Saunders PN Mental Health

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?

Light therapy

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

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?

"Discussing suicide with a client is not harmful."

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?

"I can see that you're upset. I'm willing to listen."

The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion?

"I don't feel like hurting myself anymore."

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?

"I know that I won't become depressed again."

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?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

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?

"It seems as if you or your daughter feel regret?"

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?

"It's okay to grieve and be angry with your daughter and anyone else for a time."

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?

"Our relationship is a therapeutic and a helping one."

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?

"Perhaps you could just enjoy the music without singing."

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?

"Tell me about your difficulty sleeping."

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for further teaching about this self-help group?

"The leader of this self-help group is the nurse or psychiatrist."

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?"

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate?

"What do you mean by that?"

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time?

"What is causing you to become agitated?"

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?

"You seem very distressed over learning you have asthma."

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?

"You've been feeling like a failure for a while?"

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.

-A high achiever -Personality changes -Lanugo over the back and extremities

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply.

-Age less than 32 years -Practicing a religion -Married over 10 years

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.

-Apraxia -Aphasia -Agnosia -Hyperorality

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.

-Autocratic Leader -Democratic Leader -Laissez-Faire Leader

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.

-Autonomy -Beneficence -Veracity -Fidelity -Justice

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.

-Avoidance -Hyperarousal -Reexperiencing

The nurse caring for a client with schizophrenia prepares to document which signs/symptoms exhibited by the client as negative? Select all that apply.

-Avolition -Anergia

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.

-Being on a bridge -Riding in an elevator -Being alone at home -Traveling in an airplane

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.

-Client threatened to commit suicide -Client threatened to kidnap his spouse

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

-Communicate expected -Follow through -Assist the client -Be clear w/ the client

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.

-Cutoffs -Conflict -Over involvement

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.

-Denial -Confabulation -Perseveration -Avoidance of questions

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.

-Depression -Substance Abuse -Adverse Childhood Events -PTSD

The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply.

-Diaphoretic -Temperature of 104.8 -Blood pressure of 210/130 mmHg

The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions in response to this client's medication refusal? Select all that apply.

-Document the refusal of medication -Notify the RN -Ask the client why he is refusing the medication

The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply.

-Effects on problem solving -Effects on perceptual field -Physical and other defining characteristics

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.

-Hallucinations -Delusions -Neologisms

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.

-Hesitation -Lack of eye contact -Using vague statements such as,...

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.

-I hid my silverware from dinner last night -I know that by this time tomorrow all my troubles will be over

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

-I notice you are wearing a blue shirt. -Do you have any plans of harming yourself? -I will sit here with you even if you choose not to talk with me.

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.

-I'm going to do whatever... -I'll go and participate...

The nurse in the mental health clinic hears a client yelling and threatening to hurt his sister. The nurse reports this episode to the mental health therapist. Which should the nurse anticipate the therapist to do? Select all that apply.

-Identify the specific person being threatened -Take appropriate action to protect the identified victim -Assess and predict the client's danger of violence toward another

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.

-Inability to think clearly -Inability to problem solve

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

-Incoordination -Mental confusion -Muscle hyperirritability

A 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.

-Irritability -Hypertension -GI disturbances

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.

-Is it in the best interest of society? -Does its use violate the client's rights? -Is this therapy in the best interest of the client?

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.

-Lanugo -Amenorrhea

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

-Let me know if you change your mind...

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.

-Making -Providing -Ensuring

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.

-Medication management -Monitoring and Documenting Behavioral -Notifying the health care provider... -Planning care for the needs of those...

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.

-Mild -Panic -Severe -Moderate

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply.

-Minimizing -Changing -Asking

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease should expect to observe which behaviors in this client? Select all that apply.

-Misplacing a valuable object -Difficulty coming up with the right word

A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply.

-Monitor airway -Notify the RN -Remain with the client to provide support -Administer the prescribed intramuscular antiparkinsonian medication

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.

-Mutual Learning -Increased Feedback -Instilling a sense of belonging -An opportunity to practice new skills in a relative environment

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.

-Mutual Learning -Increased Feedback -Instilling a sense of belonging -An opportunity to practice...

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.

-My husband always brings... -I have bruises all over my... -My boyfriend yells and ...

The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply.

-Oblivious to surroundings -Unable to focus on anything -Engaging in purposeless activities -Showing unproductive relief behavior

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.

-Outlandish behaviors -Purposeless arousal and movement -Grandiose delusions of being King Arthur -Incessant talking that includes sexual innuendos

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.

-Paralysis -Blindness -Paresthesia -Movement Disorder

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.

-Performing badly on stage -Looking awkward while eating or drinking in public -Not being able to answer questions in a classroom -Fear of saying something that sounds foolish in public

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.

-Poor limited setting -Staff inexperience -Provocative or controlling staff -Arbitrary revocation of privileges

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply.

-Promoting self-care and independence -Facilitating communication of distressing thoughts and feelings -Helping clients examine self-defeating behaviors and test alternatives -Assisting clients with problem solving to help facilitate activities of daily living

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?

-Protection from the risk of intimacy

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply.

-Provide -Decrease -Restrict

The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply.

-Punishment -Avoidance Training -Pairing of a maladaptive behavior

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.

-Refer to hallucinations as if they are real -Ask the client directly about the hallucinations -Watch the client for cues... -Address any underlying emotion, need, or them...

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.

-Reinforce the client's problem-solving abilities -Assess "secondary gains" that the somatic illness provides the client.

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply.

-Request that the client perform undemanding, self-care tasks -Reinforce teaching the client techniques to maintain present reality -Assist the client to reestablish relationships w/ significant others

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.

-Respond to stimuli -Conduct electrical impulses -Release chemicals called neurotransmitters

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.

-Rigidity -Inflexibility -Repetitive thoughts -Ritualistic behavior

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.

-Risk for injury -Risk for infection -Risk for aspiration -Impaired verbal communication

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.

-Set limits on behavior -Distract or redirect the client -Decrease environmental stimulation -Provide high caloric nutritional intake

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply.

-Severe -Extremeley -Desire for -Delirium -Severe drug reactions...

A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.

-Sit by client's bed holding his or her hand. -Reminisce with the client and share a humorous client enjoys -The nurse asks: "What can I do... -The nurse asks: "I noticed you grimacing... -The nurse states: "It must be very frustrating...

Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply.

-Speak slowly -Use simple statements -Provide the client with high-calorie beverages

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

-Stay with the client -Administer anxiolytics medications -Ensure the client is in an environment...

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.

-Suicide is a frequent cause of death among the older population. -Some indications of dementia may actually originate as depression. -Depression in an older person is likely to have physical manifestations.

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.

-Zoophobia -Xenophobia -Agoraphobia -Glossophobia

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 Rationale: Coping mechanisms are behaviors that are used to decrease stress and anxiety. Visiting a spouse's grave, visiting the senior citizens' center, and looking at snapshots of the family are effective coping mechanisms. Neglecting grooming and preferring to spend time alone and avoiding contact with others are behaviors that identify ineffective coping of the grieving process.

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 Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding limits set; following through with the consequences in a nonpunitive manner; and assisting the client with developing a means for setting limits on personal behaviors. Enforcing rules and informing the client that he or she will not be allowed to attend therapy groups are violations of a client's rights. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

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 Rationale:When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake must be maintained.

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 Rationale: Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.

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. "I no longer feel that I deserve the beatings my husband inflicts on me." Rationale: Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes. Option 1 is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. The nonalcoholic partner should not feel responsible when the spouse loses control (option 2). Option 3 indicates that the group is being seen as an escape, not a place to work on issues. Option 4 indicates that the wife remains codependent.

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. Agoraphobia Rationale: Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in the reduction of social and professional interactions. Hematophobia is the fear of blood. Claustrophobia is a fear of closed-in places. Clients with somatic symptom disorder focus their anxiety on physical complaints and are preoccupied with their health.

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. Interm-43 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. Call the nursing supervisor Rationale: The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Notifying the nurse supervisor is the correct option. Most health care facilities have documents that the client is asked to sign that relate to the client's responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request that the client wait to speak to the PHCP before leaving, but if the client refuses to do so, the nurse cannot hold the client against his or her will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care (option 3) and cannot be told otherwise.

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. Denial Rationale: Denial is the refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying the unacceptable attributes about oneself.

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. Escort the manic client to his or her room. Rationale: The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate has already been attempted by the psychiatric nurse's aide.

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. Feed, bathe, and dress the client as needed until the client can perform these activities independently. Rationale: The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options 2 and 3 are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option 4 will increase the client's feelings of poor self-esteem and unworthiness.

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. One-to-one suicide precautions Rationale: One-to-one suicide precautions are required for the client who has attempted suicide. Options 2 and 3 are not appropriate, considering the situation. Option 4 may be an appropriate nursing intervention, but the priority is stated in option 1. The best option is constant supervision so that the nurse may intervene as needed if the client attempts to cause harm to him or herself.

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. Open-ended questions and silence Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option 2 is not a client-centered intervention

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. The client gives away a DVD and a cherished autographed picture of the performer. Rationale: A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered. Options 2, 3, and 4 identify acting-out behaviors.

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. The client presents a harm to self. Rationale: Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care. Options 2, 3, and 4 describe the process of voluntary admission.

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. Weight loss Rationale: All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem. Medication or sleep patterns are not mentioned or addressed in the question.

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."I cannot discuss any client situation with you." Rationale: The nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right. Option 3 is correct in a sense, but it is a rather blunt statement. Both options 2 and 4 identify statements that do not maintain client confidentiality.

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.Provide safety for the client and other clients on the unit. Rationale: Safety of the client and other clients is the priority. Option 1 is the only option that addresses the client and other clients' safety needs. Option 2 addresses other clients' needs. Option 3 is not client centered. Option 4 addresses the client's needs.

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. "Are you fearful and think that others may want to hurt you?" Rationale:Option 2 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options 1, 3, and 4 do not focus on the client's feelings.

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. "How much do you use and what effect does it have on you?" Rationale: Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

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. "I cannot promise to keep a secret." Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

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 receiving diagnostic tests Rationale: The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

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. Drawing Rationale: Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

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. Examine and treat the wound sites. Rationale: The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically.

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. The mother should restrict the amount of chocolate and caffeine products in the home. Rationale: Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options 1 and 3 are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work.

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 vigorousl

2. Interrupt the client and offer to take her for a walk. Rationale: Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on vigorous activities. Options 1, 3, and 4 are inappropriate nursing actions.

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 client will participate in the treatment plan. Rationale: Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Options 1 and 3 are not likely for a client seeking voluntary admission. Option 4 is not centered on the individual client.

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 death of a loved one Rationale: A situational crisis is associated with a life event. External situations that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis relates to a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.

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. Use a night light and turn off the television. Rationale: It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention

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. Yawning, irritability, diaphoresis, cramps, and diarrhea Rationale: Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification. Option 2 identifies the clinical manifestations associated with withdrawal from opioids. Option 1 describes intoxication from hallucinogens. Option 3 describes withdrawal from alcohol. Option 4 describes withdrawal from cocaine.

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. "Sometimes people hear things or voices others can't hear." Rationale: It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.

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. "You understand that people fear for their children, but you're feeling unfairly treated?" Rationale: Focusing and verbalizing the implied concern is the therapeutic response because it assists the client to clarify thinking and to reexamine what the client is really saying. Option 3 is the only option that reflects the use of this therapeutic communication technique. Option 1 is insensitive and anxiety-provoking. Option 2 gives advice and does not facilitate the client's expression of feelings. Option 4 does not facilitate the client's expression of feelings

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. "You're feeling angry that your family continues to hope for you to be 'cured'?" Rationale: Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option 2, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option 4, the nurse makes a judgment and is nontherapeutic in the one-on-one relationship. In option 1, the nurse is attempting to assess the client's ability to openly discuss feelings with family members. Although this may be appropriate, the timing is somewhat premature and closes off facilitation of the client's feelings.

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. Assign a staff member to the client who will remain with him or her at all times. Rationale: Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one-on-one) with a staff member who is never less than an arm's length away is the safest intervention

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. Contact the primary health care provider (PHCP). Rationale: Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the PHCP. Option 1 violates client confidentiality. Option 2 is not therapeutic or appropriate. Option 4 does not apply to a voluntary admission status.

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. Conversion disorder Rationale: A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person's capacity to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

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. Inquiring about the client's feelings that may affect coping Rationale:The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

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. Observe for excessive exercise. Rationale: Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for both dehydration and electrolyte imbalance is an important nursing action. Option 3 is the only option that is not associated with care of the client with bulimia.

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. Observing rigid rules and regulations Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options 1, 2, and 4 are incorrect.

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. Offer to take the client to an examination room until he or she can be treated. Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.

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 client's report of self-destructive thoughts Rationale: The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options 1, 2, and 4 will all affect the treatment of the client but are not of greatest importance at this time.

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. What do you find difficult about this situation? Rationale: The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.

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. "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone." Rationale: There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination. Option 4 is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior.

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. "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?" Rationale: The nurse needs to encourage the family and client to verbalize their fears and concerns. Option 4 is the only option that encourages verbalization. Options 1, 2, and 3 avoid dealing with the client or family concerns.

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. "You must be feeling all alone at this point." Rationale: The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. In option 1, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response. In option 2, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option 3, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions.

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. Alcoholics Anonymous Rationale: Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism. Option 1 is a group for families of alcoholics. Option 2 is for nicotine addicts. Option 3 is for parents of children who abuse substances.

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. Assigning the client to a room at the end of the hall to prevent disturbing the other clients Rationale: The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client. The door to the client's room should be kept open, and the nurse should never turn away from the client. A security officer or male aide should be within immediate call in case the possibility of violence is suspected.

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.

4. Assist with making appropriate referrals Rationale: Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination. Options 1, 2, and 4 identify the tasks of the working phase of the relationship.

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. Body weight well below ideal range Rationale: Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. During further inspection, the client demonstrates enlargement of the parotid glands with dental erosion and caries if he or she has been inducing vomiting. Electrolyte imbalances are present.

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. Evidence of the client's altered and distorted body image Rationale: Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of distorted body image. The client's behavior is not normal.

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. Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent. Rationale: A client may request to be secluded or restrained. Federal laws require the consent of the client unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only with the written prescription of the PHCP, which must be reviewed and renewed every 24 hours, depending on state law requirements. It must also specify the type of restraint to be used.

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. Hypertension, disorientation, hallucinations Rationale: The symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

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. Psychomotor retardation and side effects of medication Rationale: In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention. Constipation can be related to inadequate food intake, lack of exercise, and poor diet.

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.

4. Sit beside the client in silence and verbalize occasional open-ended questions. Rationale: Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur. Option 4 relies on other clients to care for this one, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 is the best action because it provides for client supervision and communication as appropriate.

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 false belief that one is being singled out for harm by others Rationale: A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is being unfaithful.

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."Within a few hours" Rationale: Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

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

A 90-year-old woman with advanced Alzheimer's disease Rationale:Elder abuse is widespread and occurs among all subgroups of the population. It includes physical and psychological abuse, the misuse of property, and the violation of rights. The person at highest risk of abuse is an elder with dementia that occurs with Alzheimer's disease.

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?

A client with severe depression and terminal cancer

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?

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.

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?

Accept the client as a person and make the client feel safe.

A client is scheduled to have electroconvulsive therapy (ECT). Which information should the nurse tell the client?

Amnesia of events occurring near the period of the therapy is common.

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?

Approach the client quietly, take her to her room, and assist her in getting dressed.

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Avoid joking or laughing in the presence of the client.

The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia

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?

Develops a relationship to help reduce the frequency of the delusions

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?

Discuss common fears and questions expressed by other clients with the same diagnosis.

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?

Disulfiram

The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

Driving under the influence (DUI) conviction resulted in a 1-year suspended license

The nurse is assisting in conducting a group therapy session. A client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which nursing action is appropriate?

Encourage the client to stay and ask the client what she is feeling.

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?

Establish a trusting nurse-client relationship.

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first?

Examine the neck area and assess the airway.

When caring for a client who has been raped, which intervention should the nurse implement during the examination?

Explaining procedures to be completed and why the procedures are necessary

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Has the client open the gift with the nurse present

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

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?

I am concerned about you. Are you...

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?

Increasing the level of suicide precautions

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?

Inform the client that she is being secluded to help regain control of herself.

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?

Information regarding the location of shelters

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?

Initiate confinement measures.

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?

Keep the client talking and signal to another staff member to send help to the client.

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?

Look for organic causes of the paralysis.

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs/symptoms of anxiety and attempts to assist the client back to the client's hospital room. Which is the next appropriate nursing action at this time?

Notify the registered nurse (RN).

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?

Notify the social worker to...

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the primary health care provider immediately. Which nursing intervention is appropriate?

Offer to assist the client to an examination room until the primary health care provider is notified.

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?

Place the client on one-to-one suicide precautions.

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?

Planning a non-food related activity

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?

Privately confront the client with reality.

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?

Provide safety for both the client and other clients on the unit.

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?

Psychodrama

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?

Quietly approach the client, escort her to her room, and assist her in getting dressed.

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?

Reexperiencing recollections of the trauma

A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action should the nurse implement?

Remain with the client at all times

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?

Remove both clients to a separate, safe location.

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?

Removing the client from any immediate danger

A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority?

Risk for aspiration

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?

Safety and Security

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?

Share the observation with the client and help the client recognize his or her feelings.

The nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual?

Sibling stating, "I don't feel safe around my brother."

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?

Sounds like you're feeling pretty troubled...

Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety?

Stay with the client until the medication becomes effective.

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?

Take the client to a quiet room.

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?

Tell me more about what causes you to...

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?

The client asks to meet with a lawyer to take care of unfinished business.

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand ...

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?

The client shampoos and dries the hair, freeing it of all hair spray and creams.

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?

The client verbalizes stages of grief and plans to attend a community grief group.

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction?

The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.

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?

The client will resolve feelings of fear and anxiety related to the rape trauma.

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?

The physical condition of the client

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?

They are expected reactions to a devastating event.

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?

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings?

Use open-ended questions and silence.

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?

What do you and your husband believe....

A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response?

What do you mean by that?

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?

When no acts of aggression are observed within 1 hour after release of two extremity restraints

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time?

You sound very unhappy. Are you thinking of harming yourself?

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?

You sound very upset. Are you thinking...

The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?

reported hopelessness