of the dying family member, this is not demonstrating care and compassion to the family members who are grieving. This would be a barrier to assisting them to communicate and express their feelings of grief.

An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? Select all that apply 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic.

1, 2, 3, & 5. Correct: The nurse is aware that multiple factors can contribute to acute confusion in clients. The sudden relocation to a new environment, along with pain from injury, could definitely contribute to an acute onset of confusion. The client's ordered bedrest and response to new pain medications are additional factors that could produce an acute change in mental status. 4. Incorrect: Age alone is not a factor for confusion. New onset of confusion may be successfully resolved once any contributing factors are addressed.

A nurse observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client mostlikely experiencing? 1. Auditory hallucinations 2. Delusions 3. Catatonic excitement 4. Anergia

1. Correct: Auditory hallucinations are false sensory perceptions of sound not associated with real external stimuli. When the client begins to respond to a stimuli that is not visible to the nurse, this is a hallucination. 2. Incorrect: Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. These beliefs are not consistent with reality and guide the client's behavior. Typically the client thinks they are all powerful, or have unrealistic fears. 3. Incorrect: Catatonic excitement is manifested by a state of extreme psychomotor agitation. This client is not showing any symptoms of agitation. 4. Incorrect: Anergia is a deficiency of energy to carry out activities of daily living. There are no indications in the question that this client cannot carry out activities of daily living.

Which response by the nurse is appropriate when admitting a 5 year old child who is crying and hugging a stuffed animal? 1. "Hello, I am your nurse. I am going to show you to your room." 2. "Don't cry. Let's go to the playroom where you can meet other children." 3. "You are upset. I see you have your stuffed animal." 4. "Can I hold your stuffed animal? Then, would you like to put your stuffed animal in the bed?"

3. Correct: These statements acknowledge the child's feelings and changes focus. 1. Incorrect: This response does not acknowledge the child's feelings. 2. Incorrect: This response does not alleviate fear. 4. Incorrect: Closed-ended questions are not helpful in getting a child to express fear.

The nurse is reviewing a safety contract with a client who is suicidal. However, the client declines to sign the safety contract at this time. What action must the nurse take? 1. Check that all windows are locked and the doors secured. 2. Secure the room by removing potentially harmful objects. 3. Place client in a chair at nursing station until contract is signed. 4. Assign a staff member to stay with client, even in the bathroom.

4. CORRECT: A safety contract states the client will not do any self-harm in a specified length of time or without calling the nurse. If there is a refusal to sign such a contract, the client cannot be alone even when using the bathroom. Safety is always the priority concern for a suicidal client. 1. INCORRECT: Although facilities have specific safety precautions for doors and windows, it violates fire safety codes to lock exits. There is no indication this is a psychiatric facility but safety regulations apply to all client facilities. 2. INCORRECT: It is impossible to "secure" any room completely. If a client wishes to bring self-harm, any object can become lethal, even a soft pillow. 3. INCORRECT: Placing a client in a chair for an unspecified length of time is punitive and verges on abuse. This client may never sign a safety contract. Also, the chaos of the nursing station could further upset the client.

The nurse has been talking with a depressed client at an outpatient clinic. When asked how the client feels to live alone, the client simply stares straight ahead. How should the nurse respond? 1. Ask, "Why won't you answer me?" 2. Leave the client alone for awhile. 3. Tell a joke to lighten the mood. 4. Use therapeutic silence.

4. Correct: Use of silence allows the client time to think over what he or she wants to say and gives the client a chance to collect thoughts. 1. Incorrect: This is not therapeutic and appears aggressive and confrontational. 2. Incorrect: This is not therapeutic. Depressed clients may need extra time to formulate their thoughts. 3. Incorrect: This is not therapeutic and demonstrates disregard for the client's feelings.

A client has been given information about several complementary therapies for the treatment of anxiety disorder. Which therapy selected by the client would require the nurse to check for allergies? 1. Aromatherapy 2. Biofeedback 3. Guided Imagery 4. Acupuncture

1. CORRECT. Aromatherapy is the use of essential oils from plants and herbs in the form of baths, inhalation, or compresses applied directly to the skin to promote relaxation, decrease depression and enhance sleep. Because these oils come in contact with the client's skin, or by inhalation, it would be important to verify any allergies the client may have prior to initiating therapy. 2. INCORRECT. Biofeedback is progressive muscle relaxation with the use of electrodes placed on the client's skin. This therapy has been used to treat medical issues such as migraines or chronic pain. Allergies would not be a concern with this complementary therapy. 3. INCORRECT. Guided Imagery, also called "visualization", uses words or sounds to direct the client on an imaginary journey within the mind. This technique for dealing with anxiety would not present any concerns about allergies. 4. INCORRECT. Acupuncture is a complementary therapy that entails stimulating certain areas of the body by penetrating the skin with a variety of tiny needles in order to treat a variety of physical and emotional disorders.The nurse would not be concerned about allergies with this therapeutic treatment.

A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk for suicide or self-directed injury? 1. "I can't do anything right anymore." 2. "I am not sure what to do anymore." 3. "I just cannot take this loneliness anymore." 4. "No one cares about me."

3. Correct: This statement indicates that the person cannot tolerate the current situation. The client is at risk for harm to themselves. 1. Incorrect: The client has a negative outlook about themselves. This statement indicates low self-esteem. The client is not exhibiting suicidal tendencies. 2. Incorrect: The client is having difficulty making choices. This statement indicates indecisiveness, which is a symptom of depression. Indecisiveness is not a risk for suicide or self-directed injury. 4. Incorrect: This statement indicates possible social isolation and low self-esteem. The client maybe physically separated from people or the perception of being isolated from others. The client does not exhibit a loss of hope that is connected with suicide.

Which initial behavior by the client on a mental health unit demonstrates to the nurse that the client is assuming responsibility for anger management? 1. Plans to use exercise to work off anger. 2. Apologizes to those individuals to whom anger has been directed. 3. Develops a plan on how to react when feeling stressed. 4. Identifies stressors of past violent behavior.

4. Correct: Demonstrates client is assuming responsibility for anger management. 1. Incorrect: The client would have to identify precipitating factors first. 2. Incorrect: This does not indicate a change in behavior. It just shows that the client is aware of anger after the fact. 3. Incorrect: The client must identify stressors first.

A client is being cared for in the intensive care unit following a traumatic amputation of the left lower arm. As the nurse enters the room for a routine check, the client begins to cry and states "This is so overwhelming." What statement by the nurse would be most appropriate at this time? 1. "You have been through a lot, but look on the bright side; you are doing better now." 2. "Try to be optimistic. You are going to be fitted for a prosthesis once you are healed." 3. "I understand that you are upset, but crying is not going to help your situation." 4. "This must be very difficult for you. What seems to be the hardest part for you now?"

4. Correct: This client has experienced a very significant personal loss and can go through the grieving process, similar to those who experience the death of a loved one. The nurse should be very sensitive to the feelings of loss being felt by this client due to the loss of a body part. This client is reporting feeling overwhelmed. The best way for the nurse to respond to this client's feelings would be to first acknowledge that the situation must be very difficult for the client. The nurse can further explore this by asking what seems to be the hardest part for the client currently. This will guide the nurse with how to best assist the client at the current time and meet the most immediate emotional needs of this client. By addressing what is most overwhelming at the present time, the nurse can more effectively assist the client in gradually working through the grief process and dealing with the loss. 1. Incorrect: The nurse's comment starts out with an acceptable comment of acknowledging that the client has been through a lot but then immediately negates the client's feelings of being overwhelmed by telling the client to look on the bright side and that the client is doing better now. This statement discounts the client's feelings of loss and being overwhelmed with all that it entails. 2. Incorrect: This comment by the nurse that tells the client to be optimistic because a prosthesis will be fitted does not address the client's current feelings. This is a total disregard to the overwhelming feelings of loss that the client is experiencing. As the client works through the feelings of loss over time, the nurse can help provide a sense of hope and optimism about the use of a prosthesis, but the client's current feelings should be addressed first. 3. Incorrect: Again, the nurse's comment about recognizing that the client is upset could be appropriate, but the comment following this about crying not helping the situation could cause the client to feel belittled and may actually cause the client to become bitter or reluctant to share true feelings with the nurse. The nurse should support the client and explore how to best help the client work through these feelings of extreme loss.

A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that they have a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client? 1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal."

1. Correct: A client may sign out of the hospital at any time, unless following a mental status examination the healthcare professional determines that the client may be harmful to self or others and recommends that the admission status be changed from voluntary to involuntary. 2. Incorrect: A client may sign out of the hospital at any time, unless following a mental status examination the healthcare professional determines that the client may be harmful to self or others and recommends that the admission status be changed from voluntary to involuntary. 3. Incorrect: Lawyers do not make that decision. This client was voluntarily admitted, not involuntary. Involuntary admission can be from three different commitment procedures: judicial, administrative and agency determination. Involuntary admission can be further categorized as emergency, observational/temporary or indeterminate/extended. 4. Incorrect: This is not the best response, since the client has told you of a plan. They might decide to tell you they have no plan when in fact they do.

A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."

1. Correct: It is better to say "What do you think you should do?" This helps the client reflect on options and does not have the nurse tell the client what to do. It is much more therapeutic to help the client make the decision for themselves, instead of the nurse. This prevents any biases from impacting the outcome. 2. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions. 3. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions. 4. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions.

A client had a suspicious area of the skin biopsied and sent to the lab for analysis. The client states "I am worried that the pathology report will indicate cancer." Which response would the nurse initiate to assist the client in reducing their anxiety? 1. "You are anxious about the pathology report?" 2. "Would you like me to recommend a movie for you to watch?" 3. "I will notify your daughter that you are concerned about the pathology report." 4. "Have you tried taking long, slow deep breaths and not thinking negative thoughts?"

1. Correct: Utilizing the therapeutic communication technique of restating encourages the client to continue expressing their thoughts and feelings. This correct response by the nurse will also encourage the client to continue verbalizing or clarify their statement if needed. Restating is an effective communication technique to reduce the client's anxiety. 2. Incorrect: The nurse is presenting another option for the client to discuss that is not related to the current conversation. Sometimes distraction, a nontherapeutic communication technique, is used by the nurse to reduce their anxiety which is not client driven communication. The focus of the nurse should be the client. Communication should be client-centered to explore client feelings, identify client preferences, empower the client, provide the client choices, or in some way put emphasis on the client. 3. Incorrect: The nurse is deciding for the client to notify the daughter about the pathology report. The nurse is not demonstrating empathy to the client. The client may feel insignificant, since the nurse wants to talk to her daughter. This will discourage the client to verbalize their feelings. In addition, the nurse must comply by the Health Insurance Portability and Accountability Act (HIPAA). 4. Incorrect: The nurse is giving advice which is a nontherapeutic communication technique. Introducing relaxation techniques such as taking slow deep breaths and clearing the mind of negative thoughts will block the client from expressing their thoughts and feelings. The questions does not identify that the client has negative feelings. The nurse is telling the client how to feel. This is an example of nontherapeutic communication technique of giving advice.

The nurse is to administer a client's first dose of lithium. Prior to giving the medication, the nurse should verify that what tests have been completed? Select all that apply 1. Blood urea nitrogen (BUN) 2. Thyroid stimulating hormone (TSH) 3. Electroencephalogram (EEG) 4. Alanine Aminotransferase (ALT) 5. Electrocardiogram (ECG)

1., 2., & 5. Correct:. Lithium is an anti-mania medication used to treat bipolar disorder or other manic issues. However, this drug may adversely affect other body systems, which is why it is vital to verify the client has no undiagnosed renal, thyroid or cardiac problems. Blood urea nitrogen (BUN) reveals the function of the kidneys while thyroid stimulating hormone (TSH) indicates how well the thyroid is working. An electrocardiogram (ECG) will show arrhythmias or rhythm problems with the heart. The nurse needs to verify these tests were completed and the results were given to the primary healthcare provider. 3. Incorrect: An electroencephalogram (EEG) is a study of brain wave activity achieved by placing dozens of external electrodes on the skull. While Lithium may affect an individual's thought patterns and emotional stability, actual brain functions are not impacted. 4. Incorrect: Alanine aminotransferase (ALT) is an enzyme produced by the liver for the purpose of helping breakdown proteins for metabolism. This blood test would indicate the status of the liver, which is not a major concern while taking lithium.

A nurse is developing a proposal to implement a pet therapy program at a nursing home. What information should the nurse include in the proposal to support this program? Select all that apply 1. Evidence has shown that animals can directly influence a person's mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Petting an animal can be helpful in lowering a client's blood pressure. 4. Some researchers believe that animals actually may retard the aging process among those who live alone. 5. Nursing home clients are more submissive after petting an animal.

1., 2., 3. & 4. Correct: All of these statements are correct in reference to pet therapy programs. Petting a dog or cat has been shown to lower blood pressure. Studies indicate a 7 mm Hg drop in systolic and an 8 mm Hg decrease in diastolic BP when volunteers talked to or would pet their dogs as opposed to reading aloud or resting quietly. 5. The clients are not more submissive or passive after participating in pet therapy. Evidence does show increased mental and physical well being with pet therapy.

The crisis line nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What is the nurse's most appropriate response? Select all that apply 1. "I want to help you to resolve the problem." 2. "You should drive yourself to the emergency room." 3. "You did the right thing by calling." 4. "I want you to stay on the phone with me." 5. "Have another person call 911 for an ambulance."

1., 3., 4. & 5. Correct: The nurse wants to establish a positive relationship with the client as quickly as possible. The nurse wants to recognize positive qualities. Keeping the client on the phone may prevent the client from taking the pain killers. The crisis line nurse keeps the person on the line as long as possible as this is most important. Losing contact is a threat to the client's safety. This client is planning action with access to the plan. Emergency personnel should be called. 2. Incorrect: The client has a plan and the means available for suicide. The client does not need to drive to the emergency room. The nurse keeps the client on the phone as she activates the 911 call.

A client being treated in the intensive care unit following methamphetamine intoxication states, "Snakes are crawling all over the room, get me out of here!" How does the nurse document this assessment finding? 1. Delusions 2. Hallucinations 3. Flashbacks 4. Depersonalization

2. Correct: Hallucinations are false sensory perceptions not associated with real external stimuli. When the client begins to respond to a stimuli that is not visible to the nurse, this is a hallucination. 1. Incorrect: Delusions are false personal beliefs that are inconsistent with the person's intelligence or cultural background. These beliefs are not consistent with reality. Often the client will either feel all powerful or have extreme unrealistic fears. 3. Incorrect: Flashbacks are a spontaneous recurrence of the hallucinogenic state without ingestion of the drug. These can occur months after the drug has been taken. 4. Incorrect: Depersonalization can occur, but it is the observation of oneself having an experience. The client may report feelings of being an outside observer of their own thoughts or body with a sense of loss of control. This is sometimes described as an out-of-body experience for the client.

A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response? 1. "I understand you are upset, but you will have to go back to your unit sooner or later." 2. "You are repressing this event because it was frightening and painful for you." 3. "In my professional opinion, you are trying to undo what happened in the battle." 4. "You are splitting from the bad you, so that the good you survives."

2. Correct: Repression is the unconscious blocking from awareness an event or memory of something that is threatening or painful. It is the mind's way of forgetting or experiencing temporary amnesia until it can cope with an overwhelming circumstance. The nurse's response is concise and honest for a client that needs a trusting therapeutic relationship after a traumatic event. 1. Incorrect: The nurse is being aggressive and judgmental which is inappropriate and not therapeutic for the client. 3. Incorrect: Undoing is canceling out a behavior or trying to make amends. This is not a correct assessment of what the client has reported to the nurse. 4. Incorrect: Splitting occurs when a person cannot stand the thought that someone might have both good and bad aspects, so they polarize their view of that person as someone who is "all good" or "all bad."

A client diagnosed with major depression has been admitted to a psychiatric facility for medication management. During nighttime rounds, an LPN/VN notes the client is not in bed. Which behavior by the client should the LPN/VN report to the RN immediately? 1. Sitting in a chair crying. 2. Reports inability to sleep. 3. Rearranging furniture. 4. Pacing around the room.

3. Correct: The client has been diagnosed with major depression, but is actively moving furniture around the room. While major depression is characterized by low energy, fatigue and lack of interest. Moving furniture indicates the client is displaying manic behavior which should be reported to the RN immediately. 1. Incorrect: Crying would be an expected behavior for clients diagnosed with major depression, along with decreased energy, irritability, and disinterest in most activities. Finding this client sitting in a chair and crying would not be an unusual behavior and would not need reported to the RN. 2. Incorrect: Major depression encompasses a variety of symptoms, such as a feeling of helplessness and hopelessness, despair and sleep disturbances that range from constant sleep to not sleeping at all. The inability to sleep would not be unusual for this client and would not need to be reported by the LPN/VN. 4. Incorrect: Pacing is one of a variety of behaviors displayed by clients diagnosed with major depression, which may also include irritability, sleep disturbances and lack of focus. While pacing the room should be monitored, there is another activity that is of more concern.

The nurse is caring for a client in an outpatient clinic. The client's spouse died 8 months ago. Which statement by the client suggests that the client is achieving resolution of grief? 1. "I am starting a new life, so I have removed all of the pictures from the wall that remind me of my spouse." 2. "I'm so lonely and I'm not sure life is worth living now." 3. "Although it hasn't been easy, I accept the loss of my soul mate." 4. "If only we had spent more time together before the illness got so severe."

3. Correct: This client has begun to achieve resolution of grief by walking through the tasks of mourning: to accept the reality of the loss, to experience the pain of grief, to adjust to an environment in which the deceased is missing, and to withdraw emotional energy and perhaps invest in another relationship. 1. Incorrect: This client is still in the grieving process. Behavioral manifestations of grief include crying, withdrawal, avoiding reminders of the deceased, seeking or carrying reminders of the deceased, over activity, and a variety of changes in relationships with other people. 2. Incorrect: This client is still in the grieving process. The manifestations of grief can vary widely. This client has not accepted the reality of the loss, invested in relationships with other nor allowed themselves to go through the process of grief.4. Incorrect: This client is still in the grieving process.

An alcoholic client was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What is the priority nursing intervention at this time? 1. Hide the client's clothes so that he cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave.

4. Correct: Always assess why the client wishes to leave first. This will provide an opportunity to attempt to fix the problem and possibly revise the client's decision. 1., 2. & 3. Incorrect: Confining a client against his or her wishes, except in an emergency situation, may be considered false imprisonment. Actions that may invoke these charges include: locking an individual in a room, taking a person's clothes for the purposes of detainment against his or her will, and retaining in mechanical restraints a competent voluntary client who demands to be released.

The nurse is caring for a client diagnosed with Obsessive Compulsive Disorder (OCD). Which statement, made by the client, would be the best indicator of improvement? 1. "My friends don't know I have OCD." 2. "I only do my hand washing to reward myself when I am good." 3. "I know my thoughts and behaviors aren't very normal." 4. "I have more control over my thoughts and behaviors."

4. Correct: Control is an issue for those with OCD. Appropriate goals for this client would be to control unwanted behaviors and thoughts. 1. Incorrect: Doesn't indicate control over behavior. Not telling their friends indicates the client is ashamed of disease and doesn't show improvement. 2. Incorrect: The behaviors are not reward for good behavior; they are utilized to decrease anxiety. Compulsions are ritualistic behavior that the individual feels driven to perform in an attempt to reduce anxiety. 3. Incorrect: Clients with OCD are aware their behavior is not normal, so this would not be an indicator of improvement. Obsessions are defined as thoughts, impulses or images that persist and recur, so that they cannot be dismissed from the mind.

The nurse is talking with several high school students after a classmate from their school died in a motor vehicular accident. Which statement by the nurse is therapeutic? 1. "Sometimes bad things happen to people we care about." 2. "I was so upset that the student who died had been drinking." 3. "Why are you angry? Tell me how you feel about losing your friend." 4. "What would you like to talk about concerning the loss of your classmate?"

4. Correct: The therapeutic communication technique of giving broad openings will allow the students to move the topic of the death of their classmate in the direction of their choice. The students will feel more freedom to communicate with the nurse and the other students. 1. Incorrect: The high school students are experiencing the grief process due the death of one of their classmates. The nurse is showing a lack of understanding about the feelings of the students. The students will not experience any relief from their grief by stating that others have lost persons they cared about. This statement is an example of the nontherapeutic technique of belittling feelings expressed. 2. Incorrect: The nurse is utilizing the nontherapeutic communication technique of expressing disapproval. The students may respond by being unsettled or resentful at the nurse. This will block the communication pathway, and the students will not be receptive to what the nurse as the group leader is communicating. 3. Incorrect: The nurse is stating that the students are angry without the students sharing their feelings. Beginning the statement with the word why implies that the nurse already has identified what emotion the students have. This presumption of anger may not be correct, and students may not express their feelings freely. This is the nontherapeutic communication of requesting explanation.

The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety

Correct: Yes, this is how they deal with anxiety. The obsession causes the anxiety such as a thought that can't be dismissed from the mind. The ritualistic behavior that the client is driven to perform is an attempt to reduce anxiety. The compulsive act temporarily reduces high levels of anxiety. 1. Incorrect: No, is phobia that deals with fears. A phobia is an excessive and irrational fear reaction. If you have a phobia you may experience a deep sense of dread or panic when you encounter the source of your fear. 2. Incorrect: OCD is not about depression. Depression is a mood disorder that causes persistent feelings of sadness and loss of interest. Not the origin of OCD. 3. Incorrect: Delusions are not associated with OCD. Delusions are most often defined as false fixed beliefs that cannot be corrected by reasoning.

The client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? 1. Ask the client to take a walk with you and make another pot of coffee. 2. Ask the client to reflect on their behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when they are interrupted. 4. Tell the client to perform jumping jacks and count out loud.

1. Correct: Yes, get them away from the group and do something purposeful. Purposeful activities help the client use energy and focus on something. Distractibility is the nurse's most effective tool. 2. Incorrect: That is embarrassing and humiliating to the client. Singling out the client during group activity, does not fix the problem. This may lead to arguing and escalate the client's mania. 3. Incorrect: Sometimes this will be helpful during times of therapy, but the client is manic at this time. They may not believe them. Also, the client may be aggressive toward other group members. 4. Incorrect: This is getting them active, but the group will be interrupted by this behavior. Do not let the client continue with this attention seeking behavior. Remove the client from the group activity. The purpose of the group is to work toward a common goal. The client performing jumping jacks is not working toward a common goal.

Which action should the nurse take for a client who is of the Roman Catholic faith? 1. Notifying dietary that all food is required to be kosher. 2. Administering last rites to the client if death is imminent. 3. Ensuring there is no meat served with meals on Fridays during Lent. 4. Positioning the dying client's bed facing Mecca (east).

3. Correct: Avoiding eating meat on Fridays during Lent is a practice of those of the Catholic faith; this action demonstrates cultural sensitivity and spiritual support. 1. Incorrect: Kosher food is required in Judaism. Kosher diet is based on a section of Jewish law which identifies which foods can be eaten. 2. Incorrect: A priest, not the nurse would administer last rites of the sick. Only a priest has been trained to celebrate the Sacrament of Reconciliation and the Anointing of the sick (last rites). 4. Incorrect: Persons of the Muslim (Islam) faith who are dying want their body turned to Mecca (east). The body or the heels should be positioned to the Mecca (east).

A five year old is in kindergarten and goes to the nurse's office where she reports a "stomachache". While there, the nurse observes that the child has a large bruise on her upper arm and bruises on both ears. What should the nurse do first? 1. Ask the student about the bruises on the arms and ears. 2. Do nothing as bruises are common in 5 year old children. 3. Report the injuries immediately to the parents. 4. Discuss the findings with the child's teacher.

1. Correct: Assessment and gathering information should be the first response. The child may have experienced a severe accident that does not indicate abuse. The nurse needs further information before assuming abuse in the family. 2. Incorrect: Bruises on the upper arms and ears are not typical for a child of this age. 3. Incorrect: The parents may have inflicted the injuries on the child which will be important to assess later, but is not the first action for the nurse. 4. Incorrect: The nurse should discuss the observations with the teacher to determine if other indicators of abuse are present. The first step is to communicate with the child and further assess the situation.

A client with a history of schizophrenia was admitted with abdominal pain and has been undergoing diagnostic tests. When the nurse enters the room, the client is alone and looking at the wall and states "Why should I hurt them?" What would be an appropriate intervention by the nurse? Select all that apply 1. Directly ask the client "Are you hearing voices?" 2. State "Tell the voice that you do not want to hurt anyone." 3. Focus on reality based topics of conversation. 4. Observe for signs of increasing anxiety in the client. 5. Tell the client "You know that you are not being told to hurt someone." 6. Inquire about what the client believes he or she is being told to do.

1., 3., 4., & 6. Correct: Did you pick up on the cues that this client is experiencing auditory hallucinations? The most obvious cues that this client is hallucinating are the verbal response when there is no one present and the client is looking at the wall when responding. When you think a client is hallucinating, you should directly ask the client about the hallucination by asking such questions as: "Are you hearing voices?" In order to intervene with a client who is experiencing a hallucination, you should focus on reality-based diversions including reality-based topics of conversation. Also, hallucinations can be anxiety producing for clients, so you should observe for any signs of increasing anxiety, which can be a sign that the hallucinations are increasing. The nurse can explore the hallucination experience with this client by asking directly "What are the voices telling you to do?" Another way to specifically explore the hallucination with this client is to ask if they are being told to do something that would cause harm to someone. 2. Incorrect: You never want to react to the client's hallucinations as if they are real. In this case, you would not tell the client to talk back to the "voices" and argue with them or discuss things as if the voices are real. 5. Incorrect: You do not want to negate the client's hallucination experience, but you do offer your own perception that you do not hear the voices. Telling the client that they are not being told something would only escalate their anxiety and perhaps cause them to become irritable or upset. The voices are "real" to the client.

The driver of a motor vehicle was driving while intoxicated with a friend in the passenger seat. Both clients are admitted to the Intensive Care Unit. The nurse is caring for the driver of the vehicle who states, "I'm so scared. What if the car accident is my fault and my friend dies?" What is the most appropriate response from the nurse? 1. "I wouldn't worry about that; everything will be all right." 2. "You are worried that you may be responsible for your friend's condition?" 3. "How come you were drinking and driving?" 4. "Let's not talk about that right now."

2. Correct: This type of therapeutic communication is called restating. By repeating the client's statement, the nurse expresses an understanding of what the client said. Restating also gives the client the chance to clarify or continue his thoughts. 1. Incorrect: This statement gives the client false reassurance. It devalues the client's feelings and may discourage the client from expressing further feelings. 3. Incorrect: This statement is probing and causes the client to feel defensive. 4. Incorrect: This statement rejects the client's ideas and feelings; this may lead to decreased interaction with the nurse due to fear of future rejection.

A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct? 1. Ask the client to sit for a few minutes. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Inform the client that their actions are unacceptable.

3. Correct: Yes! Get them active. Redirect their activity. This is too much for them right now. 1. Incorrect: The client is agitated, shouting...Now do you think it is reasonable to get them to sit and think this will decrease their anxiety? No! 2. Incorrect: Setting limits is good, but here the client is disruptive. 4. Incorrect: The client is in an agitated paranoia state. Telling the client that their behavior is unacceptable will not change the behavior.

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's Disease (AD). What signs should the nurse include? Select all that apply 1. Mild disorientation 2. Difficulty with words and numbers 3. Poor personal hygiene 4. Agitation 5. Visual agnosia 6. Dysgraphia

1. & 2. Correct: Early warning signs of Alzheimer's Disease include mild disorientation and difficulty with words and numbers. This client may have difficulty recognizing numbers or doing basic calculations. The person may begin to have trouble with words. 3. Incorrect: Poor personal hygiene occurs as Alzheimer's Disease progresses due to ongoing loss of neurons. 4. Incorrect: Behavioral manifestations occur later in the disease process as a result of changes that take place within the brain. They are not intentional or controllable by the person with this disease. 5. Incorrect: With progression of this disease, additional cognitive impairments are noted, including visual agnosia, which is the inability to recognize objects by sight. 6. Incorrect: Dysgraphia is defined as difficulty communicating via writing and occurs during disease progression.

A long-term care nurse is planning care for a newly admitted client diagnosed with alzheimer's disease. What should the nurse include in the plan of care? Select all that apply 1. Assess client's ability to perform self care. 2. Educate nursing staff to help client in all activities of daily living. 3. Separate tasks into small manageable steps. 4. Relieve family members of stress by advising them to visit 1 time per week. 5. Have nursing staff spend time talking and listening to client.

1., 3., & 5. Correct: All of these should be included in this client's plan of care. Assess the client's ability to perform self care and allow client to perform any care he/she is capable of doing. Separating tasks into small steps helps the client remember the steps. Plan for staff to spend some time talking and listening to the client. 2. Incorrect: Client independence should be promoted. Teach staff to promote self care and independence. If the client is capable of performing activities of daily living, then the client should be encouraged and allowed to do so. 4. Incorrect: Encourage family to visit to maintain socialization. We do not want to limit their visitation time. This will not be helpful to relieve family stress.

The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? Select all that apply 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.

3., & 4. Correct: When a person is confused and has dementia, we need to communicate in a simple manner. Provide simple directions or instructions, short sentences, and gestures. Use pictures. Do not give instructions on multiple things. Do not argue, criticize, or correct the client. This can increase anxiety, agitation, and anger. 1. Incorrect: Use a gentle touch rather than a firm touch with these clients. You do not want to be confrontational or evoke fear in the client. 2. Incorrect: Be flexible. If one approach does not work, try another. 5. Incorrect: Avoid questions or topics that require extensive thought, memory, or words. This can increase anxiety, frustration, and agitation. 6. Incorrect: Do not require or force participation in activities or events. This can increase anxiety, frustration, and agitation.

Which statement made by the nurse is therapeutic when the client, who has experienced deficits from a recent cerebral vascular accident, tearfully states, "I can no longer care for myself."? 1. "Right now, I am going to help you get dressed and eat breakfast." 2. "You have to focus on the positive things in your life." 3. "It is hard not to be able to care for yourself." 4. "All you need is some physical therapy and you will be back to normal soon."

3. Correct: This statement shows a recognition of the client's feelings. 1. Incorrect: Changing the topic is a nontherapeutic response. 2. Incorrect: This statement deflects the client's feelings. 4. Incorrect: This statement is condescending and may not be true for this client.

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

3. Correct: Recently increased care demands place a greater strain on the time and money required to provide care. The changing level of demands may increase the risk of abuse. 1. Incorrect: The adult child has been successfully managing the children and the elderly client up to this point. The physiological changes of incontinence for the client and increased care required for this is the most significant risk factor that could cause abuse. 2. Incorrect: The divorce is not a recently added stressor so is not a current change or stressor that would trigger the risk for abuse. 4. Incorrect: There is no mention of loneliness as a possible stressor in this scenario. This would be reading into the question and assuming incorrect data.

A client experiencing a manic episode tells the night nurse, "If you do not go to bed with me, I am going to have you fired." What is the nurse's best response? 1. "That is inappropriate behavior. You will have to go to your room if you say that again." 2. "You've got to be kidding! You can't get me fired for not sleeping with you." 3. "I don't want to hear that again! Don't ever say that again." 4. "I can see that you need attention, but this is not the way to get it."

1. Correct: Set limits on manipulative behaviors. Explain what is expected and what the consequences are if limits are violated. The nurse needs to set limits on and control dangerous behavior. 2. Incorrect: Do not argue with the client. The behavior of a manic client is often aimed at decreasing the effectiveness of staff control. 3. Incorrect: This is confrontational and does not set appropriate boundaries or consequences. The manic client can elicit numerous intense emotions even in the nurse caring for them. 4. Incorrect: Remember to set limits without demeaning the client, and do not encourage this behavior. Don't acknowledge that the client is seeking attention.

A military veteran with a history of post-traumatic stress disorder (PTSD) has arrived at the Crisis Center reporting an increase in nightmares, depression and anxiety. The nurse is aware the client would obtain the most immediate relief with what intervention? 1. Increase dose of antianxiety medications. 2. Greater family support interaction. 3. Referral to community support group. 4. Opportunity to verbalize memories.

4. Correct: PTSD is an emotional response to a traumatic event, usually beginning within several months of the event, although it can be delayed for years. When a client in severe distress arrives at the Crisis Center, the priority intervention must focus on relief of client's symptoms. The best non-invasive method to alleviate symptoms is encouraging the client to verbalize both memories and feelings. Though some individuals want to forget the incident, most clients experience a decrease in anxiety by discussing the event. 1. Incorrect: While it is true that a component of PTSD treatment involves either antianxiety or antidepressant medications, these drugs take several weeks to become effective. The nurse needs to provide an intervention that will give the client more immediate relief. 2. Incorrect: Clients with PTSD generally do benefit from family support and interaction, especially during periods of increased symptoms. However, the question requests a nursingaction that would assist the client in crisis now. 3. Incorrect: Support groups are always beneficial for individuals experiencing long term problems, and are an invaluable resource to both client and family members. However, this question asks how the Crisis Center nurse could intervene to assist at this moment. This choice is a long term solution.

The nurse, caring for a client diagnosed with Alzheimer's Disease (AD), notices the client becoming agitated. What nursing strategies would be appropriate for the nurse to initiate? Select all that apply 1. Provide a snack for the client. 2. Tell the client to stop the unwanted behavior. 3. Take client for a walk. 4. Ask the client to sweep the floor. 5. Inform the client that restraints will be used if behavior continues. 6. Turn on the client's favorite music.

1., 3., 4., & 6. Correct: Nursing strategies that address difficult behavior include redirection, distraction, and reassurance as provided by these correct interventions. 2. Incorrect: These behaviors are often unpredictable and not intentional. Do not challenge the client, use redirection, distraction, and reassurance. 5. Incorrect: When dealing with a difficult client, do not threaten to restrain the client or call the primary healthcare provider. A calming family member can be asked to stay with the client until the client becomes calmer.

The primary healthcare provider (PHP) informs a client that cancer was identified in the large intestine, and surgery should be scheduled as soon as possible. After the PHP leaves the room, the client turns their head away from the nurse and begins to cry. Which action by the nurse is appropriate? 1. Exit the room quietly. 2. Touch the client's shoulder. 3. Notify the client's family. 4. Begin preoperative instruction.

2. Correct: When the nurse touched the client's shoulder, the nurse is utilizing the therapeutic communication technique of touch. Touching the client conveys caring and is a supportive action. This is especially important for the vulnerable client who has received upsetting information. 1. Incorrect: By exiting the room the nurse is communicating nonverbally that the nurse does not desire to talk to the client. The client could also perceive that the nurse leaving is abandonment during the stress of learning about the cancer diagnosis. 3. Incorrect: Notifying the client's family about the diagnosis without permission from the client is a Health Insurance Portability and Accountability Act (HIPAA) violation. The HIPAA Privacy Rule establishes national standards to protect individuals' medical record and personal health information. This action also would not assist the client during this stressful period. 4. Incorrect: The client was just informed of the diagnosis of cancer in the large intestine. Preoperative instructions should not be communicated to the client when the client's stress level is elevated. The client will not be able to focus or retain the preoperative instructions.

An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is mosttherapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"

4. CORRECT: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress. 1. INCORRECT: The nurse is dismissing the client's right to experience a specific emotion, rather than actively seeking the reason behind those feelings. The nurse is not utilizing appropriate communication techniques. 2. INCORRECT: This tactless response focuses on the orders provided by the primary healthcare provider, rather than the client's expressed concerns. Such a comment by the nurse is non-therapeutic because it ignores the client's psychological needs. 3. INCORRECT: Although the nurse offers a solution to the client, there is no chance for the client to verbalize feelings and concerns. It is more important to present the client with the therapeutic opportunity to discuss fears.

Which type of comment should the nurse expect from a client exhibiting clang associations? 1. Concrete explanations for abstract ideas 2. Reporting very small details when explaining something 3. Comments that are illogically associated 4. Use of rhyming words when talking

4. Correct: The client may use rhyming words, such as dog, bog, cog, jog. It is the meaningless rhyming of words, often in a forceful manner. 1. Incorrect: This type of comment indicates concrete thought. Concrete thinking is characterized by immediate experience rather than abstraction. 2. Incorrect: This type of comment indicates circumstantiality. This is characterized by indirectness and delay before the person gets to the point or answers a question. The person gets caught up in countless details and explanations. 3. Incorrect: These indicate loose associations or derailment. It is a sequence of unrelated or only remotely related ideas.

The psychiatric nurse notices a new client sitting alone in the dayroom, shaking and muttering indistinguishable words. What statement by the nurse is appropriate? 1. "Who are you talking to?" 2. "You look like you are cold." 3. "It is always cold in this room." 4. "Do you want to get a sweater?"

2. CORRECT: The scenario does not indicate the client's diagnosis but mentions only physical symptoms. Without more detailed information about the client, the nurse's best approach is to address the visible symptoms in a therapeutic manner. The nurse is focusing on the client and sharing the perception the shaking may indicate feeling cold. This is a good initial therapeutic interaction. 1. INCORRECT: Demanding an explanation from the client is not an appropriate therapeutic technique, except for threatened personal harm. Quite often the client is unable to provide a response to a direct inquiry or may feel threatened by such an authoritative question. 3. INCORRECT: This comment by the nurse does not focus on the client or any current needs. While the nurse may be inferring the room is cold based on the client shaking, this is a closed statement that does not encourage the client to respond. 4. INCORRECT: This question is closed and non-therapeutic. Additionally, the focus assumes the client is cold and needs a sweater, rather than attempting to initiate interactive communication.

The nurse is talking with the spouse of an alcoholic client. Which statement by the client's spouse is evidence of codependent behavior? 1. "I frequently tell my spuse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."

2. Correct: The spouse is attempting to please the alcoholic client. Codependent people are people pleasers, and they make excuses for others. The spouse is enabling the client to continue to drink. The spouse may feel keeping the client from driving while intoxicated will keep people safe. 1. Incorrect: This is a response by a person who is not codependent. This person is not afraid to show feelings and does not deny that there is a problem. 3. Incorrect: By not drinking with the client, the spouse shows that this behavior is not condoned.4. Incorrect: Again, the spouse does not deny a problem and wants to help the client quit rather than making excuses.

An elderly client comes to the clinic for a check-up. The client's daughter tells the nurse that her father's dementia symptoms become increasingly more difficult to handle in the evening. How would the nurse document this symptom? 1. Confabulation 2. Apraxia 3. Pseudodementia 4. Sundowning

4. Correct: Sundowning is a phenomenon where symptoms seem to worsen in the late afternoon and evening. Communication becomes more difficult, with increasing loss of language skills. Institutional care is usually required at this stage. 1. Incorrect: Confabulation is the term used for creating imaginary events to fill in memory gaps. This is sometimes associated with dementia, but more often with disorders like Korsakoff's syndrome, traumatic brain injuries or tumors. 2. Incorrect: Apraxia is the term used for the inability to carry out motor activities despite intact motor function. 3. Incorrect: Pseudodementia is depression. Depression is the most common mental illness in the elderly, but it is often misdiagnosed and treated inadequately. Cognitive symptoms of depression may mimic dementia.