STUDY FOR EXAM 7: MENTAL HEALTH: NCLEX & ATI BOOKS

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 who is present at the time should respond by stating which of the following? A. "The technician at the time is not going to hurt you but is going to help." B. "Are you fearful and think that others may want to hurt you?" C. "What makes you think that the technician wants to hurt you?" D. "The technician will leave and come back later for your blood."

"Are you fearful and think that others may want to hurt you?" *Option B 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 chage the client's mind, the delusion may, in fact, be even more strongly held. Options A, C, and D do not focus on the client's feelings

A nurse is reinforcing teaching withthe adoptive parent of a preschool-age child who has a new diagnosis of ADHD. Which of the following statements should the nurse make? A. "Behaviors associated with ADHD are present prior to age 3." B. "This disorder is characterized by argumentativeness." C. "Below-average intellectual functioning is associated with ADHD." D. "Because of this disorder, your child is at an increased risk for injury."

"Because of this disorder, your child is at an increased risk for injury." *Inattentive or impulsive behavior increases the risk for injury in a child who has ADHD *Behaviors associated with ADHD are present before the age of 12 *Argumentativeness is associated with oppositional defiant disorder rather than ADHD *Below-average intellectual functions is associated with intellectual development disorder rather than ADHD

A nurse is assisting with the admission of a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's caregiver, which of the following statements is the priority to report to the provider? A. "Current medical conditions include diabetes that is controlled by diet." B. "Recent medications include a course of prednisone for acute bronchitis." C. "Current vaccinations include a flu vaccine last month." D. "Current medications include furosemide for congestive heart failure."

"Current medications include furosemide for congestive heart failure." *Diuretics (furosemide) are contraindicated for use with lithium due to the risk of toxicity. This is the greatest risk for the client and is therefore the highest priority to report to the provider

A nurse is reinforcing teaching to a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by te client indicates understanding of the teaching? A. "I can expect my problems with PMDD to be worst with I'm menstruating." B. "I should avoid exercising when I am feeling depressed." C. "I am aware that my PMDD causes me to have rapid mood swings." D. "I should increase my caloric intake with a nutritional supplement when my PMDD is active."

"I am aware that my PMDD causes me to have rapid mood swings." *A clinical finding of PMDD is emotional liability. The client can experience rapid changes in mood *Clinical findings of PMDD are present furing the luteal phase of the menstrual cycle just prior to menses. *Aerobic and other exercise are effective treatments for depressive disorders, including PMDD *PMDD increases the client's risk for weight gain due to overeating. It is not appropriate to increase caloric intake

A nurse is determining a client's understanding of a new prescription of a new prescription for clonidine for the treatment of opioid use disorder. Which of the following statements by the client indicates an understanding of the instruction? A. "Taking this medication will reduce my craving for heroin." B. "While taking this medication, I should keep a pack of sugarless gum." C. "I can expect some diarrhea from taking this medication." D. "Each dose of this medication should be placed under my tongue to dissolve."

"I can expect some diarrhea from taking this medication." *Clonidine commonly causes clients to experience dry mouth, Chewing sugarless gum is an effective method to address this adverse effect *Clonidine is useful during opioid withdrawal. However, it does not reduce cravings *Clonidine reduces, rather than causes, diarrhea and other withdrawal manifestations related to autonomic hyperactivity *Buprenorphine, rather than clonidine, is administered sublingually

A nurse is reinforcing teaching to a client who has a new prescription of amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect to experience diarrhea while taking this medication. B. "I may feel drowsy for a few weeks after starting this medication." C. "I cannot eat my favorite pizza with pepperoni while taking this medication." D. "This medication will help me lose the weight that I have gained over the last year."

"I may feel drowsy for a few weeks after starting this medication." *Sedation is an adverse effect of amitriptyline during the first few weeks of therapy *Constipation rather than diarrhea can occur with TCAs, due to anticholinergic effects *Foods (pepperoni) should be avoided if the client is prescribed an MAOI rather than a TCA like amitriptyline *Observe for manifestations of hypomania or mania caused by CNS stimulation with phenelzine

A nurse is caring for several clients. Which of the following client statements should the nurse identify as expected for factitious disorder imposed on another? A. "I had to pretend I was injured in order to get disabiility benefits." B. "I know that my abdominal pain is caused by a malignant tumor." C. "I needed to make my child sick so that someone else would take care of them for a while." D. "I became deaf when I heard that my partner was having an affair with my best friend."

"I needed to make my child sick so that someone else would take care of them for a while." *A client who has factitious disorder imposed on another often consciously injures another person or causes them to be sick due to a personal need for attention or relief of responsibility *A client's falsification of an illness or injury for the purpose of personal gain is malingering *Although clients who have factitious disorder often use proper medical terminology, a client's fear of a serious illness is expected with illness anxiety disorder *Developing a sensoring impairment due to an acute stressor is an expected fiding of conversion disorder

A nurse is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the discussion A. "I can promote my client's sense of control by establishing a schedule." B. "I should encourage clients who have a schizoid personality disorder to increase socialization." C. "I should practice limit-setting to help prevent client manipulation." D. "I should implement assertiveness training with clients who have antisocial personality disorder."

"I should practice limit-setting to help prevent client manipulation." *When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation *Rather than establishing a schedule, ask for the client's input and offer realistic choices to promote the client's sense of control *Avoid trying to increase socializtion for a client who has a schizoid personality disorder *Implement assertiveness training for clients who have dependent and histrionic personality disorders

A nurse is reinforcing teaching about free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique? A. "I will write down my dreams as soon as I wake up." B. "I might begin to associate my therapist with important people in my life." C. "I can learn to express myself in a nonaggressive manner." D. "I should say the first thing that comes to my mind."

"I should say the first thing that comes to my mind." *Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind *Dream analaysis and interpretation are therapeutic tools, However, they are not an example of free association *Associating the therapist with significant persons in the client's life is an example of transference rather than free association *Learning to express feelings and solve problems in a nonaggressive manner is an example of assertiveness training, rather than free association

A nurse is reinforcing teaching to a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates uderstanding of the information provided? A. "It is common to treat depression with ECT before trying medications." B. "I can have my depression cured if I receive a series of ECT treatments." C. "I should receive ECT once a week for 6 weeks." D. "I will receive a muscle relaxant to protect me from injury during ECT."

"I will receive a muscle relaxant to protect me from injury during ECT." *A muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity *ECT is indicated for clients who have major depressive disorder and who are not respnsive to pharmacological treatment *ECT does not cure depression. However, it can reduce the incidence and severity of relapse *The typical course of ECT treatment is 2 to 3 times a week for a total of 6 to 12 treatments

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the procedure? A. "TMS is indicated for clients who have schizophrenia spectrum disorders." B. "I will provide postanesthesia care following TMS." C. "TMS treatments usually last 5 to 10 minutes." D. "I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks."

"I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks." *TMS is commonly prescribed 3 to 5 times a week for the first 4 to 6 weeks *TMS is indicated for the treatment of major depressive disorder that is not responsive to pharmacological treatment. ECT is indicated for the treatment of schizophrenia spectrum disorders *Postanesthesia care is not necessary after TMS because the client does not receive anesthesia and is alert during the procedure *The TMS procedure lasts 30 to 40 min

A nurse is assisting with the care of a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make? A. "Tell me about how you are feeling right now." B. "You should focus on the positive things in your life to decrease your anxiety." C. "Why do you believe you are experiencing this anxiety?" D. "Let's discuss the medications your provider is prescribing to decrease your anxiety."

"Tell me about how you are feeling right now." *Asking an open-ended question is therapeutic and assists the client in identifying anxiety *Offering advice is nontherapeutic and can hinder further communication *Asking the client a "why" questions is nontherapeutic and can promote a defensive client response *Postpone reinforcing health teaching until after acute anxiety subsides. Clients experiencing severe anxiety are unable to concentrate or learn

A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Care during the continuation phase focuses on treating continued manifestations of MDD." B. "The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks." C. "The client is at greatest risk for suicide during the first weeks of an MDD episode." D. "Medication and psychotherapy are most effective during the acute phase of MDD."

"The client is at greatest risk for suicide during the first weeks of an MDD episode." *The client is at greatest risk of suicide during the acute phase of MDD *The focus on the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD *The maintenance phase of treatment for MDD can last for 1 year or more *Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD

A nurse is caring for a client who states, "I'm so stressed at work because of my coworker. I am expected to finish others' work because of their laziness!" When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding? A. "You really should complete on your own work. I don't think it's right to expect me to complete your responsibilities." B. "Why do you expect me to finish your work? You must realize that I have my own responsibilities." C. "It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor." D. "When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities."

"When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities." *This response demonstrates assertive communication, which allows the client to state their feelings about the behavior and then promote a change *(A) This statement is an example of disapproving/disagreeing, which can prompt a defensive reaction and is therefore nontherapeutic *(B) This statement uses a "why" question, which implies criticism and can prompt a defesnive reaction and is therefore a defensive reaction and is therefore nontherapeutic *(C) This statement is aggressive and threatening, which can prompt a defensive reaction and is therefore nontherapeutic

A nurse is orienting a new client to a mental health unit. Which of the following statements should the nurse make when explaining the unit's community meetings? A. "You and a group of other clients will meet to discuss your treatment plans." B. "Community meetings have a specific agenda that is established by staff." C. "You and the other clients will meet with staff to discuss common problems." D. "Community meetings are an excellent opportunity to explore your personal mental health issues."

"You and the other clients will meet with staff to discuss common problems." *Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit *Individual treatment plans druing individual therapy rather than a community meeting *Community meetings can be structured so that they are client-led with decisions made by the group as a whiole *Personal mental health issues are discussed during individual therapy rather than a community meeting

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication? A. "I wish you would not make me angry. B. "I feel angry when you leave me." C. "It makes me angry when you interrupt me." D. "You'd better listen to me."

"You'd better listen to me." *This statement implies a threat and a lack of respect for another individual. The other 3 statements do not imply a threats, nor do they indicate a lack of respect for another individual.

A nurse us reviewing informaiton about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "ECT is the recommended initial treatment for bipolar disorder." B. "ECT is contraindicated for clients who have suicidal ideation." C. "ECT is effective for clients who are experiencing severe mania." D. "ECT is prescribed to prevent relapse of bipolar disorder."

. "ECT is effective for clients who are experiencing severe mania." *ECT is appropriate for the treatment of severe mania associated with bipolar disorder *Pharmacological intervention is the recommended initial treatment for bipolar disorder *ECT is effective for clients who have bipolar disorder and suicidal ideation *ECT is prescribed for clients experiencing an acute episode of bipolar disorder rather than for the prevention of relapse

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse is not acceptable? A. "Stop screaming, and walk with me outside." B. "Why are you so angry and screaming at everyone?" C. "You will not get your way by screaming." D. "What was going through your mind when you started screaming?"

. "Stop screaming, and walk with me outside." *This is an inappropriate therapeutic response. Setting limits and the use of physical activity (walking) to de-escalate anger is an appropriate intervention *(B)"Why" questions imply criticism and will often cause the client to become defensive *(C) This is a closed-ended, nontherapeutic statement *(D) The client is not ready to discuss this issue

A nurse is caring for a client who states, "I plan to commit suicide." Which of the following findings should the nurse identify as the priority? A. Client's educational and economic background B. Lethality of the method and availability of means C. Quality of the client's social support D. Client's insight into the reasons for the decision

. Lethality of the method and availability of means *The greatest risk to the client is self-harm as a result of carrying out a suicide plan The priority finding is to determine how lethal the method is, how available the method is, and how detailed the plan is

A nurse is discussing normal grief with a client wo recently lost a child. Which of the following statements made by the client indicates understanding? (Select all that apply) A. "I may experience feelings of resentment." B. "I will probably withdraw from others." C. "I can expect to experience changes in sleep." D. "It is possible that I will experience suicidal thoughts." E. "It is expected that I will have a loss of self-esteem."

1. "I may experience feelings of resentment." 2. "I will probably withdraw from others." 3. "I can expect to experience changes in sleep." *Suicidal ideations are associated with complicated grieving. The client who is experiencing a distorted or exaggerated grief response can direct anger towards themselves. Monitor the client for thoughts of suicide or self-injury *A client who is experiencing a complicated grief response commonly experiences a loss of self-esteem and a sense of worthlessness. These findings are not associated with normal grief

A nurse is assisting the charge nurse with a court-ordered evaluation of a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (select all that apply) A. Demonstrates extreme anxiety when placed in a social situation B. Often engages in magical thinking C. Attempts to convince other clients to relinquish their belongings D. Becomes agitated if personal area is not neat and orderly E. Blames others for personal past and current problems

1. Attempts to convince other clients to relinquish their belongings 2. Blames others for personal past and current problems *Exploitation and manipulation of others is an expected finding of antisocial personality disorder *Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder *Anxiety in social situations is an expected finding of clients who have avoidant personality disorder *Magical thinking and odd beliefs are findings observed in clients who have schizotypal personality disorder *Perfectionism with a focus on orderliness and control is an expected finding of clients who have obsessive-compulsive personality disorder

A nurse is assisting with planning a group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the orientation phase? (select all that apply) A. Encourage the group to work toward goals B. Define the purpose of the group C. Discuss termination of the group D. Identify informal roles of members within the group E. Establish an expectation of confidentiality within the group

1. Define the purpose of the group 2. Discuss termination of the group 3. Establish an expectation of confidentiality within the group *During the orientation phasem also known as the initial phase, identify the purpose of the group, discuss termination of the group, and set the tone of the group *During the working phase, the group works toward goals and identify informal roles that other members in the group often assume

A charge nurse is reviewing Kubler-Ross: Five stages of Grief with a group of newly licensed nurses. Which of the following stages should the charge nurse include in the review? (Select all that apply) A. Disequilibrium B. Denial C. Bargaining D. Anger E. Depression

1. Denial 2. Bargaining 3. Anger 4. Depression *Disequilibrium is the second stage of Bowlby's four stages of grief

A nurse is caring for a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? (Select all that apply) A. Decreased level of consciousness B. Drooling C. Involuntary arm movements D. Urinary retention E. Continual pacing

1. Drooling 2. Involuntary arm movements 3. Continual pacing *Decreased LOC is an indication of neuroleptic malignant syndrome rather than an EPS *Urinary retention is an antocholinergic effect rather than an EPS

A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply) A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy

1. Educational groups 2. Medication dispensing programs 3. Individual counseling programs 4. Family therapy *Detoxification programs are services provided in a partial hospitilization program

A nurse is performing data collection on a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply) A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Sleep disturbances

1. Excessive worry for 6 months 2. Restlessness 3. Sleep disturbances *Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 6 months, restlessness, and sleep disturbances (the inability to fall asleep), procrastination in decision making, and muscle tension

A nurse is reinforcing discharge teaching with the partner of a client who has Alzheimer's disease about home safety. Which of the following instructions should the nurse give to the partner to decrease the client's risk for injury? (select all that apply) A. Install extra locks at the top of exit doors B. Place rugs over electrical cords C. Put cleaning supplies on the top of a shelf D. Place the client's mattress on the floor E. Install light fixtures above stairs

1. Install extra locks at the top of exit doors 2. Place the client's mattress on the floor 3. Install light fixtures above stairs *Placing door locks up high where they are difficult to reach can prevent exiting the home and wandering outside *Placing the client's mattress on the floor reduces the risk for falls out of bed *Stairs should have adequate lighting to reduce the risk for falls *Rugs create a fall risk hazard and should be removed. Electrical cords should be secured to baseboards rather than covered *Cleaning supplies with colored tape does not prevent the client's access to hazardous materials

A nurse is working with a client who has recently lost a guardian. The nurse recognizes that which of the following factors influence a client's gried and coping ability? (Select all that apply) A. Interpersonal relationships B. Culture C. Birth order D. Religious beliefs E. Prior experience with loss

1. Interpersonal relationships 2. Culture 3. Religious beliefs 4. Prior experience with loss *Birth order is not a factor that influences grief and ability to cope

A nurse is caring for a client who is experiencing a crisis. Which of the following medications should the nurse plan to administer? (select all that apply) A. Lithium carbonate B. Paroxetine C. Risperidone D. Haloperidol E. Lorazepam

1. Paroxetine 2. Lorazepam *SSRI antidepressants (paroxetine) can be prescribed to decrease the anxiety and depression of a client who is experiencing a crisis *Benzodiazepines (lorazepam) can be prescribed to decrease the anxiety of a client who is experiencing a crisis *Mood stabililizers (lithium carbonate) are prescribed for bipolar disorder *Antipsychotic medications (risperidone and haloperidol) can be prescribed for disturbed thought processes, usually when accompanied by other psychotic manifestations (hallucinations, delusions, blunt affect)

A nurse is contributing to the plan of care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply) A. Voice changes B. Seizure activity C. Disorientation D. Cough E. Neck pain

1. Voice changes 2 Cough 3. Neck pain *Voice changes are a common advser effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and Pharynx. Coughing is a potential adverse effect of VNS. Neck pain is a potential adverse effect of VNS. However, this usually subsides with time *Seizure activity and disorientation is associated with ECT rather than VNS.

A nurse is assisting with caring for a group of clients. Which of the following clients should a nurse consider recommending for referral to an assertive community treatement (ACT) group? A. A client in an acute mental health facility who has fallen several times while running down the hallway B. A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who reports increasing anxiety during group therapy D. A client in a weekly grief support who reports still missing a deceased partner who has been dead for 3 months

A client who lives at home and keeps "forgetting" to come in for a scheduled monthly antipsychotic injection for schizophrenia *An ACT group works with clients who are nonadherent with traditional therapy (the client in a home setting who keep "forgetting" a scheduled injection). *A client in acute care who has been running and falling should be helped by the treatment team on the client's unit *A client who has anxiety might be referred to a counseler or mental health provider *A client who is grieving for a deceased partner who die 3 months ago is currently involved in an appropriate intervention

A nurse is assisting with planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse collect data from first? A. A client who received a burn on the arm while using a hot iron at home B. A client who requests a change of antipsychotic medication due to some new adverse effects C. A client who reports hearing a voice saying that life is not worth living anymore D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

A client who reports hearing a voice saying that life is not worth living anymore *A client who hears a voice saying this is not worth living anymore is at greatest risk for self-harm, and the nurse should collect data from this client first *(A) This client has needs that should be met, but there is another client whom the nurse should collect data from first *(B) This client has needs that should be met, but there is another client who the nurse should collect data from first *(C) This client has needs that should be met, but there is another client whom the nurse should collect data from first

A nurse is assisting in conducting a class for a group of newly licensed nurses on caring for clients who are at risk for suicide. Which of the following information should the nurse include in the teaching? A. A client's verbal threat to oneself is attention-seeking behavior B. Interventions are ineffective for clients who really want to commit suicide C. Using the term suicide increases the client's risk for a suicide attempt D. A no-suicide contract decreases the client's risk for suicide

A no-suicide contract decreases the client's risk for suicide *A no-suicide contract decreases the client's risk for suicide by promoting and maintaining trust between the nurse and the client. However, it should not replace other suicide prevention strategies *It a a myth that a threat or attempt to kill oneself is attention-seeking behavior, that interventions are ineffective for clients who really want to commit suicide (suicide precautions are shown to be effective in reducing the risk of a death by suicide), and that using the term suicide increases the client's risk for a suicide attempt (discuss suicide openly with the client).

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following laboratory tests? A. AST/ALT and LDH B. Creatinine and BUN C. WBC and granulocyte counts D. Blood sodium and potassium

AST/ALT and LDH *Routine monitoring of liver function tests is necessary due to the risk for hepatotoxicity *Baseline levels can be drawn. However, routine monitoring of creatinine and BUN, WBC and granulocyte counts, blood sodium and potassium is not necessary

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take? A. Administrer the next dose of lithium carbonate as scheduled B. Prepare for administration of aminophylline C. Notify the provider for a possible increase in the dosage of lithium carbonate D. Request a stat repeat of the client's lithium blood level

Administrer the next dose of lithium carbonate as scheduled *During a manic episode, the lithium blood level should be 0.8 to 1.4 mEq/L. It is appropriate to administer the next dose as scheduled *Aminophylline can be prescribed for treatment of severe toxicity for levels greater than 1.5 mEq/L *A dosage increase would place the client at risk for toxicity and is therefore not and appropriate action *A lithium level of 1.2 mEq/L is an expected finding for a client who is experiencing a manic episode. It is not necessary to request a stat repeat of the lab test

A nurse is caring for an adult client who has injuries resulting from partner violence to law enforcement authorities. Which of the following nursing actions is the highest priority? A. Advise the client about the location of safe houses and shelters B. Encourage the client to participate in a support group for survivors of abuse C. Implement case management to coordinate community and social services D. Educate the client about the use of stress management techniques

Advise the client about the location of safe houses and shelters *The greatest risk to this client is injury from further abuse; therefore, the priority action is to assist the client with the development of a safety plan that includes the identification of safe places to live

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? A. Al-Anon B. Fresh Start C. Families Anonymous D. Alcholics Anonymous

Alcholics Anonymous *Alcoholisc Anonymous is a major self-help organization for the treatment of alcoholism. Option A is a group for families of alcholics. Option B is for nicotine addicts. Option C is for parents of children who abuse substances

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan? A. Reports not going to work for the past week B. Complains of not being able to "do anything' anymore C. Arrives at the clinic neat and appropriate in appearance D. Reports sleeping 12 hours per night and 3 to 4 hours during the day

Arrives at the clinic neat and appropriate in appearance *Depressed individuals will sleep for long periods, are not able to go to work, and feel as if they cannot "do anything." Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints, as well as demonstrate an improvement in their appearance

A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons? A. Nacissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

Attempt to reduce anxiety *Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety *Narcissism causes clients to seek admiration from others *Fear of rejection might cause a client to avoid social situations and might be associated with social phobia anxiety disorder *Clients who have OCD might take an antidepressant to help control repetitive behavior

A nurse is caring for a cliet who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example? A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy

Aversion therapy *Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior. *Flooding is planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response *Biofeedback is a behavioral therapy to control pain, tension, and anxiety *Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student inidicates a need to further research the disorder? A. Dental erosion B. Electrolyte imbalances C. Enlarged parotid glands D. Body weight well below ideal range

Body weight well below ideal range *Clients with bulimia nervosa may not initally 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 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? A. Call the nursing supervisor B. Call security to block all exit areas C. Tell the client that she cannot return this hospital again if she leaves now D. Restrain the client until the primary health care provider (PHCP) can be reached

Call the nursing supervisor *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 to relate to the client;s responsibilites 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 wil. Restraining the client and calling security to block exits constitutes as false imprisonment. Any client has a right to health care (option C) and cannot be told otherwise

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? A. Call the client's family B. Persuade the client to stay a few more days C. Contact the primary health care provider (PHCP) D. Tell the client that discharge is not possible at this time

Contact the primary health care provider (PHCP) *Generally, voluntary admission is sougt by the client or client's guargian. Voluntary clients have the right to demand and ontain release. The best nursing action is to contact the PHCP. Option A violates client confidentiality. Option B is not therapeutic or appropriate. Option D does not apply to a voluntary admission status

A nurse is reviewing the medical record of a client who has conversion disorder. Which of the following findings should the nurse identify as placing the client at risk for conversion disorder? A. Death of a child 2 months ago B. Recent weight loss of 30 lb C. Retirement 1 year ago D. History of migraine headache

Death of a child 2 months ago *The death of a child 2 months ago is an acute stressor that places the client at risk for conversion disorder *A recent weight loss of 30 lb does not place the client at risk for conversion disorder. Recent acute stress can be a risk factor *Retiring 1 year ago does not place the client at risk for conversion disorder. PTSD can be a risk factor *A history of migraine headaches does not place the client at risk for conversion disorder. History of depression can be a risk factor

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication? A. Dementia B. Schizophrenia C. Seizure disorder D. Obsessive-compulsive disorder

Dementia *Donepezil hydrochloide is a cholinergic agent used in the treatment of mild to moderate dementia of the Alzheimer type. It enhances cholinergic function by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease. This medication is not used to treat the disorders in OPtion B, C, and D

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 mechanis,? A. Denial B. Projection C. Regression D. Rationalization

Denial *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 nurse in the emergency department is assisting with the care of a client who sustained minor injuries in a motor vehicle crash. The client's spouse was killed in the accident. Which of the following actions should the nurse take first? A. Determine if the client has thoughts of self-harm B. Ask the client how the accident occurred C. Assist the client in setting short-term treatment goals D. Instruct the client on use of coping strategies

Determine if the client has thoughts of self-harm *The greatest risk to the client experiencing a crisis is the risk of harm to himself or others. Therefore, determining if the client has thoughts of self-harm is the action to take first.

A nurse is caring for a client who has alcohol use disorder. The client is no longer experiencing withdrawal manifestations. Which of the following medications should the nurse anticipate administering to assist the client with maintaining abstinence from alcohol? A. Chlordiazepoxide B. Buproprion C. Disulfiram D. Carbamazepine

Disulfiram *Expect to administer disulfiram to help the client maintain abstinence from alcohol *Chlordiazepoxide is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol *Buproprion is indicated for nicotine withdrawal rather than to maintain abstinence from alcohol *Carbamazepine is indicated for acute alcohol withdrawal rather than to maintain abstinence from alcohol

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? A. A puzzle B. Drawing C. Checkers D. Paint by number

Drawing *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

A nurse is reinforcing teaching with an adolescent clietn who has a new prescription for clomipramine for OCD. Which of the following information should the nurse provide? A. Eat a diet high in fiber B. Check temperature daily C. Take medication first think in the morning before eating D. Add extra calories to the diet as between-meal snacks

Eat a diet high in fiber *Eating a diet high in fiber will decrease constipation, an anticholinergic effect associated with TCA use *Checking the client's temperature daily is not necessary while taking a TCA *Taking the medication at bedtime rather than in the morning will prevent daytime sleepiness *Following a well-balanced diet rather than adding extra calories as snacks will help prevent weight gain, a common adverse effect of TCAs

The police arrive at the emergency room with a client who has seriously lacerated both wrists. What is the initial nursing action? A. Administer an antianxiety agent B. Examine and treat the wound sites C. Secure and record a detailed history D. Encourage and assist the client with venting their feelings

Examine and treat the wound sites *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 nurse is assisting with an educational seminar on stress for other nursing staff. Which of the following information should the nurse recommend for inclusion? A. Excessive stressors cause the client to experience distress B. The body's initial adaptive response to stress is denial C. Absence of stressors results in homeostasis D. Negative, rather than positive, stressors produce a biological response

Excessive stressors cause the client to experience distress *Distress is the result of excessive or damaging stressors (anxiety or anger) *Denial is part of the grief process. The body's initial adaptive reponse to stress is known as the fight-orflight mechanism *Individuals need the presence of some stressors to provide interest and purpose to life *Both positive and negative stressors produce a biological reponse in the body

A nurse is assisting with systematic desensitication for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy? A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior. B. Advise the client to say "stop" out loud every time they begin to feel an anxiety response related to an elevator C. Gradually expose the client to an elevator while practicing relaxation techniques D Stay with the client in an elevator until the anxiety reponse diminishes

Gradually expose the client to an elevator while practicing relaxation techniques *Systemiatic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety responses *Demonstration followed by client imitation of the behavior is an example of modeling *Instructing a client to say "stop" when anxiety occurs is an example of thought stopping *Exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response is an example of flooding

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirum. The nurse should monitor for which symptoms? A. Hypotension, ataxia, vomiting B. Stupor, agitation, muscular rigidity C. Hypotentions, bradycardia, agitation D. Hypertension, disorientation, hallucinations

Hypertension, disorientation, hallucinations *The symptoms associated with alcohol withdrawl delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are stating, "kill your doctor." Which of the following actions should the nurse take first? A. Encourage the client to participate in group therapy on the unit B. Initiate one-to-one observation of the client C. Focus the client on reality D. Notify the provider of the client's statement

Initiate one-to-one observation of the client *A client who is experiencing a command hallucination is at risk for injury to self or others. Safety is the priority, and initiating one-to-one observation is the first action the nurse should take *Encourage the client to participate in group therapy to assist with reality testing and to increase coping skills. However, there is another action to take first *Attempt to focus the client on reality. However, there is another action to take first *Notify the provider of the client's hallucination. However, there is another action to take first

A nurse is assisting with the preparation of a community education seminar about family violence. When discussing types of violence, the nurse should recommend to include which of the following? A. Refusing to pay bills for a dependent, even when funds are available, is neglect B. Intentionally causing someone to fall is an example of physical violence C. Striking a sexual partner is an example of sexual violence D. Failure to provide a stimulating environment for normal development is emotional abuse

Intentionally causing someone to fall is an example of physical violence *Physical violence occurs when physical pain or harm is directed toward another individual *Refusing to pay bills for a dependent is economic abuse, rather than neglect *Striking a sexual partner or other individual is an example of physical, rather than sexual, violence. Sexual violence occurs when sexual contact takes place without consent *Failure to provide a stimulating environment for normal development in neglect, rather than emotional abuse

A nurse is assisting with a family therapy session. The younger child tells the nurse about plans to make the older sibling look bad, believing this will earn more freedom and privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction

Manipulation *Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda *Placation is the dysfunctional behavior of taking responsibility for problems to keel peace among family members *Blaming is the dysfunctional behavior of blaming others to shift focus away from the individual's own inadequacies *Distraction is the dysfunctional of inserting irrelevant information during attempts at problem solving

A nurse is conducting chart reviews of multiple clients at a mental health facility. Which of the following events should the nurse identify as an example of a maturational crisis? A. Rape B. Marriage C. Severe physical illness D. Job loss

Marriage *Marriage is an example of a maturational crisis, which is a naturally occurring event during the life span *Rape is an example of an adventitious crisis *Severe physical illess is an example of a situational crisis *Loss of a job is an example of a situational crisis

A nurse is assisting with the care of a client who has bipolar disorder. Which of teh following is the priority nursing action? A. Set consistent limits for expected client behavior B. Administer prescribed medications as scheduled C. Provide the client with step-by-step instructions during hygiene activities D. Monitor the client for escalating behavior

Monitor the client for escalating behavior *The greatest risk to this client is harming self or others due to the potential of a manic episode. Therefore, the priority actions the nurse should take is to monitor the client for escalating behavior *Set consistent limits for expected client behavior, administer prescribed medications as scheduled, and provide the client with step-by-step instructions during hygiene activities. However these do no address the client's priority need for safety and is therefore not the priority action

A nure is assisting with planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse expect to be assigned to perform first? A. Monitor the client's risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Assist the client to participate in treatment decisions

Monitor the client's risk for self-harm *The greatest risk to a client who has a body dysmorphic is self-harm or suicide. Therefore, the first action to take is to monitor the client's risk for self-harm to ensure that the client is provided with a safe environment *Instill hope for positive outcomes, without providing reassurance, as part of milieu therapy; however there is another action to take first *Encourage the client to participate in group therapy to assist the client in order to address social impairments that result from the disorder; however, there is another action to take first *Encourage the client to participate in treatment decisions as part of milieu therapy; however, there is another action to take first

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the day room. Which of the following is the priority nursing action? A. Encourage the client to express feelings out loud B. Maintain eye contact with the client C. Move the client away from others D. Tell the client that the behavior is not acceptable

Move the client away from others *The behavior indicates that the client is at greatest risk for harming others. The priority action for the nurse is to move the client away from others.

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

Observing rigid rules and regulations *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 A, B, and D are incorrect

A nurse is assisting with a staff education program on substance use in older adults. Which of the following information should the nurse to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect B. Older adults commonly use rationalization to cope with a substance use disorder C. Older adults are at an increased risk for substance use following retirement D. Older adults develop substance use to mask manifestations of dementia

Older adults are at an increased risk for substance use following retirement *Requirement and other life change stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use *Requiring higher doses of a substance to achieve a desired effect is a result of the length and severity of substance use rather than age *Denial, rather than rationalization, is a defense mechanism commonly used by substance users of all ages *Substance use in the older adult can result in manifestations of dementia

A nurse working on an acute mental health unit is collecting data from a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actios is the nurse's priority? A. Place the client on one-to-one observation B. Assist the client to perform ADLs C. Encourage the client to participate in counseling D. Reinforce teaching to the client about medication adverse effects

Place the client on one-to-one observation *The greatest risk for a client who has MDD and comorbid anxiety is injury due to self-harm. The highest priority intervention is placing the client on one-to-one observation *The client who has MDD can require assistance with ADLs. However, this does not address the greatest risk to the client and is therefore not the priority intervention *Encourage the client who has MDD to participate in counseling. However, this does not address the greatest risk to the client and is therefore not the priority intervention *Reinforce teaching to the client who has MDD about medication adverse effects. However, this does not address the greatest risk to the client and is therefore not the priority intervention

A nurse is collecting data from a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect? A. Wide fluctuation in mood B. Report of a minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years D. Inflated sense of self esteem

Presence of manifestations for at least 2 years *Manifestations of persistent depressive disorder last for at least 2 years in adults *Wide fluctuations in mood are associated with bipolar disorder *MDD contains a minimum of five clinical findings of depression *A decreased, rather than inflated, sense of self-esteem is associated with persistent depressive disorder

A nurse is reinforcing teaching with a school-age child who has conduct disorder and a new prescription for methylphenidate transdermal patches. Which of the following information should the nurse provide about the medication? A. Apply the patch once daily at bedtime B. Place the patch carefully in a trash can after removal C. Apply the transdermal patch to the anterior waist area D. Remove the patch each day after 9 hr

Remove the patch each day after 9 hr *The transdermal patch is applied once daily in the morning to a clean, dry area on the hip and is removed after 9 hr. For safety when discarding the transdermal preparation, the client should fold the patch and flush it down the toilet to prevent others from using it. The waist area should be avoided

A nurse is collecting data froma 4-year-old for indications of autism spectrum disorder. Which of the following findings should the nurse expect? A. Impulsive behavior B. Repetitive counting C. Destructiveness D. Somatic problems

Repetitive counting *Repetitive counting and strict routines are an indication of autism spectrum disorder *Impulsive behavior is an indication of ADHD rather than autism spectrum disorder *Destructiveness is an inidication of conduct disorder rather than autism spectrum disorder *Somatic problems are an indication of posttraumatic stress disorder rather than autism spectrum disorder

A nurse is reinforcing teaching with a client who has a new prescription for alprazolam for generalized anxiety disorder. Which of the following information should the nurse reinforce? A. Three to six weeks of treatment is required to achieve therapeutic benefit B. Combining alcohol with alprazolam will produce a paradoxical reponse C. Alprazolam has a lower risk for dependence than other antianxiety medications D. Report confusion as a potential indication of toxicity

Report confusion as a potential indication of toxicity *Confusion is a potential indication of alprazolam toxicity that the client should report to the provider *Buspirone, rather than alprazalom, requires 3-6 weeeks to achieve therapeutic benefit *Combining alcohol with alprazalam can produce CNS and respiratory depression rather than a paradoxical response *Alprazolam is preferably used for short-term treatment because of the increased risk of dependence

A nurse is caring for a client who is experiencing a panic attack, Which of the following actions should the nurse take? A. Discuss new relaxation techniques B. Show the client how to change the behavior C. Distract the client with a television show D. Stay with the client and remain quiet

Stay with the client and remain quiet *During a panic attack, quietly remain with the client. This promotes safety and reassurance without additional stimuli *During a panic attack the client is unable to concentrate on learning new information. *During a panic attack, avoid further stimuli that can increase the client's level of anxiety

A nurse on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts? A. Triangulation B. Group process C. Subgroup D. Hidden agenda

Subgroup *A subgroup is a small number of people withing a larger group who function separately from that group *Triangulation is when a third party is drawn into a relationship withing two members whose relationship is unstable *Group process is the verbal and nonverbal communication that occurs within the group during group sessions *A hidden agenda is when some group members have a different goal than the states group goals. The hidden agenda is often disruptive to the effective functioning of the group

A client tells a nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me." Which of the following actions should the nurse take? A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding the knife B. Keep the client's communication confidential, but watch the client and their roommate closely C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others D. Report the incident to the health care team, but do not inform the client of the intention to do so

Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others *The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue

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

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

A nurse is reviewing the medical record of a client who has a new prescription for buproprion for depression. Which of the following findings is the priority for the nurse to report to the provider? A. The client has a family history of seasonal pattern depression B. The client currently smokes 1.5 packs of cigarettes per day C. The client had a motor vehicle crash last year and sustatined a head injury D. The client has a BMI of 25 and has gained 10 lb over the last year

The client had a motor vehicle crash last year and sustatined a head injury *The greatest risk to the client is development of seizures. Buproprion can lower the seizure threshold and should be avoided by clients who have a history of a head injury. This information is the highest priority to report to the provider

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? A. The client presents a harm to self B. The client requested the admission C. The client consented to the admission D. The client provided written application to the facility for admission

The client presents a harm to self *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 B, C, and D describe the process of voluntary admission

The nurse in a psychitric 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? A. The client will be angry and will refuse care B. The client will participate in the treatment plan C. The client will be very resistant to treatment measures D. The client's family will be very resistant to treatment measures

The client will participate in the treatment plan *Generally, voluntary admission is sought by the client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program. Option A and C are not likely for a client seeking voluntary admission. Option D 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? A. Witnessing a murder B. The death of a loved one C. A fire that destroyed the client's home D. A recent rape episode experienced by the client

The death of a loved one *A situational crisis is associated with a lfie 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. Option A, C, and D 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 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? A. The false belief that one is a very powerful person B. The false belief that one is a very important person C. The false belief that one's partner is being unfaithful D. The false belief that one is being singled out for harm by others

The false belief that one is being singled out for harm by others *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

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse's use of interpersonal communication? A. The nurse discusses the client's weight loss during a health care team meeting B. The nurse examines their own personal feelings about clients who have anorexia nervosa C. The nurse asks the client about personal body image perception D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents

The nurse asks the client about personal body image perception *The nurse's one-on-one communication with the client is an example of interpersonal communication *The nurses's discussion of client information with members of the health care team is an example of small-group communication *The nurse's self-assessment of feelings is an example of intrapersonal communication *The nurse's educational presentation to a large group of adolescents is an example of public communication

A client taking lithium carbonate reports vomiting, abdominal pain, diarrheam blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up, and the level is 3.0 mEq/L. The nurse knows that this is which level? A. Toxic B. Normal C. Slightly above normal D. Excessively below normal

Toxic *The therapeutic serum level of lithium is 0.8 to 1.2 mEq/L. A level of 3 mEq/L indicates toxicity

A nurse is talking with a client who reports experiencing increased stress because a new partner is "pressuring me and my kids to go live with him. I love him, but I'm not ready to do that." Which of the following recommendations should the nurse make to promote a change in the client's situation? A. Learn to practice mindfulness B. Use assertiveness techniques C. Exercise regularly D. Rely on the support of a close friend

Use assertiveness techniques *Assertive communication allows the client to assert their feelings and then make a change in the situation *Mindfulness is appropriate to decrease the client's stress. However, it does not promote a change in the client's situation *Regular exercise is appropriate to decrease the client's stress. However, it does not promote a change in the client's sitation *Social supprt is appropraite to decrease the client's stress. However, it does not promote a change in the client's situation

A hospitalized client is taking clozapine for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication? A. Platelet count B. Cholesterol level C. White blood cell count D. Blood urea nitrogen level

White blood cell count *Hematological reactions can occur in the client taking clozapine and include agranulocytes and mild leukopenia. The white blood cell count should be checked before intitiating treatment ad should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. Options A, B, and D are unrelated to this medication

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? A. Dilated pupils, tachycardia, and diaphoresis B. Yawning, irritability, diaphoresis, cramps, and diarrhea C. Tachycardia, hypertension, sweating, and marked tremors D. Depressed feelings, high drug craving, fatigue, and agitation

Yawning, irritability, diaphoresis, cramps, and diarrhea *Opioids are central nervouse 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 B identifies the clinical manifestations associated with withdrawal from opioids. Option A describes intoxication from hallucinogens. Option C describes withdrawal from alchohol. Option D describes withdrawal from cocaine

a client taking buspirone (buspar) for 1 month returns to the clinic for a follow-up visit. which of the following would indicate medication effectiveness? A. no rapid heartbeats or anxiety B. no paranoid thought process C. no thought broadcasting or delusions D. no reports of alcohol withdrawal symptoms

no rapid heartbeats or anxiety *Buspirone hydrochloride is not recommended for the treatment of drug or alcohol withdrawal, paranoid thought disorders, or schizophrenia (thought broadcasting or delusions). Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take? A. Insist that the client stop yelling B. Request that other staff members remain close by C. Move as close to the client as possible D. Walk away from the client

Request that other staff members remain close by *Request that other staff members remain close by to assist if necessary *Do not make demands of the client by insiting that they stop yelling *Clients who are angry need a large personal space *Never walk away from a client who is angry. It is the nurse's responsibility to intervene as appropriate

Flueoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about the administration of this medication? A. "I should take the medication with my evening meal." B. "I should take the medication at noon with an antacid." C. "I should take the medication in the morning when I first arise." D. "I should take the medication right before bedtime with a snack."

"I should take the medication in the morning when I first arise." *Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). It is administered in the early morning without consideration to meals. Options A, B, and D are incorrect

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? A. The client's report of not eating or sleeping B. The presence of bruises on the client's body C. The client's report of self-destructive thoughts D. The family member is disapproving of the treatment

The client's report of self-destructive thoughts *The client's thoughts are extremely important when verbalized. Self-destructive thoughts are the highest priority. Options A, B, and D will all affect the treatment of the client but are not of greatest importance at this time

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." Whole helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? A. The mother should restrict the daughter's socializing time with her friends. B. The mother should restrict the amount of chocolate and caffeine products in the home C. The mother should keep her daughter out of school until she can adjust to the school environment D. The mother should consider taking time off of work to help her daughter readjust to the home enviroment

The mother should restrict the amount of chocolate and caffeine products in the home *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 A and C are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work

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

Use a night light and turn off the television *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 nurse's stations is not the intial intervention

A nurse hears a newly licensed nurse discussing a client's hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first? A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

Tell the nurse to stop discussing the behavior. *The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a a public place. The first action to take is to tell the newly licensed nurse to stop discuinning the client's hallucinations in a public location *Notify the nurse manager if the clien't right to privacy is violated. However, there is another action to take first *Provide an in-service program for staff about confidentiality, However, there is another action to take first *Complete an incident report about the violation there is another action to take first

A nurse is reinforcing teaching with a client about stress-reduction techniques. Which of the following client statements indicates understanding of the information? A. "Cognitive reframing will helpe me change my irrational thoughts to something positive." B. "Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate." C. "Biofeedback causes my body to release endorphins so that I feel less stress and anxiety." D. "Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety."

"Cognitive reframing will helpe me change my irrational thoughts to something positive." *Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way *Biofeedback, rather than progressive muscle training, uses a mechanical device to promote voluntary control over autonomic functions *Physical exercise, rather than biofeedback, causes a release of endorphins that lower anxiety and reduce stress *Priority restructuring, rather than mindfulness, teaches the client to prioritize differently to reduce the number of stressors

A nurse is assisting with the care of a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following reponses should the nurse make? A. "Why do you think you feel the need to give money away." B. "I am here to provide care and cannot accept this from you." C. "I can request that your case manager discuss appropriate charity options with you." D. "You should know that giving away your money us inappropriate."

"I am here to provide care and cannot accept this from you." *This statement is matter-of-fact and concise and is a therapeutic reponse to a client who has bipolar disorder *Asking a "why" question is a nontherapeutic form of communication and can promote a defensive client response *(C) This statement does not recognize the possibility of poor judgment, which is associated with nbipolar disorder. *(D) This statement offers disapproval and can be interpreted by the client as aggressive, which can promote a defensive client response

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A. "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

"I am no one, and everyone is me." *This comment indicates the client is experiencing a loss of identity or depersonalization *(A) This comment indicates the client is experiencing delusions of grandeur *(C) This comment indicates the client is experiencing a tactile hallucination *(D) This comment indicates the client is experiencing thought withdrawal

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, "I have to get home." Which of the following statements should the nurse make? A. "You have forgotten that this is your home." B. "You cannot go outside without a staff member." C. "Why would you want to leave? Aren't you happy with your care?" D. "I am your nurse. Let's walk together to your room."

"I am your nurse. Let's walk together to your room." *It is inappropriate to introduce oneself with each new interaction and to promote reality in a calm, reassuring manner *Avoid statements that can be interpreted as argumentative or demeaning *Use positive, rather than negative, statements *Using a "why" question can promote a defensive reaction and does not reinforce reality

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make? A. "Many clients are concerned about their weight. However, the dietitian will ensure that you don't get too many calories in your diet." B. "Instead of worrying about your weight, try to focus on other problems at this time." C. "I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." D. "You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you."

"I understand you have concerns about your weight, but first, let's talk about your recent accomplishments." *This statement acknowledges the client's concern and then focuses the conversation on the client's accomplishments, which can promote client self-esteem and self-image *(A) This statement minimizes and generalizes the client's concern and is therefore a nontherapeutic reponse *(B) This statement minimizes the client's concern and is therefore a nontherapeutic response *(C) This statement minimizes the client's concern and is therefore a nontherapeutic reponse

A nurse is reinforcing discharge teaching for a client who has schizophrenia and a new prescription for iloperidone. Which of the following client statements indicates understanding of the instructions? A. "I will be able to stop taking this medication as soon as I feel better." B. "If I feel drowsy during the day, I will stop taking this medication and call my provider." C. "I will be careful not to gain too much weight while taking this medication." D. "This medication is highly addictive and must be withdrawn slowly."

"I will be careful not to gain too much weight while taking this medication." *Antipsychotic medications (iloperidone) have a high risk of for significant weight gain. *Antipsychotic medications are considered a long-term treatment for schizophrenia. Discontinuing the medication can result in an exacerbation of manifestations *Drowsiness is a common adverse effect of antipsychotic medications. However, it is not appropriate to discontinue the medication *Antipyschotic medications are not considered addictive, and it is not necessary to titrate iloperidone when discontinuing treatment

A nurse is caring for a client who is to begin taking fluoxetine for treatment of panic disorder. Which of the following statements indicates the client understands the use of this medication? A. "I will take the medication at bedtime." B. "I will follow a low-sodium diet whike taking this medication." C. "I will need to discontinue this medication slowly." D. "I will be at risk for weight loss with long-term use of this medication."

"I will need to discontinue this medication slowly." *When discontinuing fluoxetine, the client should taper the medication slowly according to a prescribed tapered dosing schedule to reduce the risk of withdrawal symptoms *The client should take fluoxetine in the morning to minimize sleep disturbances *The client is at risk for hyponatremia while taking fluoxetine *The client is at risk for weight gain, rather than loss, with long-term use of fluoxetine

A nurse is caring for a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding? (select all that apply) A. Amenorrhea B. Hypokalemia C. Yellowing of the skin D. Slightly elevated body weight E. Presence of lanugo on the face

1. Hypokalemia 2. Slightly elevated body weight *Amenorrhea, Yellowing of the skin, and presence of lanugo is an expected finding of anorexia rather than bulimia nervosa

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements should the nurse expect from a client who has this type of personality disorder? A. "I'm scared that you're going to leave me." B. "I'll go to group therapy if you'll let me smoke." C. "I need to feel that everyone admires me." D. "I sometimes feel better if I cut myself."

"I'm scared that you're going to leave me." *Clients who have avoidant personality disorder often have a fear of abandonment. This type of statement is expected *(B) Thie statement indicates manipulation, which is expected from a client who has antisocial personality disorder *(C) This statement indicates a need for admiration, which is expected from a client who has narcissistic personality disorder *(D) This statement indicates a risk for self-injury, which is expected from a client who has borderline personality disorder

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing? A. "Life isn't worth living if I gain weight." B. "Don't pretend like you don't know how fat I am." C. "If I could be skinny, I know I'd be popular." D. "When I look in the mirror, I see myself as obese."

"Life isn't worth living if I gain weight." *This statement reflects the cognitive distortion of catastrophizing because the client's perception of their appearance or situation is much worse than their current condition *(B) This statement reflects the cognitive distortion of personalization rather than catastrophizing *(C) This statement reflects the cognitive distortion of overgeneralization rather than catastrophizing *(D) This statement reflects a perception of distorted body image commonly experienced by the client who has anorexia nervosa. However, it is not an example of catastrophizing

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of teaching? A. "Children older than 5 are at greater risk for abuse." B. "Substance use disorder does not increase the risk for violence." C. "Entering an intimate relationship increases the risk for violence." D. "Pregnancy increases the risk for violence from a spouse of partner."

"Pregnancy increases the risk for violence from a spouse of partner." *Pregancy tends to increase the likelihood of violence from a spouse or partner *Children younger than 4 years of age are at an increased risk for abuse *Substance use disorder increases the risk for violence *Vulnerable persons are an increased risl for violence when they try to leave the relationship

A nurse is caring for a client who is prescribed lithium therapy. The client tells the nurse of the plan to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Regular aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium fall too low."

"Regular aspirin would be a better choice than ibuprofen." *Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk of lithium toxicity. *Ibuprofen is not recommended for clients taking lithium. It does not decrease the effectiveness of ibuprofen but concurrent use is not recommended due to the risk of toxicity. It increases the risk for a toxic, rather than low, lithium level

A nurse is reinforcing teaching to a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy? A. "Even if my anxiety improves I will need to continue this therapy for 6 weeks." B. "The therapist will focus on my past relationships during our sessions." C. "Psychoanalysis will help me reduce my anxiety by changing my behaviors." D. "This therapy will address my conscious feelings about stressful experiences."

"The therapist will focus on my past relationships during our sessions." *Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder *Classical psychoanalysis is a therapeutic process that requires many sessions over months to years *Classical psychoanalysis focus on identifying and resolving the cause of the anxiety rather than changing behavior *Classical psychoanalysis assesses unconscious, rather than conscious, thoughts and feelings

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. "This medication increases the release of serotonin and norepinephrine." B. "I should tell the client about the likelihood of insomnia while taking this medication." C. "This medication is contraindicated for clients who have an eating disorder." D. "Sexual dysfunction is a common adverse effect of this medication."

"This medication increases the release of serotonin and norepinephrine." *Mirtazapine provides relief from depression by increasing the release of serotonin and norepinephrine *Tell the client about the likelihood of drowsiness rather than insomnia when taking this medication *Buproprion, rather than mirtazapine, is contraindicated in clients who have an eating disorder *Sexual dysfunction is an adverse effect of SSRIs rather than mirtazapine

A nurse is reinforcing teaching with a cliet who has alcohol use disorder and a new presciption for carbamezepine. Which of the following information should the nurse include? A. "This medication will help prevent seizures during alcohol withdrawal." B. "Taking this medication will decrease your cravings for alcohol." C. "This medication maintains your blood pressure at a normal level during alcohol withdrawal." D. "Taking this medication will improve your ability to maintain abstinence from alcohol."

"This medication will help prevent seizures during alcohol withdrawal." *Carbamazepine is used during withdrawal to decrease the risk for seizures *Carbamazepine is used to promote safe withdrawal rather than to decrease cravings for alcohol *Clonidine or propranolol is used during withdrawal to depress the autonomic response and its effect on blood pressure *Carbamazepine is used to promote safe withdrawal rather than abstinence

A nurse is caring for a client who has early stage Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication? A. "You should avoid taking over-the-counter acetaminophen while on donezepil." B. "You should take this medication before going to bed at the end of the day." C. "You will be screened for underlying kidney disease prior to starting donezepil." D. You should stop takine donezepil if you experience nausea or diarrhea."

"You should take this medication before going to bed at the end of the day." *Clients should take donezepil at the end of the day, just before going to bed, with or without food. *Clients taking donepezil should avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding *Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease *Gastrointestinal adverse effects are common with donepezil and can result in a dosage reduction

A nurse is caring for a client who lost their mother to cancer last month. The client states, "I'd still have my mother if the doctor would have made a diagnosis sooner." Which of the following responses should the nurse make? A. "You sound angry. Anger is a normal feeling associated with loss." B. "I think you would feel better if you talked about your feelings with a support group." C. "I understand just how you feel. I felt the same when my mother died." D. "Do other members of your family also feel this way?"

"You sound angry. Anger is a normal feeling associated with loss." *This is a therapeutic reponse for the nurse to make. This reposne acknowledges the client's emotion and privides education on the normal grief response. *(B) This response offers advice, which is a nontherapeutic technique *(C) This response minimizes the client's feelings and takes the focus away from the client, which are nontherapeutic communication techniques *(D) This reponse takes the focus away from the client, which is a nontherapeutic communication technique.

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? A. "Have you talked to your family about this?" B. "Everyone feels this way when they are depressed." C. "You will feel better once your medication begins to work." D. "You sound very upset. Are you thinking of hurting yourself?"

"You sound very upset. Are you thinking of hurting yourself?" *Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists. Option A, B, and C are not therapeutic responses

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

"You understand that people fear for their children, but you're feeling unfairly treated?" *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 C is the only option that reflects the use of this therapeutic communcation technique. Option A is insensitive and anxiety-provoking. Option B gives advice and does not facilitate the client's expression of feelings

A nurse is reinforcing teaching with the family of a client who has a substance use disorder. Which of the following statements by a family member indicates an understanding of the instruction? (Select all that apply) A. "We need to understand that our sibling is responsible for their disorder." B. "Eliminating codependent behavior will promote recovery." C. "Our sibling should participate in an Al-Anon group to assist with recovery." D. "The primary goal of treatment is abstinence from substance use." E. "Our sibling needs to discuss personal feelings about substance use to help with recovery."

1. "Eliminating codependent behavior will promote recovery." 2. "The primary goal of treatment is abstinence from substance use." 3. "Our sibling needs to discuss personal feelings about substance use to help with recovery." *Families should be aware of codependent behavior (enabling) that can promote substance use rather than recovery *Abstinence is the primary treatment goal for a client who has a substance use disorder *Clients must acknowledge their feelings about substance use as part of a substance use recovery program *Clients are not responsible for their disease but are responsible for their recovery *Al-Anon is a recovery group for the familu of a client, rahter than the client who has a substance use disorder

A nurse is discussin the use of methadone with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the instruction (select all that apply) A. "Methadone is a replacement for physical dependence to opioids." B. "Methadone reduces the unpleasant effects associated with abstinence syndrome." C. "Methadone can be used during opioid withdrawal and to maintain abstinence." D. "Methadone increases the risk for acetaldehyde syndrome." E. "Methadone must be prescribed and dispensed by an approved treatment center."

1. "Methadone is a replacement for physical dependence to opioids." 2. "Methadone reduces the unpleasant effects associated with abstinence syndrome." 3. "Methadone can be used during opioid withdrawal and to maintain abstinence." 4. "Methadone must be prescribed and dispensed by an approved treatment center." *Disulfiram, rather than methadone, places the client at risk for acetaldehyde syndrome if the client consumes alcohol while taking the medication

A nurse is collecting data from a client who has a major depressive disorder. The nurse should identify which of the following client statements as an overt comment about suicide? (select all that apply) A. "My family will be better off if I'm dead." B. "The stress in my life is too much to handle." C. "I wish my life was over." D. "I don't feel like I can ever be happy again. E. "If I kill myself then my problems will go away."

1. "My family will be better off if I'm dead." 2. "I wish my life was over." 3. "If I kill myself then my problems will go away." *These statements are overt commets about suicide in which the client directly talks about their perception of an outcome of their death. Monitor the client further for a suicide plan. the other 2 statements are covert comments in which the client identifies a problem but does not directly talk about suicide. Monitor the client further for suicidal ideation

A nurse is caring for a client who has alcohol use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? (Select all that apply) A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

1. Fine tremors of both hands 2. Vomiting 3. Restlessness *An expected finding of alcohol withdrawal is tachycardia rather than bradycardia *An expected finding of alcohol withdrawal is hypertension rather than hypotension

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include? (Select all that apply) A. "What is your relationship like with your family?" B. "Why do you want to lose weight?" C. "Would you describe your current eating habits?" D. "At what weight do you believe you will look better?" E. "Can you discuss your feelings about appearance?"

1. "What is your relationship like with your family?" 2. "Would you describe your current eating habits?" 3. "Can you discuss your feelings about appearance?" *A nursing history of a client who has anorexia nervosa should include data collection of family and interpersonal relationships, the client's current eating habits, and the client's perception of the issue *Asking a "why" question promotes a defensive client response and is therefore nontherapeutic *(D) This question promotes cognitive distortion, places the focus on weight, and implies that the client's current appearance is not acceptable

A nurse is caring for a client who has substance-induced psychotic disorder and is experiencing auditory hallucinations. The client states, "The voices won't leave me alone!" Which of the following statements should the nurse make? (select all that apply) A. "When did you start heaing these things?" B. "The voices are not real, or else we would both hear them." C. "It must be scary to hear voices." D. "Are the voices you hear telling you to hurt yourself?" E. "Why are the voices talking to only you?"

1. "When did you start heaing these things?" 2. "It must be scary to hear voices." 3. "Are the voices you hear telling you to hurt yourself?" *Ask the client directly about the hallucinations *Focus on the client's feelings rather than agreeing with the client's hallcunications *Monitor for command hallucinations and the client's risk for injury to self or others *Do not argue with the client's view of the situation *Avoid asking a "why" question, which is nontherapeutic and can promote a defensive client response

A nurse is reinforcing teaching with a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (select all that apply) A. An adverse effect of this medication is CNS depression B. Administer the medication in the morning C. Monitor for weight loss while taking this medication D. Therapeutic effects of this medication while taking this medication E. This medication blocks the synaptic reuptake of serotonin in the brain

1. Administer the medication in the morning 2. Monitor for weight loss while taking this medication 3. This medication blocks the synaptic reuptake of serotonin in the brain *Fluoxetine should be administered in the morning due to the potential for insomnia. It can result in weight loss. And it works by blocking the synaptic reuptake of serotonin, allowing more serotonin to stay at the junction of the neurons *An adverse effect of fluoxetine is CNS stimulation rather than CNS depression *Initial therapeutic effects of fluoxetine occur in 1 to 2 weeks, with full effectiveness occurring by 12 weeks.

A nurse is discussing the factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include? (Select all that apply) A. Age older than 65 years B. Anxiety disorder C. Childhood trauma D. Coronary artery disease E. Obesity

1. Anxiety disorder 2. Childhood trauma *Age 16 to 25 years, anxiety disorder, and childhood trauma are risk factors for somatic symptom disorder *CAD and Obesity are not risk factors

A nurse is completing admission data collection for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat affect

1. Auditory hallucination 2. Use of clang associations 3. Delusion of persecution 4. Constantly waving arms *Lack of motivation, or avolition and flat affect are examples of negative symptoms

A nurse is discussing manifestations of schizophrenia with a newly licensed nurse. Which of the following manifestations should the nurse identify as being effectively treated by first-generation antipsychotics? (select all that apply) A. Auditory hallucinations B. Withdrawal from social situations C. Delusions of grandeuer D. Severe agitation E. Anhedonia

1. Auditory hallucinations 2. Delusions of grandeuer 3. Severe agitation *First-generation antipsychotics have minimal effectiveness with negative symptoms of schizophrenia (social withdrawal and anhedonia)

A nurse is reinforcing teaching with a group of guardians about manifestations of conduct disorder. Which of the following findings should the nurse include? (select all that apply) A. Bullying of others B. Threats of suicide C. Law-breaking activities D. Nacissistic behavior E. Flat affect

1. Bullying of others 2. Threats of suicide 3. Law-breaking activities *Low self-esteem, rather than narcissism and irritability and temper outbursts, rather than flat affect are expected findings of conduct disorder

A nurse is collecting data on a client 4 hr after receiving an initial dose of fluoxetine. Which of the following findings should the nurse report to the RN and provider as indications of serotonin syndrome? (Select all that apply) A. Hypothermia B. Hallucinations C. Muscular flaccidity D. Diaphoresis E. Agitation

1. Hallucinations 2. Diaphoresis 3. Agitation *Fever, rather than hypothermia and muscle tremors, rather than flaccidity, are indications of serotonin syndrome

A nurse is caring for a client who takes paroxetine to treat post traumatic stress disorder. The client states, "I grind my teeth during the night, which causes pain in my mouth." The nurse should identify which of the following interventions as possible measures to manage the client's bruxism? (Select all that apply) A. Concurrent administration of buspirone B. Administration of a different SSRI C. Use of a mouth guard D. Changing to a different class of antianxiety medication E. Increasing the dose of paroxetine

1. Concurrent administration of buspirone 2. Use of a mouth guard 3. Changing to a different class of antianxiety medication *Other SSRIs will also have bruxism as an adverse effect and increasing the dose of paroxetine can cause the adverse effect to worsen; therefore these are not effective measures

A nurse is assisting with the development of protocols to address the increasing number of suicide attempts in the community. Which of the following interventions should the nurse include as a primary intervention? (Select all that apply) A. Conducting a suicide risk screening on all new clients B. Creating a support group for family members of clients who died by suicide C. Informing high school teens about suicide prevention D. Initiating one-on-one observation for a client who has current suicidal ideation E. Reinforcing teaching middle-school educators about warning indicators of suicide

1. Conducting a suicide risk screening on all new clients 2. Informing high school teens about suicide prevention 3. Reinforcing teaching middle-school educators about warning indicators of suicide *Primary interventions include suicide prevention through the use of screenings to identify individuals at risk and through the use of community education. Conducting a suicide risk screening on all new clients is an example of a primary intervention. Informing high school teens about suicide prevention and reinforcing teaching with middle-school teachers to recognize the warning indicators are examples of primary intervention. *Creating a support group for family members of clients who died by suicide is an example of a tertiary intervention *Initiating one-on-one observation for a client who has current suicidal ideation is an example of a secondary intervention

A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (select all that apply) A. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

1. Depressed immune system 2. Increased blood pressure 3. Unhappiness *A depressed immune system, increased blood pressure, and unhappiness is an indicator of acute stress *Chronic pain and panic attacks indicates a prolonged or maladaptive stress response

A nurse is assisting the guardians of a school-age child who has oppositional defiant disorder in identifying strategies to promote positive behavior. Which of the following strategies should the nurse recommend? (Select all that apply) A. Allow the child to choose which behaviors are unacceptable B. Use role-playing to act out unacceptable behavior C. Develop a reward system for acceptable behavior D. Encourage the child to participate in school sports E. Be consistent when addressing unacceptable behavior

1. Develop a reward system for acceptable behavior 2. Encourage the child to participate in school sports 3. Be consistent when addressing unacceptable behavior *The guardians should have a method to reward the child for acceptable behavior. Encourage physical activity through which the child can use energy and obtain success, and set clear limits on unacceptable behavior. They should focus on acceptable behavior and demonstrate this through modeling

A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (select all that apply) A. Difficulty concentrating on tasks B. Obsessive need to talk about the traumatic event C. Negative self-image D. Recurring nightmares E. Diminished reflexes

1. Difficulty concentrating on tasks 2. Negative self-image 3. Recurring nightmares *Manifestations of PTSD include the inability to concentrate on or complete tasks, feeling guilty and having a negative self-image, and recurring nightmares or flashbacks *A client who has PTSD is reluctant to talk about the traumatic event that triggered the disorder *A client who has PTSD has an increased startle reflex and hypervigilence

A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (Select all that apply) A. Male sex B. History of chronic bronchitis C. Recent death in client's family D. Family history of depression E. Personal history of panic disorder

1. History of chronic bronchitis 2. Recent death in client's family 3. Family history of depression 4. Personal history of panic disorder *Depressive disorders are more common in a client who has a chronic medical condition, are more likely to occur in a client who is experiencing a high amount of stress (when grievin the death of a family member), those who have a family history of depression, and has a history of an anxiety or personality disorder. Females are twice as likely as males to experience a depressive disorder

A nurse is assisting with the preparation of a staff education session on personality disorders. Which of the following personality characteristics associated with all of the personality disorders should the nurse include? (Select all that apply) A. Difficulty in getting along with other members of a group B. Belief in the ability to become invisible during times of stress C. Display of defense mechanisms when routines are changed D. Claiming to be more important than other persons E. Difficulty understanding why it is inappropriate to have a personal relationship with staff

1. Difficulty in getting along with other members of a group 2. Display of defense mechanisms when routines are changed 3. Difficulty understanding why it is inappropriate to have a personal relationship with staff *Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types *Maladaptive responses to stress is a personality characteristic that can be seen in clients who has experiencing personality disorders *Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types *Clients who have schizotypal personality disorder can display magical thinking or delusions. However, this is not associated with all personality disorder types *Clients who have narcissistic personality disorder can display gradiose thinking. However, this is not associated with all personality disorder types

A nurse is reinforcing teaching about relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse review? (select all that apply) A. Use caffeine in moderation to prevent relapse B. Difficulty sleeping can indicate a relapse C. Begin taking your medications as soon as a relapse begins D. Participating in psychotherapy can help prevent a relapse E. Anhedonia is a clinical manifestation of a depressive relapse

1. Difficulty sleeping can indicate a relapse 2. Participating in psychotherapy can help prevent a relapse 3. Anhedonia is a clinical manifestation of a depressive relapse *The client who has bipolar disorder should avoid the use of caffeine because it can precipitate a relapse *The client who has bipolar disorder should take prescribed medications to prevent and minimize a relapse

A nurse is assisting in the discharge planning for a client following alcohol detoxification. The nurse should expect prescriptions to promote long-term abstinence from alcohol? (select all that apply) A. Lorazepam B. Diazepam C. Disulfiram D. Naltrexone E. Acamprosate

1. Disulfiram 2. Naltrexone 3. Acamprosate *Disulfiram promotes abstinence through aversion therapy *Naltrexone promotes abstinene by suppressing the cravig and pleasurable effects of alcohol *Acamprosate decreases the unpleasant effects resulting from abstinence *Lorazepam is prescribed for short-term use during withdrawal *Diazepam is prescribed for short-term use during withdrawal

A nurse is collecting data for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect? (select all that apply) A. History of gradual memory loss B. Family report of personality changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

1. Family report of personality changes 2. Hallucinations 3. Restlessness *The client who has delirium can experience rapid personality changes *The client who has delirium can have perceptual disturbances (hallucinations and illusions) *The client who has delirium commonly exhibits restlessness and agitation *The client who has delirium can experience memory loss with sudden rather than gradual onset *The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate

A nurse is collecting data from a client following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply) A. Hypotension B. Paralytic ileus C. Memory loss D. Polyuria E. Confusion

1. Memory loss 2. Confusion *Transient short-term memory loss and confusion is an expected finding immediately following ECT *Following ECT, the client's blood pressure is expected to be elevated *Paralytic ileus and polyuria are not an expected findings of ECT

A nurse is assisting with planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse recommend for inclusion in the plan of care? (Select all that apply) A. Provide flexible client behavior expectations B. Offer concise explanations C. Establish consistent limits D. Disregard client concerns E. Use a firm approach with communication

1. Offer concise explanations 2. Establish consistent limits 3. Use a firm approach with communication *Offering concise explanations improves the client's ability to focus and comprehend the information *Establishing consistent limits decreases the risk for client manipulation *Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors *Establish consistent behavior expectations to decrease the risk for client manipulation *Repond to valid client concerns to foster a trusing nurse-client relationship

A nurse is caring for a client who takes ziprasidone. The client reports difficulty swallowing the oral medication and becomes extremely agitated with injectable administration. The nurse should contact the provider to request a change to which of the following medications? (select all that apply) A. Olanzapine B. Quetiapine C. Aripriprazole D. Clozapine E. Asenapine

1. Olanzapine 2. Aripriprazole 3. Clozapine 4. Asenapine *Quetiapine is available only in tablets or extended-release tablets and will therefore not address the current concerns with medication administration. The other medications areavailable in an orally disintegrating appropriate for clients who have difficulty swallowing tablets. This route also decreases the risk for agitation associated with an injection.

A nurse is caring for a client who is taking phenelzine. For which of the following manifestations should the nurse monitor as an adverse effect of this medication? (Select all that apply) A. Elevated blood glucose level B. Orthostatic hypotension C. Priapism D. Hypomania E. Bruxism

1. Orthostatic hypotension 2. Hypomania *An elevated blood glucose is anot an adverse effect of phenelzine *Priapism is an adverse effect of trazodone, rather than phenelzine *Bruxism is an adverse effect of SSRIs, rahter than phenelzine

A nurse is collecting data on a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is experiencing prodromal syndrome? (select all that apply) A. Lethargy B. Pacing C. Orientation D. Facial grimacing E. Agitation

1. Pacing 2. Facial grimacing 3. Agitation *Lethargy is more likely to be observed in a client who has depression *Disorientation is more likely to be found in a client who has a cognitive disorder

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the discussion? (Select all that apply) A. Constipation B. Polyruria C. Rash D. Muscle weakness E. Tinnitus

1. Polyruria 2. Muscle weakness *Diarrhea, rather than constipation, is an early indication of lithium toxicity *A rash is not indicated of lithium toxicity *Tinnitus is an indication of severe, rather than early, toxicity

A nurse is assisting with planning cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse recommend to include in the plan of care? (Select all that apply) A. Priority restructering B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation

1. Priority restructering 2. Monitoring thoughts 3. Journal keeping *Diaphragmatic breathing is a form of behavioral reframing technique *Meditation is a form of behavioral therapy rather than a cognitive reframing technique

A nurse is preparing to collect data from an infant. Which of the following is an expected finding of shaken baby syndrome? (select all that apply) A. Sunken fontanels B. Respiratory distress C. Retinal hemorrhage D. Altered level of consciousness E. Increase in head circumference

1. Respiratory distress 2. Retinal hemorrhage 3. Altered level of consciousness 4. Increase in head circumference *Bulging, rather than sunken, fontanels are an expected finding of shaken baby syndrome

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) A. Restating B. Listening C. Asking the client, "Why?" D. Maintaining neutral responses E. Giving advice, approval, or diapproval F. Providing acknowledment and feedback

1. Restating 2. Listening 3. Maintaining neutral responses 4. Providing acknowledment and feedback *Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad opening 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 non-verbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic

A nurse is collecting data from a preschool-age child who reports abdominal pain. Which of the following findings should alert the nurse to possible abuse? (select all that apply) A. Abrasions on knees B. Round burn marks on forearms C. Mismatched clothing D. Abdominal rebound tenderness E. Areas of ecchymosis on torso

1. Round burn marks on forearms 2. Areas of ecchymosis on torso *Minor injuries (abrasions) on the arms and legs are common in this age group *Mismatched clothing is consistent with the child's need for independence at this age *Abdominal rebound tenderness is a possible indication of appendicitis rather than abuse

A nurse is reinforcing teaching with the parents of a child who has autism spectrum disorder and a new prescription for imipramine about indications of toxicity. Which of the the following should the nurse include? (select all that apply) A. Seizures B. Agitations C. Photophobia D. Dry mouth E. Irregular pulse

1. Seizures 2. Agitations 3. Irregular pulse *Photophobia and dry mouth are an anticholinergic effect rather than an indication of TCA toxicity

A nurse is caring for a client following the loss of a partner due to a terminal illness. Identify the sequence of Engel's five stages of grief that the nurse should expect the client to experience A. Developing awareness B. Restitution C. Shock and disbelief D. Recovery E. Resolution of the loss

1. Shock and disbelief (the client experiences a sense of numbness and denial over the loss) 2. Developing awareness (the client becomes aware of the reality of the loss resulting in intense feelings of gried. This begins withing hours of the loss) 3. Restitution (The client carries out cultural/religious rituals {a funeral} following the loss) 4. Resolution (The client is preoccupied with the loss. This preoccupation gradually decreases over about a 12-month period) 5. Recovery (The client moves past the preoccupation with the loss and moves forward with life.)

A nurse is collecting data during the admission of an adolescent client who has depression. Which of the following findings should the nurse expect? (select all that apply) A. Fear of being alone B. Substance use C. Weight gain D. Irritability E. Aggressiveness

1. Substance use 2. Irritability 3. Aggressiveness *solitary play or work, rather than the fear of being alone and Loss of weight and appetite, not weight gain are expected findings associated with depression

A nurse is assisting with a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse recommend to help prevent developing a trauma-related disorder? (Select all that apply) A. Avoid thinking about the incident when it is over B. Take breaks during the incident for food and water C. Debrief with others following the incident D. Avoid displays of emotion in the days following the incident E. Take advantage of offered counseling

1. Take breaks during the incident for food and water 2. Debrief with others following the incident 3. Take advantage of offered counseling *Thinking and talking about a traumatic incident can help prevent development of a trauma-related disorder *Displaying emotions following a traumatic incident can help prevent development of a trauma-related disorder

A nurse is reinforcing teaching to a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching? (select all that apply) A. Void just before taking the medication B. Increase the dietary intake of potassium C. Wear sunglasses when outside D. Change positions slowly when getting up E. Chew sugarless gum

1. Void just before taking the medication 2. Wear sunglasses when outside 3. Chew sugarless gum *Voiding minimizies urinary hesitancy or retention, sunglasses minimizes the effect of photophobia, and chewing sugarless gum minimizes the effect of dry mouth. orthostatic hypotension is not an anticholinergic effect and the client's potassium level is not effected with imipramine

A nurse is reinforcing teaching with an adolescent client who is to begin taking atomoxetine for ADHD. The nurse should instruct the client to monitor for which of the following adverse effects? A. Somnolence B. Yellowing skin C. Increased appetite D. Fever E. Malaise

1. Yellowing skin 2. Fever 3. Malaise *Yellowing skin, fever, and malaise is a potential indication of hepatotoxicity that the client should report to the provider *Insomnia, rather than somnolence, is an adverse effect that the client should report to the provider *Decreased appetite with resulting weight loss, rather than an increased appetite is a potential adverse effect that the client should report to the provider

A nurse is collecting data for a client who has illness anxiety disorder. Which of the following are expected for this disorder? (select all that apply) A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of health care providers D. Depressive disorder E. Narcisstic disorder

1A. Obsessive thoughts about disease 2. History of childhood abuse 3. Avoidance of health care providers 4. Depressive disorder *Low self-esteem is an expected finidng in a client who has illness anxiety disorder

A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role? A. A member who praise input from other members B. A member who follows the direction of other members C. A member who brags about accomplishments D. A member who evaluates the group's performance toward a standard

A member who brags about accomplishments *An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals *An individual who praises the input of others is acting in a maintenance role *An individual who is a follower is acting in a maintenance role *An individual who evaluates the group's performance is acting in a task role

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior.

Ask the client, "Are you seeing something on the ceiling?" *Ask the client directly about the halluncation to identify client needs to monitor for a potential risk for injury *Address the client's current needs related to the possible hallucincation rather than stop the interview *Avoid agreeing with the client, which can promote psychotic thinking *Address the client's current needs related to the possible hallucination rather than ignoring the change in behavior

A nurse wants to use democratic keadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions? A. Observes group techniques without interfering interfering with the group process B. Discusses a technique and then directs members to practice of the technique C. Asks for group suggestions of techniques and then supports discussion D. Suggests techniques and asks group members to reflect on their use

Asks for group suggestions of techniques and then supports discussion *Democratic leadership supports group interaction and decision making to solve problems *Laissez-faire leadership allows the group process to progress without any attempt by the leader to control the direction of the group *Autocratic leadership controls the direction of the group

A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe metal illness and requires supervision. The client's partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care? A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visting a community mental health center on a daily basis

Attending a partial hospitalization program *A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present *Daily care provided by a home health aide and weekly visits from a case worker will not provide adequate supervision for this client *Daily visits to a community mental health center will not provide consistent supervision for this client

A nurse is reinforcing teaching to a client who has tobacco use disorder about the use of nicotine gum. Which of the following information should the nurse reinforce? A. Chew the gum for no more than 10 min B. Rinse out the mouth immediately before chewing the gum C. Avoid eating 15 min prior to chewing the gum D. Use of the gum is limited to 90 days

Avoid eating 15 min prior to chewing the gum *The client should avoid eating or drinking 15 min prior to and while chewing the gum *The client should chew the gum slowly and intermittently over 30 min *The client should avoid drinking 15 min prior to chewing gum *Use of nicotine gum is not recommended for longer than 6 months

A nurse is attending a peer group discussion about the indications for ECT. Which of the following indications should the nurse recommend for inclusion in the discussion? A. Borderline personality disorder B. Acute withdrawal related to a substance use disorder C. Bipolar disorder with rapid cycling D. Dysphoric disorder

Bipolar disorder with rapid cycling *ECT is indicated for the treatment of bipolar with rapid cycling *ECT has not been found to be effective for the treatment of personality disorders, substance use disorders, or dysphoric disorder

A client was admitted to a medical unit with acute blindness. Many tests are performer, and ther eseems 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 family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? A. Psychosis B. Repression C. Conversion disorder D. Dissociative disorder

Conversion disorder *A conversion disorder is the alteration or loss of a physical function that cannot be explained by any know 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. Pyschosis 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

A nurse is assisting with developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include? A. Encourage the client to spend time alone in their room B. Monitor the client for self-harm once per day C. Allow the client unlimited time to discuss physical manifestations D. Discuss alternative coping strategies with the client

Discuss alternative coping strategies with the client *Discuss alternative coping strategies withthe client, Encourage the client to communicate with others and participate in group therapy and support groups, Continuously monitor the client for risk of self-harm, Establish a time limit for discussion of physical manifestations

A nurse is contributing to the plan of care for a client during the termination phase of the nurse-client relationship. Which of the following interventions should the nurse include? A. Discussing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries

Discussing ways to use new behaviors *Discussing ways for the client to incorporate new healthy behaviors is an appropriate task for the termination phase *Practicing new problem-solving skills is an appropriate task for the working phase *Developing goals is an appropraite task for the orientation phase *Establishing boundaries is an appropriate task for the orientation phase

A nurse is caring for a client who is on suicide precautions. Which of the following interventions should the nurse contribute to the plan of care? A. Assign the client to a private room B. Document the client's behavior every hour C. Allow the client to keep perfume in their room D. Ensure that the client swallows medication

Ensure that the client swallows medication *Ensure that the client swallows medication to prevent hoarding of medication for an attempt to exceed the prescribed dose *Clients who are suicidal should not be assigned a private room *Client's behavior should be documented every 15 min or according to facility policy *Remove perfume from the client's room

A community mental health nurse is assisting with the plannin of care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse recommend the RN implement as a method of tertiary prevention? A. Educate clients on health promotion techniques to reduce the risk of depression B. Perform screenings for depression at community health problems C. Establish rehabilitation programs to decrease theeffecets of depression D. Provide support groups for clients at risk for depression

Establish rehabilitation programs to decrease theeffecets of depression *Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness *(A) This intervention is an example of primary prevention *(B) This interventio is an example of secondary prevention *(D) This intervention is an example of primary prevention

A nurse is assisting with providing care for a client who has benzodiazepine toxicity. Which of the following actions is the nurse's priority? A. Administer flumazenil B. Idenitify the client's level of orientation C. Ensure the administration of IV fluids D. Prepare the client for gastric lavage

Idenitify the client's level of orientation *When taking the nursing process approach to client care, the intial step is data collection. Identifying the client's level of orientation is the priority action *Administer flumazenil will reverse the effects of benzodiaxepine, ensure the administration of IV fluids to maintain blood pressure, and gastric lavage will remove excessive medication from the client's GI system; however, another action is the priority

A nurse is contributing to the plan of care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following interventions should the nurse include? A. Allow the client to select preferred meal times B. Establish consequences for purging behavior C. Provide the client with a high-fat diet at the start of treatment D. Implement one-to-one observation during meal times

Implement one-to-one observation during meal times *Closely monitor the client during and after meals to prevent purging *Provide a highly structured milieu, including meal times, for the client requiring acute care for the treatment of anorexia nervosa *Use a positive approach to client care that includes rewards rather than consequences *Limit high-fat and gas-producing foods at the start of treatment

A nurse is contributing to the plan of care of a client who is experiencing benzodiazepine withdrawal. Which of the following interventions should the nurse identify as the priority? A. Orient the client frequently to time, place, and person B. Offer fluids and nourishing diet as tolerated C. Implement seizure precautions D. Encourage participation in group therapy sessions

Implement seizure precautions *The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention *The other 3 are appropriate interventions but are not the highest priority

A nurse is discussing home care with the partner of a client who is in the late stage of Alzheimer's disease. The partner, who wil be the primary caregiver, wishes to discuss concerns about the client's nutrition and the stress of providing care. Which of the following actions should the nurse take? A. Verify that a current power of attorney document is on file B. Instruct the client's partner to offer finger foods to increase oral intake C. Provide information on resources for respite care D. Schedule the client for placement of an enteral feeding tube

Provide information on resources for respite care *Providing information on resources for respite care is a correct action to provide the client's partner with a break from caregiving responsibilities *A power of attorney document does not address the client's care or the concerns of the caregiver *Clients in late-stage Alzheimer's disease are at risk for choking and are unable to eat without assistance. Offering finger foods is not a correct action *Placement of an enteral feeding tube is correct only with a prescription from the provider following a discussion that includes the provider, nurse, client's partner, and possibly social services and additional family members

A nurse is caring for a client who has schizophrenia and exhibits a lack of grooming and a flat effect. The nurse should expect a prescription from the provider for which of the following medications? A. Chlorpromazine B. Thithixene C. Risperidone D. Haloperidol

Risperidone *Second-generation antipsychotics (risperidone) are effective in treating negative symptoms of schizophrenia (lack of grooming and flat effect) *First-generation antipsychotics (Chlorpromazine, Thithixene, and Haloperidol) are used mainly to control positive, rather than negative, symptoms of schizophrenia

A nurse is caring for a client whp has borderline personality disorder. The client says, "The nurse on the evening shift is always nice! You are the meanest nurse ever!" The nurse should recognize the client's statement is an example of which of the following defense mechanism? A. Regression B. Splitting C. Undoing D. Identification

Splitting *Splititng occurs when a person is unable to see both positive and negative qualities at the same time. The client who has borderline personality disorder tends to see a person as all bad one time and all good another time *Regression refers to resorting to an earlier way of functioning (having a temper tantrum) *Undoing is a behavior that is intended to undo or reverse unacceptable thoughts or acts (buying a gift for a spouse agfter having an extramarital affair) *In identification, the person imitates the behavior of someone admired or feared

A nurse is assisting with collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect? A. The client remembers many details about the traumatic incident B. The client expresses heightened elation about what is happening C. The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occurred D. The client expresses a sense of unreality about the traumatic incident

The client expresses a sense of unreality about the traumatic incident *The client who has ASD often expresses dissociative manifestations regarding the even, which includes a sense of unreality *The client who has ASD tends to be unable to remember details about the incident and can block the entire incident from memory *The client who has ASD reacts to what is happening with negative emotions (anger, guilt, depression, and anxiety). Elation is an emotion that can occur in clients who have mania *Manifestations of ASD occur immediately to a few days following the event

A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization? A. The client describes a feeling of floating above the ground B. The client has suspicions of being targeted in order to be killed and robbed C. The client states that the furniture in the room seems to be small and far away D. The client cannot recall anything that happened during the past 2 weeks.

The client states that the furniture in the room seems to be small and far away *Stating that one's surroundings are far away or unreal in some way is an example of derealization *Feeling that one's body is floating above the ground is an example of depersonalization, in which the person seems to observe their own body from a distance *Having the idea of being targeted in order to be killed and robbed is an example of a paranoid delusion *Being unable to recall any events from the past 2 weeks is an example of amnesia

A nurse in an acute mental health facility is assisting with planning care for a client who has dissociative fugue. Which of the following interventions should the urse recommend? A. Reinforce with the client to recognize how stress brings on a personality change in the client B. Repeatedly present the client with information about past events C. Make decisions for the cliient on grounding techniques D. Work with the client on grounding techniques

Work with the client on grounding techniques *Grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful for clients whp have a dissociative disorder and are experiencing manifestations of derealization *The client who has dissociative identity disorder displays multiple personalities, while the client who has dissociative fugue has amnesia regarding their identity and past *Avoid flooding the client with information about past events, which can increase the client's level of anxiety *Encourage the client to make decisions regarding routine daily activities in order to promote improved self-esteem and decrease the client's feelings of powerlessness

A client with a diagnoses 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? A. A client with pneumonia B. A client receiving diagnostic tests C. A client who thrives on managing others D. A client who could benifit from the client's assistance at mealtimes

A client receiving diagnostic tests *The client is receiving diagnostic tests is an appropriate roommate. The client withanorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client 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 ti sublimation and suppression of his or her own hunger

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

"Sometimes people hear things or voices others can't hear." *It is important for the nurse to reinforce reality with the client. Options A, B, and D do not reinforce reality but reinforce the hallucination that the voices are real

A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission? A. A client who has schizophrenia with delusions of grandeur B. A client who has manifestations of depression and attempted suicide a year ago C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod D. A client who has bipolar disorder and paces quickly around the room while talking to themselves

A client who has borderline personality disorder and assaulted a homeless man with a metal rod *A client who is in current danger to self or others is a candidate for a temporary emergency admission

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. A crisis state indicates that the individual is suffering from a mental illness B. A crisis state indicates that the individual is suffering from an emotional illess C. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis D. 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 client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person *Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness

Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication? A. A history of hyperthryoidism B. A history of diabetes insipidus C. When the last full meal was consumed D. When the last alcoholic drink was consumed

When the last alcoholic drink was consumed * Disulfiram is used as an adjacent treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administed. The most important data are to determine when the las alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothryoidism, epilepsy, cerebral damage, nphritis, and hepaptic disease. It is contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication

A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to reinforce necessary information to the client? (select all that apply) A. Reassure the client that everything will be okay B. Discuss prior use of coping mechanisms with the client C. Ignore the client's anxiety so that she will not be embarrassed D. Demonstrate a calm manner while using simple and clear directions E. Gather information from the client using closed-ended questions

1. Discuss prior use of coping mechanisms with the client 2. Demonstrate a calm manner while using simple and clear directions *Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor *Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others *Providing false reassurance is an example of nontherapeutic communication *Recognizing the client's current level of anxiety assists the client to begin the process of problem solving *Using open-ended questions for client communication encourages the client to express feelings and identify the source of the anxiety

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? A. Agoraphobia B. Hematophobia C. Claustrophobia D. Hypochondriasis

Agoraphobia *Agoraphobia is a fear of being alone in open of 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 situtations 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

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? A. "My medications won't make me anxious." B. "I'll go to a support group and talk so that I won't hurt anyone." C. "I won't get anxious or hear things if I get enough sleep and eat well." D. "I can call my therapist when I'm hallucinating so I can talk about my feelinds and plans and not hurt anyone."

"I can call my therapist when I'm hallucinating so I can talk about my feelinds and plans and not hurt anyone. *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 muscluar activity associated with a hallucination. Option D is a specific agreement to seek help and evidences self-responsible commitment and control over his or her own behavior

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? A. "In 7 days" B. "In 14 days" C. In 21 days" D. "Within a few hours"

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

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? (Select all that apply) A. Discourage reminiscing B. Make the decisions for the family C. Encourage expression of feelings, concerns, and fears D. Explain everything that is happening to all family members E. Extend touch, and hold the client or family member's hand if appropriate F. Be honest and truthful, and let the client and family know that you will not abandon them

1. Encourage expression of feelings, concerns, and fears 2. Extend touch, and hold the client or family member's hand if appropriate 3. Be honest and truthful, and let the client and family know that you will not abandon them *The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision making process if asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. It is important to extend touch and to hold the client of family member's hand if appropriate

A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? (select all that apply) A. Figs B. Yogurt C. Crackers D. Aged cheese E. Tossed salad F. Oatmeal cookies

1. Figs 2. Yogurt 3. Aged cheese *Phenelzine sulfate is a monoamine oxidase inhibitor. the client should avoid consuming foods that are high in tyramine. Eating these foods could trigger a potentially fatal hypertensive crisis. Some foods to avoid inclide yogurt, aged cheeses, smoked or process meats, red wines, and fruits such as avocados, raisins, and figs

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? A. Request that a peer remain with the client at all times B. Remove the client's clothing and place the client in a hospital gown C. Assign a staff member to the client who will remain with him or her at all times D. Admit the client to a seclusion room where all potentially dangerous articles are removed

Assign a staff member to the client who will remain with him or her at all times *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

A nurse in a mental health practitioner's office is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" Which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

Restating *Restating allows the nurse to repeat the main idea expressed *Offering general leads allows the nurse to take the direction of the discussion *Summarizing enables the nurse to bring together important points of discussion to enhance understanding *Focusing concentrates the attention on one single poing

A client arrives at teh health care clinic and tells the nurse that they have been doubling their daily dosage of bubpropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem? A. Insomnia B. Weight gain C. Seizure activity D. Orthostatic hypotension

Seizure activity *Buproprion is an atypical antidepressant and does not cause significant orthostatic blood pressure changes. Seizure activity is common in dosages greater than 450 mg daily. Buproprion frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity causes a greater client risk

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? A. Ask direct questions to encourage talking B. Leave the client alone and intermittently check on them C. Sit beside the client in silence and verbalize occasional open-ended questions D. Take the client into the dayroom with other clients so they can help watch him

Sit beside the client in silence and verbalize occasional open-ended questions *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 symtoms rarely occur. Option D relies on other clients to care for this one, which is an appropriate expectation. Asking direct questions of this client is not therapeutic. Option C is the best action because it provides for client supervision and communication as appropriate

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? A. "Why did you get started on these drugs?" B. "How much do you use and what effect does it have on you?" C. "How long did you think you could take thse drugs without someone finding out?" D. The nurse does not ask any questions because of fear that the client is in denial and will thrown the nurse out of the room

"How much do you use and what effect does it have on you?" *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 A is incorrect because it is judgmental, off focus, and reflects the nurse's bias. Option C is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option D is incorrect bercause it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention

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? A. "I cannot discuss any client situation with you." B. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" C. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." D. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"

"I cannot discuss any client situation with you." *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 C is correct in a sense, but it is a rather blunt statement. Both options B and D identify statments that do not maintaing client confidentiality

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? A. "No, I won't tell anyone." B. "I cannot promise to keep a secret." C. "If you tell me the secret, I will tell it to your doctor." D. "If you tell me the secret, I will need to document it in your record."

"I cannot promise to keep a secret." *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

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

"I feel better able to care for my father now that I know where to obtain assistance." *Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance with careing for aging family members can bring much needed relief. Taking advantage of these alternatives is a postive alternative coping strategy, which many families use

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? A. "I no longer feel that I deserve the beatings my husband inflicts on me." B. "My attendance at the meetings has helped me to see that I provoke my husband's violence." C. "I enjoy attending the meetings because they get me out of the house and away from my husband." D. "I can tolerate my husband's destructive behaviors now that I know they are common for alcoholics."

"I no longer feel that I deserve the beatings my husband inflicts on me." *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 A is the healthiest response becuase it exemplifies an understanding that the alcholic 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 B). Oprion C indicates that the group is being seen as an escape, not a place to work on issues. Option D indicates that the wife remains codependent

A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child's condition, which of the following responses should the nurse make? A. "I think your child is getting better. What have you noticed?" B. "I'm sure everything will be okay. It just takes time to heal." C. "I'm not sure what's wrong. Have you asked the doctor about your concerns." D. "I understand you're concerned. Let's discuss what concerns you specifically."

"I understand you're concerned. Let's discuss what concerns you specifically." *This therapeutic response reflects upon, and accepts, the caregovers' feelings, and it allows them to clarify what they are feeling *(A) This nontherapeutic response interjects the nurse's opinion and can cause the caregiver to withhold their thoughts and feelings *(B) This nontherapeutic response interjects the nurse's opinion and provides false reassurance which can cause the caregiver to withhold their thoughts and feelings *(C) This nontherapeutic response avoids addressing the caregiver's concerns directly and indicates disinterest by the nurse for wanting to discuss the concerns with the parents

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? A. "It sounds as though you need to speak to the psychiatrist. B. "Perhaps you'd like to see the ECT room and speak to the staff." C. "Your child has decided to have this treatment. You should be supportive of the decision." D. "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?"

"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?" *The nurse needs to encourage the family and client to verbalize their fears and concerns. Option D is the only option that encourages verbalization. Options A, B, and C avoid dealing with the client or family concerns

A nurse is talking with a client who is at risk for suicide following their partner's death. Which of the following statements should the nurse make? A. "You will feel much better with time. I promise." B. "Suicide is not the appropriate way to cope with loss." C. "Losing someone close to you must be very upsetting." D. "I know how difficult it is to lose someone close to you."

"Losing someone close to you must be very upsetting." *This statement is an empathetic response that attempts to understand the client's feelings *(A) This statement gives the client false reassurance and is therefore not therapeutic *(B) This statement implies judgment and is therefore not an empathetic or therapeutic reponse *(D) This statement focuses on the nurse's experiences rather than the client's and is therefore not therapeutic

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 reponse by the nurse should be which statement? A. "Why don't you tell your husband about this?" B. "This is not the best time to make that decision." C. "What do you find difficult about this situation?" D. "I agree with you. You should get out of this situation."

"What do you find difficult about this situation?" *The most helpful response is the one that encourages the client to problem solve. Giving advice implied 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 unrse 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? A. "You need to stop that behavior now!" B. "You will need to be placed in seclusion!" C. "What is causing you to become agitated?" D. "You will need to be restrained if you do not change your behavior."

"What is causing you to become agitated?" *The best statement is to ask the client what is causing the agitation. This will assist the client with becoming aware of the behavior and will assist the nurse with planning appropriate interventions for the client. Option A is demanding behavior, which could cause increased agitation in the client. Option B and D are threats to the client and are inappropriate

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? A. "With whom do you live?" B. "Who is available to help you?" C. "What leads you to seek help now?" D. "What do you usually do to feel better?"

"What leads you to seek help now?" *The nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option C will assist with determining data related to the precipitating event that led to the crisis. Options A and B identify situational supports. Option D identifies personal coping skills

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 lvoed are dead." Which response by the nurse is therapeutic? A. "Right! Why not just 'pack it in?" B. "That seems rather unlikely to me." C. "I don't believe that, and neither do you." D. "You must be feeling all alone at this point."

"You must be feeling all alone at this point." *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 A, the nurse uses sarcasm, which gives advice and is nontherapeutic as a nursing response. In option B, the nurse is voicing doubt, which is often used when a client verbalizes delusional ideas. In option C, the nurse is disagreeing with the client, which implies that the nurse has passed judgment on the client's ideas or opinions

A nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following tasks should the nurse include in the discussion? (Select all that apply) A. The needs of both partipants are met B. An emotional commitment exists between the participants C. It is goal-directed D. Behavioral change is encouraged E. A termination date is established

1. It is goal-directed 2. Behavioral change is encouraged 3. A termination date is established *A therapeutic nurse-client relationship is goal oriented, encourages positive behavioral changes, has an established termination date, and focuses on the needs of the client. An emotional commitment between the particpants is characteristic of an intimate or social relationship rather than one that is therapeutic

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? A. "Have you shared your feelings with your family?" B. "I think we should talk more about your anger with your family?" C. "You're feeling angry that your family continues to hope for you to be 'cured'?" D. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

"You're feeling angry that your family continues to hope for you to be 'cured'?" *Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying. In option B, the nurse attempts to use focusing, but the attempt to discuss central issues is premature. In option D, the nurse makes a judgment and in nontherapeutic in the one-on-one relationship. In option A, 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 nurse is caring for a client who in mechanical restraints. Which of the following statements should the nurse include in the documentation? (select all that apply) A. "Client ate most of their breakfast." B. "Client was offered 8 oz of water every hr." C. "Client shouted obscenities at assistive personnel." D. "Client received chlorpromazine 15 mg by mouth at 1000." E. "Client acted out after lunch."

1. "Client was offered 8 oz of water every hr." 2. "Client shouted obscenities at assistive personnel." 3. "Client received chlorpromazine 15 mg by mouth at 1000." *The amount and frequency of fluids, a description of the client's verbal communication, and the dosage and time of medication offered is objective data that should be documented *Document objective information regarding intake in the client's medical record "the client ate 70% of their breakfast." *Document objective information regarding the client's behavior in the client's medical record

A nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (select all that apply) A. "To check cognitive ability. I should ask the client to count backward by sevens." B. "To check affect, I should observe the client's facial expression." C. "To check language ability, I should instruct the client to write a sentence." D. "To check remote memory, I should have the client repeat a list of objects." E. "To check the client's abstract thinking. I should ask the client to identify our most recent presidents"

1. "To check cognitive ability. I should ask the client to count backward by sevens." 2. "To check affect, I should observe the client's facial expression." 3. "To check language ability, I should instruct the client to write a sentence." *asking the client to repeat a list of objects is appropriate to check immediate, rather than remote, memory *Asking the client to identify recent presidents is appropriate to check cognitive knowledge rather than abstract thinking

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

1. Communicate expected behaviors to the client 2. Follow through about the consequences of behavior in a nonpunitive manner 3. Assist the client with developing a means of setting limits on personal behavior 4. Be clear with the client regarding the consequences of exceeding limits set regarding behavior *Intervetions 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 conndequences 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) A. Monitor vital signs B. Maintaing an NPO status C. Provide a safe environment D. Address hallucinations therapeutically E. Provide stimulation in the environment F. Provide reality orientation as appropriate

1. Monitor vital signs 2. Provide a safe environment 3. Address hallucinations therapeutically 4. Provide reality orientation as appropriate *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

A nurse is assisting with a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Which of the following information should the nurse include in the discussion? (select all that apply) A. The DSM-5 includes client education handouts for mental health disorders B. The DSM-5 establishes diagnostic criteria for individual mental health disorders C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders D. The DSM-5 assists nurses in planning care for client's who have mental health disorders E. The DSM-5 indicares expected data collection findings of mental health disorders

1. The DSM-5 establishes diagnostic criteria for individual mental health disorders 2. The DSM-5 assists nurses in planning care for client's who have mental health disorders 3. The DSM-5 indicares expected data collection findings of mental health disorders *The DSM-5 is used by mental health professionals. However, it does not include client education handouts *The DSM-5 does not indicate pharmacological treatment for mental health disorders

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? A. Facing the client when providing care B. Ensuring that a security officer is within the immediate area C. Keeping the door to the client's room open when with the client D. Assigning the client to a room at the end of the hall to prevent disturbing the other clients

Assigning the client to a room at the end of the hall to prevent disturbing the other clients *The client should be placed in a room near the nurse's 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 plase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? A. Plan short-term goals B. Identify expected outcomes C. Assist with making appropriate referrals D. Assist with developing realistic solutions

Assist with making appropriate referrals *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 A, B, and D identify the tasks of the working phase of the relationship

A nurse is caring for a client who smokes and has lung cancer. The client reports, "I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client using which of the following defense mechanisms? A. Reaction formation B. Denial C. Displacement D. Sublimation

Denial *This is an example of denial, which is pretending the truth is the not the reality to manage the anxiety of acknowleding what is real *(A) This is not an example of reactio formation, which is overcompensating or demonstrating the opposite behavior of what is felt *(C) This is not an example of displacement, which is shifting feelings related to an object, person, or situation to another less threatening object, person, or situation *(D) This is not an example of sublimation, which is dealing with unacceptable forms of expression

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? A. Escort the manic client to his or her room B. Orient the client to time, person, and place C. Tell the client that the behavior is not appropriate D. Tell the client that smoking privileges are revoked for 24 hours

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

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? A. Normal B. Regressive C.. Indicative of the client's ambivalence D. Evidence of the client's altered and distored body image

Evidence of the client's altered and distored body image *Altered or distored 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 disorted body image. The client's behavior is not normal

A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse's actions are an example of which of the following torts? A. Invasion of privacy B. False imprisonment C. Assault D. Battery

False imprisonment *A civil wrong that violates a client's civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area (a seclusion room) if the reason for such confinement is for the convenience of staff.

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

Feed, bathe, and dress the client as needed until the client can perform these activities independently *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 evem the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client. Options B and C are incorrect because the client lacks the energy and motivation to perform these tasks independently. Option D will increase the client's feelings of poor self-esteem and unworthiness

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication? A. Cardiovascular symptoms B. Gastrointestinal dysfunctions C. Problems with mouth dryness C. Problems with excessive sweating

Gastrointestinal dysfunctions *The most common adverse effects related to fluoxetine include CNS and GI system dysfunction. This medication affects the GI system by causing nausea and vomiting, cramping, and diarrhea. Options A, C, and D are nor adverse effects of this medication

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

Get a written prescription from the primary health care provider (PHCP) and ontain an informed consent *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 permitter 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

A nurse in an outpatient mental health clinic is preparing to assist with an initial interview. When conducting the interview, which of the following actions should the nurse identify as the priority? A. Coordinate holistic care with social services B. Identify the client's perception of their mental health status C. Include the client's family in the interview D. Instruct the client about their current mental health disorder

Identify the client's perception of their mental health status *Data collections is the priority action when using the nursing process approach to client care. Identifying the client's perception of their mental health status provides important information about the client's psychosocal history *It is appropriate to coordinate holistic care for the client with social services as part of case management. However, another action is the priority *If the client wishes, it is appropriate to include the client's family in the interview. However, another action is the priority *It is appropriate to instruct the client about their disorder. However, another action is the priority

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? A. Identifying the client's ability to function B. Identifying the client's potential for self-harm C. Inquiring about the client's feelings that may affect coping D. Inquiring about the client's perception of the cause of the neighbor's death

Inquiring about the client's feelings that may affect coping *The client must first deal with feelings and negative responses before the client is able to walk through the meaning of the crisis. Option C pertains directly to the client's feelings. Options A, B, and D do not directly address the client's feelings

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 doiing vigorous push-ups. Which nursing action is appropriate? A. Interrupt the client and weigh her immediately B. Interrupt the client and offer to take her for a walk C. Allow the client to complete her exercise program D. Tell the client that she is not allowed to exercise vigorously

Interrupt the client and offer to take her for a walk *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 A, C, and D are inappropriate nursing actions

A nurse is assisting with instructing a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? A. Personal space B. Posture C. Eye contact D. Intonation

Intonation *Identify intonation as a component of verbal communication. Intonation is the tone of one's voice and can communicate a variety of feelings *Personal space, posture, and eye contacts are components of nonverbal communication

A nurse is reinforcing preoperative teaching with a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, "This is difficult to comprehend. I feel shaky and nervous." The nurse should identify thay the client is experiencing which of the following levels of anxiety? A. Mild B. Moderate C. Severe D. Panic

Moderate *Moderate anxiety decreases problem solving and may hamper the client's ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious *In mild anxiety, the client's ability to understand information may actually increase *Severe anxiety causes restlessness, decreased perception, and an inability to take direction *During a panic attack, the person is completely distracted, unable to function, and can lose touch with reality

A nurse is contributing to the plan of care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention? A. Assist the client with systematic desensitization therapy B. Reinforce the use of the client appropriate coping mechanisms C. Check the client for comorbid health conditions D. Monitor the client for adverse effects of medications

Monitor the client for adverse effects of medications *Assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention *Reinforcing the use of appropriate coping mechanisms is a counseling or health teaching *Checking for comorbid health conditions is health promotion and maintenance, rather than a psychobiological intervention

The nursing studen is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student document which intervention in the plan that is not specific to this disorder? A. Monitor intake and output B. Monitor electrolyte levels C. Observe for excessive exercise D. Monitor for the use of laxatives and diuretics

Observe for excessive exercise *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 C is the only option that is not associated with care of the client with bulimia

An intoxicated client is brought to the emergency department by local police. The client is told that the oprimary 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 y the PHCP immediately. The nurse assising to care for the client should take which appropriate nursing intervention? A. Watch the behavior escalate before intervening B. Attempt to talk with the client to de-escalate the behavior C. Offer to take the client to an examination room until he or she can be treated D. Inform the client that he or she will be asked to leave if the behavior continues

Offer to take the client to an examination room until he or she can be treated *Safety of the client, other clients, and staff is of prime concern. Options C is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment when 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 D would only further aggravate an already agitated individual

A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? A. Offering advice B. Reflecting C. Listening attentively D. Giving information

Offering advice *Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends ti interfere with the client's ability to make personal decisions and choices *The technique of reflection directs the focus back to the client in order for the client to examine their feelings *The skill of active listening is an important therapeutic technique to help hear and understand the information and messages the client is trying to convey *Giving information informs the client of needed information to assist in the treatment planning process

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? A. One-to-one suicide precautions B. Suicide precations, with 30 minute checks C. Checking the whereabouts of the client every 15 minutes D. Asking the client to report suicidal thoughts immediately

One-to-one suicide precautions *One-to-one suicide precautions are required for the client who has attempted suicide. Options B and C are not appropriate, considering the situation. Option D may be an appropriate intervention, but the priority is stated in option A. 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? A. Open-ended questions and silence B. Focusing on self-disclosure regarding food preferences C. Stating the reasons that the client may not want to wat D. Offering opinions about the necessity of adequate nutrition

Open-ended questions and silence *Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options C and D 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 B is not a client-centered intervention

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 belligerant. Based on these observations, which is the nurse's immediate priority of care? A. Provide safety for the client and other clients on the unit B. Provide the clients on the unit with a sense of comfort and safety C. Assist the staff with caring for the client in a controlled environment D. Offer the client a less-stimulating area to calm down and gain control

Provide safety for the client and other clients on the unit *Safety of the client and other clients is the priority. Option A is the only option that addresses the client and other clients' safety needs. Option B addresses other client's needs. Option C is not client centered. Option D adresses the client's needs

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? A. Poor dietary choices B. Lack of exercise and poor diet C. Inadequate dietary intake and dehydration D. Psychomotor retardation and side effects of medication

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

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions by the client indicates transference behavior? A. The client asks the nurse if they can go out to dinner together B. The client accuses the nurse of being controlling just like an ex-partner C. The client reminds the nurse of a friend who died from substance toxicity D. The client becomes angry with the nurse and threatens to engage in self harm

The client accuses the nurse of being controlling just like an ex-partner *When a client views the nurse as having characteristics of another person who has been significant to their personal life and died from substance use (an ex-partner), this indicates trasnferance *(A) This indicates the need to discuss boundaries but does not indicate transferance *(C) This indicates countertransference rather than transferance *(D) This indicates the need for safety intervention but does not indicate transferance

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that 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? A. Weight loss B. Sleep pattern C. Medication compliance D. Onset of the crying spells

Weight loss *All the options are possible issues to addressl 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