Saunders Mental Health

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention? 1. Feed, bathe, and dress the client as needed until the client can perform these activities independently. 2. Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. 3. Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for the activities of daily living. 4. Have the client's peers confront the client about how their noncompliance with addressing activities of daily living affects the milieu.

1

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? 1. Weight loss 2. Sleep pattern 3. Medication compliance 4. Onset of the crying spells

1

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? 1. Denial 2. Projection 3. Regression 4. Rationalization

1

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note? 1. The client presents a harm to self. 2. The client requested the admission. 3. The client consented to the admission. 4. The client provided written application to the facility for admission.

1

A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action should the nurse implement? 1. Remain with the client at all times. 2. Request that the client's peer remain with the client at all times. 3. Remove the client's clothing and place the client in a hospital gown. 4. Place the client in a seclusion room where all dangerous articles are removed.

1

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse? 1. Agoraphobia 2. Hematophobia 3. Claustrophobia 4. Hypochondriasis

1

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house ready to plan our activities for the day." Which is the therapeutic nursing response? 1. "It must be hard to accept that she has passed away." 2. "Are you saying that she made all the social plans for you?" 3. "Focus on the fact that her suffering is over and that she had a good life with you." 4. "Try to focus on the fact that you have three wonderful children and that you and your wife loved one another for years."

1

A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response? 1. "What do you mean by that?" 2. "Did you have a bad night?" 3. "You are just tired, and you don't really mean that." 4. "Your family would be upset if they heard you say that."

1

A client who was hospitalized for depression is being prepared by the nurse for discharge. In evaluating the coping strategies learned during hospitalization, the nurse should recognize which statement by the client is an indication that further teaching is needed? 1. "I know that I won't become depressed again." 2. "I know that I can't be all things to all people." 3. "I need to take my medications just as prescribed." 4. "I have learned ways to deal with the stresses in my life."

1

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior? 1. The client is at increased risk for suicide. 2. The client is dealing with pertinent issues. 3. The client may need some time off the unit. 4. The client is responding normally to hospitalization.

1

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Tell the client that she cannot return to this hospital again if she leaves now. 4. Restrain the client until the primary health care provider (PHCP) can be reached.

1

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention? 1. Escort the manic client to his or her room. 2. Orient the client to time, person, and place. 3. Tell the client that the behavior is not appropriate. 4. Tell the client that smoking privileges are revoked for 24 hours.

1

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action should the nurse perform? 1. Inform the client that she is being secluded to help regain control of herself. 2. Remain silent because verbal interaction would be too stimulating for the client. 3. Tell the client that she will be allowed to rejoin the others when she can behave. 4. Determine whether the client understands the reason that the seclusion is necessary.

1

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which nursing action should the nurse do first? 1. Take the client to a quiet room. 2. Teach the client how to take deep breaths. 3. Ask the client to describe the events of the accident. 4. Ask the client to talk to the police about what she witnessed.

1

An unlicensed assistive personnel (UAP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the UAP indicates to the nurse that the UAP understands suicide? 1. "Discussing suicide with a client is not harmful." 2. "Those clients who talk about suicide never do it." 3. "Depressed clients are the only people who commit suicide." 4. "When a person talks about making suicide threats, the person is seeking attention.

1

During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1. A fear of leaving the house 2. A fear of riding in elevators 3. A fear of speaking in public 4. A fear of uncleanliness and the need to bathe every hour

1

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate? 1. "What do you and your husband believe is the right thing for your children?" 2. "By all means have them attend. Not to do so would promote postmortem grief." 3. "It's a difficult decision, but given their young age, perhaps omitting the wake and just including the funeral should be best." 4. "I agree with your mother-in-law. Your mother-in-law is upset enough as it is. Tell your children that their grandfather is in heaven.

1

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common for alcoholics."1

1

The nurse employed in a psychiatric unit receives a client assignment for the day. Which client assigned to the nurse is at the highest risk for committing suicide? 1. A client with severe depression and terminal cancer 2. A client who just had an argument with another client 3. A newly divorced client who has custody of the children 4. A client with mild depression and severe cognitive deficits

1

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least likely to be helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Maintain a safe distance with the client. 4. Assist the client to an area that is quiet.

1

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates a need for further teaching about this self-help group? 1. "The leader of this self-help group is the nurse or psychiatrist." 2. "The members of this self-help group provide support to each other." 3. "This self-help group is designed to serve people who have a common problem." 4. "In this self-help group, people who have a similar problem are able to help others."

1

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit? 1. Place the client on one-to-one suicide precautions. 2. Ask the client to immediately report any suicidal thoughts. 3. Place the client on suicide precautions with 15-minute checks. 4. Ask the unlicensed assistive personnel (UAP) to check the client's vital signs.

1

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? 1. Open-ended questions and silence 2. Focusing on self-disclosure regarding food preferences 3. Stating the reasons that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition

1

The nurse is assigned to care for a client who is suicidal. Which nursing intervention is appropriate for this client? 1. Provide authority, action, and participation. 2. Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Provide hope and reassurance that the problems will resolve themselves.

1

The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions, with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking that the client to report suicidal thoughts immediately

1

The nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse should expect to note which behavior in the client? 1. Slowed walking and talking 2. Rapid pacing back and forth 3. Verbalization of increasingly angry feelings 4. Standing without moving, as if a statue, for long periods

1

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids? 1. Fever, yawning, irritability, diaphoresis, and diarrhea 2. Increased appetite, irritability, anxiety, and restlessness 3. Depressed feelings, high drug craving, fatigue, agitation, and disorientation 4. Tachycardia, mild hypertension, fever, sweating, nausea, vomiting, and marked tremors

1

The nurse is caring for a client with seasonal affective disorder (SAD). Which type of therapy is considered a first-line treatment for this disorder? 1. Light therapy 2. Melatonin therapy 3. Antidepressant therapy 4. Cognitive behavioral therapy (CBT)

1

The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client? 1. "It seems as if you or your daughter feel regret?" 2. "Oh well, we can only love our children, do our very best, and hope they reflect our upbringing." 3. "Don't blame yourself. You seem to have been very caring. Some people just turn out evil despite all we do for them." 4. "Do I hear you saying that you feel that your son's behavior was caused by the indulgence he received from his sister?"

1

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff with caring for the client in a controlled environment. 4. Offer the client a less-stimulating area to calm down and gain control.

1

The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client? 1. Ping-pong 2. A paint-by-number activity 3. A brown bag lunch and a book review 4. A deep breathing and progressive relaxation group

1

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" 3. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." 4. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"

1

The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching? 1. "I am the nurse and, as such, I'll have you know that all information is kept confidential." 2. "I realize this is hard for you to speak about, but anything you tell me will be kept strictly confidential." 3. "I know that some of these questions are difficult for you, but as the nurse, I must legally respect your confidentiality." 4. "I understand you must hate being asked these sorts of questions, but I promise anything you tell me will be kept private."

1

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? 1. The client gives away a DVD and a cherished autographed picture of the performer. 2. The client runs out of the therapy group swearing at the group leader and then runs to their room. 3. The client gets angry with her roommate when the roommate borrows their clothes without asking. 4. The client becomes angry while speaking on their cell phone and slams the phone down on her bed.

1

Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety? 1. Stay with the client until the medication becomes effective. 2. Crush the medication and disguise it in the client's meal items. 3. Ask the client why he or she is experiencing so much anxiety. 4. Explain that restricting alcohol is not necessary while taking this medication.

1

Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply. 1. Poor limit setting 2. Staff inexperience 3. Provocative or controlling staff 4. Arbitrary revocation of privileges 5. Predominantly male staff members 6. Doors to client's rooms that open from inside to out

1,2,3,4

The nurse is caring for a client with long-term Alzheimer's disease (AD). Which are some of the behavioral manifestations the nurse should expect to observe? Select all that apply. 1. Apraxia 2. Aphasia 3. Agnosia 4. Hyperorality 5. Somatization 6. Operant conditioning

1,2,3,4

The nurse is caring for a client who is diagnosed with anxiety. The nurse knows that according to Hildegard Peplau, there are different levels of anxiety that include which? Select all that apply. 1. Mild 2. Panic 3. Severe 4. Rational 5. Moderate 6. Hallucinatory

1,2,3,5

The nursing instructor is helping students learn about bioethics, which is the study of specific ethical questions that arise in health care. The instructor reviews with the students which basic principles of bioethics? Select all that apply. 1. Autonomy: Respecting the rights of others to make their own decisions (e.g., acknowledging the client's right to refuse medication promotes autonomy) 2. Beneficence: The duty to act to benefit or promote the good of others (e.g., spending extra time to help calm an extremely anxious client) 3. Veracity: One's duty to communicate truthfully (e.g., describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way) 4. Confidentiality: The duty to keep the client's history and health care private (e.g., not sharing client information with anyone who is not providing direct care to the client) 5. Fidelity (nonmaleficence): Maintaining loyalty and commitment to the client and doing no wrong to the client (e.g., maintaining expertise in nursing skill through nursing education) 6. Justice: The duty to distribute resources or care equally, regardless of personal attributes (e.g., an ICU nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm)

1,2,3,5,6

The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply. 1. Mutual learning 2. Increased feedback 3. Instilling a sense of belonging 4. Acutely manic clients can attend 5. Opportunity to practice individual roles 6. An opportunity to practice new skills in a relatively safe environment

1,2,3,6

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply. 1. "My husband always brings me flowers and apologizes after he hits me." 2. "I have bruises all over my body. I am frequently clumsy and fall a lot." 3. "My partner and I do almost everything together; we have the same hobbies." 4. "My boyfriend yells and accuses me of having an affair if I am late after work." 5. "My husband stays out all night drinking and then passes out on the couch."

1,2,4

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen. The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply. 1. Making nutritious snacks available anytime 2. Providing meals on an isolation tray that contains plastic utensils 3. Removing unit privileges, based on her willingness to eat appropriately 4. Ensuring that her diet consists of bland, easy-to-digest foods and beverages 5. Explaining that while being thin is desirable, she needs to eat to be healthy

1,2,4

A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply. 1. Depression 2. Substance abuse 3. Potential for violence 4. Adverse childhood events 5. Posttraumatic stress disorder (PTSD) 6. Obsessive-compulsive disorder (OCD)

1,2,4,5

The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply. 1. Zoophobia 2. Xenophobia 3. Alonophobia 4. Agoraphobia 5. Glossophobia 6. Germophobia

1,2,4,5,

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Giving advice, approval, or disapproval 6. Providing acknowledgment and feedback

1,2,4,6

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Follow through about the consequences of behavior in a nonpunitive manner. 3. Ensure that the client knows that he or she is not in charge of the nursing unit. 4. Assist the client with developing a means of setting limits on personal behavior. 5. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

1,2,4,6,

The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply. 1. Autocratic leader 2. Democratic leader 3. Independent leader 4. Conservative leader 5. Laissez-faire leader 6. Problem-solving leader

1,2,5

The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply. 1. Respond to stimuli 2. Conduct electrical impulses 3. Allow inward flow of sodium 4. Change membrane permeability 5. Release chemicals called neurotransmitters 6. Inhibit actions leading to a negative outcome

1,2,5

The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply. 1. Refer to hallucinations as if they are real. 2. Ask the client directly about the hallucinations. 3. Don't focus on reality-based, "here-and-now" activities such as conversations or simple projects. 4. Discourage the use of competing auditory stimuli such as listening to music through headphones. 5. Watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, muttering, or talking to self. 6. Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accusing voices.

1,2,5,6

A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply. 1. Cutoffs 2. Conflict 3. Symbiotic 4. Mutualistic 5. Interpersonal 6. Over involvement

1,2,6

The nurse is admitting a victim abuse client to the mental health unit with a diagnosis of severe anxiety. The nurse notes which signs/symptoms that indicate it is difficult for the victim to talk about the situation? Select all that apply. 1. Hesitation 2. Lack of eye contact 3. Speaking crude words 4. Using assertive communication 5. Respecting one's personal space 6. Using vague statements such as, "It's been rough lately."

1,2,6

An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply. 1. Is it in the best interest of society? 2. Is it covered by the client's insurance? 3. Does its use violate the client's rights? 4. Is this therapy in the best interest of the client? 5. How many days before positive results are seen? 6. Has the client's family given permission for this therapy?

1,3,4

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply. 1. Looks at old snapshots of family 2. Constantly neglects personal grooming 3. Visits the spouse's grave once a month 4. Visits the senior citizens' center once a month 5. Prefers to spend time alone and avoids contact with others

1,3,4

The nurse is assessing a client who has been diagnosed with Alzheimer's disease. The nurse knows that in the initial stages the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease? Select all that apply. 1. Denial 2. Confusion 3. Confabulation 4. Perseveration 5. Avoidance of questions 6. Repetition of phrases or behavior

1,3,4,5

The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? Select all that apply. 1. Paralysis 2. Skin rash 3. Blindness 4. Paresthesia 5. Movement disorder 6. Fractures noted on x-rays

1,3,4,5

The nurse is admitting a client who has a history of bipolar disorder to the hospital, and the primary health care provider has indicated that the client is currently in the manic phase. Which actions should the nurse include in the plan of care? Select all that apply. 1. Set limits on behavior. 2. Encourage group activities. 3. Distract or redirect the client. 4. Decrease environmental stimulation. 5. Provide information on medications. 6. Provide high caloric nutritional intake.

1,3,4,6

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Maintain an NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6. Provide reality orientation as appropriate.

1,3,4,6

Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply. 1. Medication management 2. Administering antidepressants 3. Monitoring and documenting behavioral changes 4. Notifying the health care provider of behavioral changes 5. Keeping the family involved in the client's plan of care 6. Planning care for the needs of those clients with mental illness

1,3,4,6

The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply. 1. Outlandish behaviors 2. Takes a shower every other day 3. Purposeless arousal and movement 4. Occasional episodes of mild depression 5. Grandiose delusions of being King Arthur 6. Incessant talking that includes sexual innuendos

1,3,5,6

The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply. 1. Rigidity 2. Hostility 3. Inflexibility 4. Adaptability 5. Repetitive thoughts 6. Ritualistic behavior

1,3,5,6

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply. 1. Promoting self-care and independence 2. Acting as an intermediary between the client and family 3. Accompanying the client to all group therapy sessions 4. Facilitating communication of distressing thoughts and feelings 5. Helping clients examine self-defeating behaviors and test alternatives 6. Assisting clients with problem solving to help facilitate activities of daily living

1,4,5,6

A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image. The client reports an extreme fear of public speaking. The nurse recognizes that this client is suffering from social phobia. Which are some other manifestations of social phobias? Select all that apply. 1. Performing badly on stage 2. Being afraid of strangers 3. Excessive anxiety when riding in an elevator 4. Looking awkward while eating or drinking in public 5. Not being able to answer questions in a classroom 6. Fear of saying something that sounds foolish in public

1,4,5,6,

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room

2

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose? 1. Clonidine 2. Disulfiram 3. Pyridoxine 4. Chlordiazepoxide

2

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority? 1. Encourage the client to move the arms. 2. Look for organic causes of the paralysis. 3. Encourage the client to talk about feelings. 4. Refer the client for a psychiatric evaluation

2

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1. "Do you think that having asthma will kill you?" 2. "You seem very distressed over learning you have asthma." 3. "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" 4. "Asthma is a very treatable condition. It is important to properly administer your medications. Let's practice with your inhalant

2

A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with which behavior? 1. Manipulation 2. Improvement 3. Attention seeking 4. Desire to be accepted

2

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? 1. A client with pneumonia 2. A client receiving diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtimes

2

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? 1. Move the client next to the nurse's station. 2. Use a night light and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room.

2

A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which to assist the client in meeting nutritional needs? 1. Provide meals as requested. 2. Provide small, frequent meals. 3. Give the client a large fruit basket for snacking. 4. Force foods to maintain minimum intake levels.

2

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client? 1. The client reports three additional coping strategies. 2. The client verbalizes stages of grief and plans to attend a community grief group. 3. The client verbalizes connections between the significant loss and low self-esteem. 4. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide.

2

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? 1. The mother should restrict the daughter's socializing time with her friends. 2. The mother should restrict the amount of chocolate and caffeine products in the home. 3. The mother should keep her daughter out of school until she can adjust to the school environment. 4. The mother should consider taking time off of work to help her daughter readjust to the home environment.

2

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? 1. "I know just how you feel because I lost my husband last summer." 2. "It's okay to grieve and be angry with your daughter and anyone else for a time." 3. "You need to focus on the many good years you both enjoyed together and move on." 4. "Although it's a troubling time for you, try to focus on your children and grandchildren."

2

During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't stop myself from wondering if he killed her, but the police have ruled him out as a suspect." Which statement reflects a therapeutic nursing response? 1. "I agree. What do you want to bet he did it?" 2. "Have you shared your concerns with the police?" 3. "I don't think that you should blame yourself one little bit." 4. "It feels terrible to lose a daughter. I'd have suspicions about him, too."

2

In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? 1. Plan nothing until the client asks to participate in the milieu. 2. Encourage the client to participate in a structured daily program of activities. 3. Give the client a menu of daily activities and insist that the client participate in all activities offered. 4. Provide an activity that is quiet and solitary in nature to avoid increased fatigue, such as drawing or reading a book.

2

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement? 1. "The technician is not going to hurt you but is going to help." 2. "Are you fearful and think that others may want to hurt you?" 3. "What makes you think that the technician wants to hurt you?" 4. "The technician will leave and come back later for your blood."

2

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note? 1. The client will be angry and will refuse care. 2. The client will participate in the treatment plan. 3. The client will be very resistant to treatment measures. 4. The client's family will be very resistant to treatment measures.

2

The nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. Which interpretation should the nurse make of these behaviors? 1. They are signs of depression. 2. They are expected reactions to a devastating event. 3. They are evidence that the client is a high suicide risk. 4. They are indicative of the need for hospital admission

2

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. Which best intervention should the nurse include when formulating a plan of care? 1. Increase socialization of the client with peers. 2. Avoid using a whisper voice in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? 1. Dilated pupils, tachycardia, and diaphoresis 2. Yawning, irritability, diaphoresis, cramps, and diarrhea 3. Tachycardia, hypertension, sweating, and marked tremors 4. Depressed feelings, high drug craving, fatigue, and agitation

2

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority? 1. Notifying the case worker of the family situation 2. Removing the client from any immediate danger 3. Adhering to the mandatory abuse reporting laws 4. Obtaining treatment for the abusing family member

2

The nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which activity would be most appropriate initially for this client? 1. Chess 2. Writing 3. Ping-pong 4. Basketball

2

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse? 1. "Why did you get started on these drugs?" 2. "How much do you use and what effect does it have on you?" 3. "How long did you think you could take these drugs without someone finding out?" 4. The nurse does not ask any questions because of fear that the client is in denial and will throw the nurse out of the room.

2

The nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, which nursing action would be appropriate? 1. Lower the head of the bed. 2. Notify the registered nurse. 3. Document the blood pressure. 4. Reassess the blood pressure in 30 minutes.

2

The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem? 1. Verbalize feelings of being unloved. 2. Maintain a well-groomed appearance. 3. Institute measures to prevent tooth decay. 4. Maintain a daily diary of negative feelings.

2

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? 1. A puzzle 2. Drawing 3. Checkers 4. Paint by number

2

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise vigorously.

2

The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion? 1. "I need to go to the bathroom." 2. "I don't feel like hurting myself anymore." 3. "I want to be alone for a while in my own room." 4. "I can't breathe in here. The walls are closing in on me."

2

The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client? 1. The client refuses to attend group therapy. 2. The client asks to meet with a lawyer to take care of unfinished business. 3. The client has an argument with her significant other during visiting hours. 4. The client swears at her roommate because she takes too much time in the bathroom.

2

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record."

2

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2

The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term? 1. Reality therapy 2. Psychodrama 3. Psychoanalytical therapy 4. Short-term psychotherapy

2

The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time? 1. "No, we can't talk right now; it is bedtime." 2. "I can see that you're upset. I'm willing to listen." 3. "Try to get some sleep, and we will talk in the morning." 4. "I don't have time right now, but I'll get someone else to talk to you."

2

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client with venting their feelings.

2

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." Which is the appropriate nursing response? 1. "You're not a loser—you are just sick right now." 2. "You don't think you can ever do anything right?" 3. "Everything will get better—just you wait and see." 4. "What makes you think you can't do anything right?"

2

he nurse is caring for a client with anorexia nervosa. The nurse planning care for the client recognizes that which manifestation is likely to be present? 1. Hypertension 2. Amenorrhea 3. Heat intolerance 4. Weight loss at or below 10%

2

A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." Although the nurse interprets this response as denial, which findings support a severe level of anxiety? Select all that apply. 1. Decreased pulse rate 2. Inability to think clearly 3. Inability to problem solve 4. Impulsively reacting to situations 5. Dry skin and mucous membranes

2,3,

The nurse is admitting a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis? Select all that apply. 1. Fear of heights 2. Being on a bridge 3. Riding in an elevator 4. Being alone at home 5. Travelling in an airplane 6. Refusing to speak in public

2,3,4,5

The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply. 1. Selective inattention 2. Oblivious to surroundings 3. Unable to focus on anything 4. Engaging in purposeless activity (walking around aimlessly) 5. Physical behavior may become erratic, uncoordinated, and impulsive. 6. Showing unproductive relief behavior (stomping, wringing hands, dropping things)

2,3,4,6

The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply. 1. Anxiety 2. Avoidance 3. Flashbacks 4. Hyperarousal 5. Reexperiencing 6. Difficulty concentrating

2,4,5

The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply. 1. Hypertension 2. A high achiever 3. Heat intolerance 4. Personality changes 5. Lanugo over the back and extremities

2,4,5

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply. 1. Hopelessness 2. Risk for injury 3. Acute delirium 4. Risk for infection 5. Risk for aspiration 6. Impaired verbal communication

2,4,5,6

client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply. 1. Eupnea 2. Irritability 3. Moist skin 4. Bradycardia 5. Hypertension 6. Gastrointestinal disturbances

2,5,6

A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. Which initial nursing action is appropriate? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation

3

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need? 1. Self-esteem 2. Physiological care 3. Safety and security 4. Love and belonging

3

A client has been hospitalized and has participated in substance abuse therapy group sessions. The client has consented to participate in Alcoholics Anonymous (AA) community groups after discharge. Which statement by the client best indicates to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use? 1. "I know I'm ready to be discharged; I feel like I can say no and leave a group of friends if they are drinking. No problem." 2. "I'll keep all my appointments and go to all my AA groups. I'll do everything I'm supposed to. Nothing will go wrong that way." 3. "I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people." 4. "This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family and friends will all help me like the people in this group have. They'll all help me; I know they will. They won't let me go back to my old ways."

3

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is an appropriate response by the nurse? 1. "Why do you believe this?" 2. "Tell me more about the details of your belief." 3. "I hear what you are saying, but I don't share your belief." 4. "If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute."

3

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action? 1. Approach the client in the hallway and insist that she go to her room. 2. Ask the other clients to ignore her behavior; eventually she will return to her room. 3. Quietly approach the client, escort her to her room, and assist her in getting dressed. 4. Confront the client on the inappropriateness of her behaviors and offer her a time-out.

3

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? 1. Request that a peer remain with the client at all times. 2. Remove the client's clothing and place the client in a hospital gown. 3. Assign a staff member to the client who will remain with him or her at all times. 4. Admit the client to a seclusion room where all potentially dangerous articles are removed.

3

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning? 1. The client is allowed to set the goals for the plan of care. 2. Letting the client act out and using the quiet room and restraints will be required initially. 3. Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition. 4. Refraining from pointing out the inconsistencies of the client's communication is essential to initial treatment.

3

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which? 1. More than one assault 2. Refusing to admit the rape-trauma episode 3. Reexperiencing recollections of the trauma 4. Imagining the use of force in a sexual situation

3

A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority? 1. Fear 2. Anxiety 3. Risk for aspiration 4. Altered health maintenance

3

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be 'cured'?" 4. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

3

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder

3

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse? 1. "When children are hurt the way you hurt them, people want you isolated." 2. "You're lucky it doesn't escalate into something pretty scary after your crime." 3. "You understand that people fear for their children, but you're feeling unfairly treated?" 4. "You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened."

3

A client with a diagnosis of a recurrent major depression, exhibiting psychotic features, is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse designs a plan of care that deals specifically with which aspect of the client's disorder? 1. Inability to care for self 2. Potential lack of appetite 3. Altered thought processes 4. Lack of knowledge regarding the depression

3

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed (PRN)

3

A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first? 1. Restrain the client. 2. Fill out an incident report. 3. Remove both clients to a separate, safe location. 4. Call the hospital risk management department.

3

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take? 1. Tell the client that this is not true and that we all have a purpose in life. 2. Remain with the client and sit in silence until the client verbalizes feelings. 3. Identify recent behaviors or accomplishments that demonstrate skill or ability. 4. Reassure the client that you know how the client is feeling and that things will get better.

3

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about what causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"

3

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which therapeutic response to the client? 1. "Why do you think this way?" 2. "Here, I'll taste the food for you." 3. "It must be frightening to you. Has something made you feel that your food is poisoned?" 4. "Your food is not poisoned. Our kitchen staff are nice people, and they are not allowed to poison people."

3

A mental health nurse caring for a client diagnosed with mania selects which activity for this client? 1. Painting in art therapy 2. Letter writing to family 3. Going for a walk with staff 4. Listening to favorite music

3

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? 1. Watch the behavior escalate before intervening. 2. Attempt to talk with the client to de-escalate the behavior. 3. Offer to take the client to an examination room until he or she can be treated. 4. Inform the client that he or she will be asked to leave if the behavior continues.

3

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills? 1. "I will be more careful to make sure that my father's needs are met." 2. "Now that my father is moving into my home, I will need to change my ways." 3. "I feel better able to care for my father now that I know where to obtain assistance." 4. "I am so sorry and embarrassed that the abusive event occurred. It won't happen again."

3

During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which response by the nurse would be therapeutic? 1. "Don't worry so much." 2. "Everything is going to be all right." 3. "I can see that you are upset about this. Let's talk about this some more." 4. "Why are you having so much trouble with maintaining realistic behavior?

3

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason? 1. Satisfaction with self 2. A form of functional coping 3. Protection from the risk of intimacy 4. Long-term lack of compliance with weight programs

3

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan? 1. Instructions regarding calling the police 2. Instructions regarding self-defense classes 3. Information regarding the location of shelters 4. Explaining the importance of leaving the violent situation3

3

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1. Call the client's family. 2. Persuade the client to stay a few more days. 3. Contact the primary health care provider (PHCP). 4. Tell the client that discharge is not possible at this time.

3

The nurse having strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by which action? 1. Getting angry at the supervisor 2. Slamming cupboards in the office 3. Telling a friend that this employee hates her 4. Apologizing and offering to go out to lunch together

3

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? 1. Identifying the client's ability to function 2. Identifying the client's potential for self-harm 3. Inquiring about the client's feelings that may affect coping 4. Inquiring about the client's perception of the cause of the neighbor's death

3

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? 1. The client's report of not eating or sleeping 2. The presence of bruises on the client's body 3. The client's report of self-destructive thoughts 4. The family member is disapproving of the treatment.

3

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone and intermittently check on them. 3. Sit beside the client in silence and verbalize occasional open-ended questions. 4. Take the client into the dayroom with other clients so they can help watch him.

3

The nurse is caring for a client diagnosed with somatic symptom disorder who continuously complains of a severe headache. Which interventions are most appropriate when planning care for this client? 1. Educate the client on alternative therapies to deal with pain. 2. Organize a family meeting between the client and family members to confront client's diagnosis. 3. Shift the focus from the client's somatic concerns to feelings and coping skills. 4. Focus on reality testing by telling the client that you do not believe that they are real.

3

The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client? 1. "If you didn't want our care, why did you come here?" 2. "Why are you being so difficult? I only want to help you." 3. "Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request." 4. "I will respect your feelings. I'll just leave this cup for you to collect your urine in. After breakfast, I will take more blood from you."

3

The nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which nursing response would be therapeutic? 1. "Only you can help?" 2. "You decided not to take your medication?" 3. "Do you recall needing to be hospitalized because you stopped your medication?" 4. "If you can make this wise observation, you probably don't need your medication any longer."

3

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? 1. "I know you feel 'they are out to get you,' but it's not true." 2. "I can hear the voice, and she wants you to come to dinner." 3. "Sometimes people hear things or voices others can't hear." 4. "I talked to the voices you're hearing and they won't hurt you now."

3

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need to always make the right decision

3

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? 1. Plan short-term goals. 2. Identify expected outcomes. 3. Assist with making appropriate referrals. 4. Assist with developing realistic solutions.

3

The nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which intervention? 1. Follow-up appointments 2. Providing the hospital phone number 3. Contracts and immediate available crisis resources 4. Encouraging the family to always be with the client

3

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? 1. "You need to stop that behavior now!" 2. "You will need to be placed in seclusion!" 3. "What is causing you to become agitated?" 4. "You will need to be restrained if you do not change your behavior."

3

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse? 1. Keep the client talking and allow the client to vent his feelings. 2. Use therapeutic communications, especially the reflection of feelings. 3. Keep the client talking and signal to another staff member to send help to the client. 4. Insist that the client give you his name and address so that you can get the police there immediately.

3

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder? 1. Monitor intake and output. 2. Monitor electrolyte levels. 3. Observe for excessive exercise. 4. Monitor for the use of laxatives and diuretics.

3

The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates that which actions should the parents take? 1. Enforcing strict rules 2. Discussing dinner plans 3. Planning a non-food related activity 4. Planning a game of volleyball on the beach

3

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement? 1. "Why don't you tell your husband about this?" 2. "This is not the best time to make that decision." 3. "What do you find difficult about this situation?" 4. "I agree with you. You should get out of this situation."

3

When caring for a client who has been raped, which intervention should the nurse implement during the examination? 1. Avoiding conversation about what the client has experienced 2. Minimizing physical contact as much as possible except during the exam 3. Explaining procedures to be completed and why the procedures are necessary 4. Offering to secure a prescription for an antianxiety medication before discharge

3

Which client is most likely at risk to become a victim of elder abuse? 1. A 75-year-old man with moderate hypertension 2. A 68-year-old man with newly diagnosed cataracts 3. A 90-year-old woman with advanced Alzheimer's disease 4. A 70-year-old woman with early diagnosed Lyme disease

3

While the nurse is providing care, a client angrily reports to the nurse that the primary health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which nursing response would likely be a barrier to further communication with the client? 1. "Can you tell me more about the misinformation?" 2. "I'm not sure what information you are referring to." 3. "The primary health care provider would never lie to you." 4. "Have you thought about talking to your doctor about this?

3

The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply. 1. Depression in an older person is rarely treatable. 2. Depression in an older person is considered a normal finding. 3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations.

3,4,5,

The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply. 1. Effects on environment 2. Dysfunctional behavior 3. Effects on problem solving 4. Effects on perceptual field 5. Healthy reaction necessary for survival 6. Physical and other defining characteristics

3,4,6

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply. 1. "I'll think about it." 2. "I'll go once, but if I don't like it, I won't go back." 3. "I'm going to do whatever it takes to get better." 4. "I'll do whatever I have to do to get out of this place." 5. "I'll go and participate as much as I can in the group discussions."

3,5

A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was 10 years old!" Which response is appropriate for the nurse to make? 1. "Why didn't you just report your parents for abuse?" 2. "What are you saying? Your parents abused you, so you got pregnant?" 3. "Sounds like you decided to have a baby so you'd have someone for yourself." 4. "It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?"

4

A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement made by the parent indicates a characteristic associated with child abuse? 1. "Once my child is potty-trained, I can still expect some accidents." 2. "A 2-year-old's vocabulary usually is limited to about 200 words." 3. "My child is expected to try to do things on her own such as dress." 4. "When I tell my child to do something once, I don't expect to have to repeat it."

4

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on which information? 1. The object of the crisis 2. The client's coping mechanisms 3. The presence of support systems 4. The physical condition of the client

4

A client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. The nurse takes which initial action? 1. Collect detailed information to develop a database. 2. Determine the client's history and past experiences with acting out. 3. Explain to the client that nothing is wrong and accept the behavior. 4. Provide for safety by recognizing the level of client anxiety and setting limits.

4

A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action? 1. Tell the client firmly to get off of the male client's lap. 2. Ask the client to go to her room and put some underwear on. 3. Tell the client that her privileges are suspended because of her behavior. 4. Approach the client quietly, take her to her room, and assist her in getting dressed.

4

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action? 1. Reinforces the safety policies with the client 2. Tells the client what a beautiful package it is 3. Permits the visitor to spend time alone with the client 4. Has the client open the gift with the nurse present

4

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition should be the initial choice? 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible. 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

4

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response? 1. "It sounds as though you need to speak to the psychiatrist." 2. "Perhaps you'd like to see the ECT room and speak to the staff." 3. "Your child has decided to have this treatment. You should be supportive of the decision." 4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

4

A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic? 1. "You must go. You have no choice." 2. "Life is short! Enjoy it while you can." 3. "Why don't you really want to attend?" 4. "Perhaps you could just enjoy the music without singing."

4

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention? 1. The client does not take scheduled antiseizure medications. 2. The client receives no visitors and participates in limited unit activities. 3. The client is placed on nothing-by-mouth (NPO) status for 18 to 24 hours. 4. The client shampoos and dries the hair, freeing it of all hair spray and creams.

4

A client is scheduled to have electroconvulsive therapy (ECT). Which information should the nurse tell the client? 1. Many clients experience long-term memory loss. 2. There are no expected side effects associated with ECT. 3. The client will receive no medications during the procedure. 4. Amnesia of events occurring near the period of the therapy is common.

4

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client? 1. "Go on...." 2. "Sleeping?" 3. "The last couple of nights?" 4. "Tell me about your difficulty sleeping."

4

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group? 1. Al-Anon 2. Fresh Start 3. Families Anonymous 4. Alcoholics Anonymous

4

A client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. The nurse would focus the initial data collection on which information? 1. The past treatment regimen 2. Food intake for the past 24 hours 3. The client's interaction with peers 4. The presence of existing suicidal thoughts

4

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client? 1. "I don't see you as a failure." 2. "You have everything to live for." 3. "Feeling like this is all part of being ill." 4. "You've been feeling like a failure for a while?"

4

A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." Which response by the nurse is therapeutic? 1. "Have you told your family how you feel?" 2. "They are right. You shouldn't be so worried." 3. "You certainly have enough to worry about right now." 4. "You're feeling angry that your family is hoping for a cure?"

4

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client? 1. Explain the unit rules. 2. Orient the client to the unit. 3. Stabilize the client's psychiatric needs. 4. Accept the client as a person and make the client feel safe.

4

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding? 1. Normal 2. Regressive 3. Indicative of the client's ambivalence 4. Evidence of the client's altered and distorted body image

4

A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs? 1. When medication that has been administered has taken effect 2. When the nurse explores with the client the reasons for the angry behavior 3. When the client apologizes and tells the nurse that it will never happen again 4. When no acts of aggression are observed within 1 hour after release of two extremity restraints

4

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." Which should be the nurse's best response? 1. "I don't believe this is true." 2. "The doctor is not talking to the CIA." 3. "What makes you think the doctor wants to get rid of you?" 4. "I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"

4

A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. I told you to be quiet." Looking at the nurse, the client says, "Can't you hear them shouting at me?" Which would be the nurse's best response? 1. "How often are you hearing voices?" 2. "If you took your medications, you wouldn't be hearing voices." 3. "The voices aren't real. Go to the day room and watch television." 4. "I don't hear the voices, but I can see how upsetting it must be for you."

4

After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action? 1. Ignore the delusion. 2. Take the client to a quiet room. 3. Support the client's denial of illness. 4. Privately confront the client with reality.

4

An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which action would be least helpful in preparing the client to return to a safe and effective care environment? 1. Encourage sharing of feelings. 2. Identify the family's strengths and weaknesses. 3. Provide and offer the family options and resources. 4. Suggest that the mother's boyfriend move out of the home.

4

An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms? 1. "Well, a picture paints a thousand words." 2. "You just felt like destroying your textbooks?" 3. "Your parents and teachers are very concerned about your drawings." 4. "I am concerned about you. Are you now or have you ever been abused?"

4

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action? 1. Call the police. 2. Obtain psychiatric help for the son. 3. Tell the son that he cannot visit with his mother. 4. Notify the social worker to investigate the situation.

4

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

4

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior? 1. The client needs to be admitted to the hospital. 2. The client needs to be referred to the psychiatrist as soon as possible. 3. The client requires further treatment and is not ready to be discharged. 4. The client is displaying typical behaviors that can occur during termination.

4

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1. Call the client's family. 2. Place the client in seclusion immediately. 3. Inform the client that seclusion has not been prescribed. 4. Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

4

The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place priority on which action when planning care for this client? 1. Demand active participation in care. 2. Monitor for obsessive-compulsive behavior. 3. Educate the client about self-care demands. 4. Establish a trusting nurse-client relationship.

4

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply? 1. "In 7 days" 2. "In 14 days" 3. "In 21 days" 4. "Within a few hours"4

4

The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client? 1. "Don't yell at me." 2. "Why do you feel this way?" 3. "I am calling your psychiatrist!" 4. "I can see that you are upset. I'll be back in a few minutes to see how you are doing."

4

The nurse is assisting in conducting a group therapy session and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which? 1. Ask the client to leave. 2. Refer the client to another group. 3. Tell the client to stop monopolizing the group. 4. Suggest that the client stop talking and try listening to others.

4

The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate? 1. Defends the delusional thinking 2. Relinquishes the need for delusional thinking 3. Verbalizes the reasons for delusional thinking 4. Develops a relationship to help reduce the frequency of the delusions

4

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? 1. A crisis state indicates that the individual is suffering from a mental illness. 2. A crisis state indicates that the individual is suffering from an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. 4. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

4

The nurse is caring for a client who has been treated with long-term antipsychotic medication. The nurse plans to monitor for tardive dyskinesia. Which signs should the nurse observe with tardive dyskinesia? 1. Abnormal breathing through the nostrils 2. Severe headache, flushing, tremor, and ataxia 3. Severe hypertension, migraine headache, and "marbles in the mouth" syndrome 4. Abnormal movements and involuntary movements of the mouth, tongue, and face

4

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? 1. Poor dietary choices 2. Lack of exercise and poor diet 3. Inadequate dietary intake and dehydration 4. Psychomotor retardation and side effects of medication

4

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? 1. "Right! Why not just 'pack it in'?" 2. "That seems rather unlikely to me." 3. "I don't believe that, and neither do you." 4. "You must be feeling all alone at this point."

4

The nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which data would indicate that the client is a very high risk for suicide? 1. The client is impulsive. 2. The client is disorganized. 3. The client has a history of suicide attempts. 4. The client has an immediate plan for a suicide attempt.

4

The nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome? 1. The client becomes tearful during the interview. 2. The client states, "I didn't deserve being hurt like this." 3. The client states, "I was dumb enough to be out that late." 4. The client reports nightmares involving being stalked when alone at night.

4

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms? 1. Hypotension, ataxia, vomiting 2. Stupor, agitation, muscular rigidity 3. Hypotension, bradycardia, agitation 4. Hypertension, disorientation, hallucinations

4

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective? 1. "I'll eat until I don't feel hungry." 2. "I no longer have a weight problem." 3. "I don't want to starve myself anymore." 4. "My friends and I went out to lunch today

4

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care? 1. Facing the client when providing care 2. Ensuring that a security officer is within the immediate area 3. Keeping the door to the client's room open when with the client 4. Assigning the client to a room at the end of the hall to prevent disturbing the other clients

4

The nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which as the primary means to accomplish work with this client? 1. Group therapy 2. Medical diagnosis 3. Recreational therapy 4. Goals and objectives

4

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? 1. "My medications won't make me anxious." 2. "I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or hear things if I get enough sleep and eat well." 4. "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone.

4

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal? 1. Physical wounds will heal. 2. The client will participate in the treatment plan. 3. The client will verbalize feelings about the event. 4. The client will resolve feelings of fear and anxiety related to the rape trauma.

4

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts? 1. The false belief that one is a very powerful person 2. The false belief that one is a very important person 3. The false belief that one's partner is being unfaithful 4. The false belief that one is being singled out for harm by others

4

The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations? 1. Minimize the time spent talking to the client. 2. Ask the client why he or she is reluctant to ask questions. 3. Ask a family member to be present when caring for the client. 4. Discuss common fears and questions expressed by other clients with the same diagnosis.

4

The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial? 1. Allow the client to pace. 2. Escort the client to a quiet room. 3. Change the conversation to a less threatening subject. 4. Share the observation with the client and help the client recognize his or her feelings.

4

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder? 1. Dental erosion 2. Electrolyte imbalances 3. Enlarged parotid glands 4. Body weight well below ideal range

4