ATI MENTAL HEALTH Chapter 1-21

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 include in the plan of care? Select all that apply. A Priority restructuring B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation

A Priority restructuring B. Monitoring thoughts D. Journal keeping Rationale: A. Priority restructuring is a cognitive re framing technique B. Monitoring thoughts is a cognitive re framing technique D. Journal keeping is a cognitive re framing technique (diaphragmatic breathing and meditation is a form of behavioral therapy.)

A nurse in an acute mental health facility is caring for a 35-year-old female client who has manifestation of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression? Select all that apply. A. Age B. Sex C. History of chronic asthma D. Smoking E. Being Married

A. Age B. Sex C. History of chronic asthma D. Smoking Rationale: A. Depressive disorders are more prevalent in adults between the ages of 15 and 40. B. Depressive disorders are twice as common in women than man C. Depressive disorders are more common in clients who have a chronic medical illness D. Depressive disorders are more common in clients who have a substance use disorder, such as nicotine use disorder.

A nurse is collecting data during admission from a client who hs 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

A. Auditory hallucination C. Use of clang associations D. Delusion of persecution E. Constantly waving arms Rationale: A. Hallucinations are an example of positive symptom. C. Alterations in speech are a positive symptom. D. Delusions are an example of a positive symptom E. Bizarre motor movements are a positive symptom

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

A. Aversion therapy Rationale: Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior Flooding is planned exposure, Biofeedback is a behavioral therapy to control pain, tension and anxiety, and Dialectical behavior therapy is a cognitive behavioral therapy for clients who have personality disorder and exhibit signs of hurting one self.

A nurse is reinforcing teaching to a client about stress-reduction techniques. Which of the following client statement indicate understanding of the teaching? A. Cognitive reframing will help 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.

A. Cognitive reframing will help me change my irrational thoughts to something positive. Rationale: A. Cognitive reframing helps the client look at irrational cognitions (thoughts) ina more realistic light and to restructure those thoughts in a more positive way.

A nurse is reviewing the medical record of a client who has suddenly developed total blindness. 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 asthma

A. Death of a child 2 months ago Rationale: A. The death of a child 2 months ago is an acute stressor that places the client at risk for conversion disorder in which neurologic manifestations such as sudden blindness occurs in the absence of a neurologic medical diagnosis

A nurse is assisting with the plan of care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first? A. Determine the client's risk for self harm B. Instill hope for positive outcomes C. Encourage the client to participate in group therapy sessions D. Encourage the client to participate in treatment decisions

A. Determine the client's risk for self harm Rationale: A. The greatest risk to a client who has an anxiety or OCD is self harm or suicide. The first action the nurse should take is to determine the client's risk for self-harm to ensure that the client is provided with a safe environment.

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

A. Difficulty concentrating on task C. Negative self-image D. Recurring nightmares. Rationale: A. Manifestations of PTSD include the inability to concentrate on or complete tasks. C. Manifestations of PTSD include feeling guilty and having a negative self-image D. Manifestations of PTSD include recurring nightmares or flashbacks.

A nurse is assisting with 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 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 way it is inappropriate to have a personal relationship with staff

A. Difficulty getting along with other members of a group C. Display of defense mechanisms when routines are changed E. Difficulty understanding way it is inappropriate to have a personal relationship with staff Rationale: A. Difficulty with social and professional relationships is a personality characteristic that can be seen with all personality disorder types C. Maladaptive response to stress is a personality characteristic that can be seen with all personality disorder types. E. Difficulty understanding personal boundaries is a personality characteristic that can be seen with all personality disorder types.

A newly licensed nurse is applying for a nursing job in a community mental health center. When working in this type of setting, the nurse should be prepared to assist with which of the following services? Select all that apply A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family Therapy

A. Educational groups B. Medication dispensing programs C. Individual counseling programs E. Family Therapy Rationale: A. Educational groups are services provided in a community mental health center. B. Medication dispensing programs are provided in a community mental health center. C. Individual counseling programs are provided in a community mental health center E. Family therapy is provided in a community mental health center.

A nurse is collecting data from 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. Implusive decision-making C. Delayed reflexes D. Restlessness E. Need for reassurance

A. Excessive worry for 6 months D. Restlessness E. Need for reassurance Rationale: A. Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 6 months. D. Generalized anxiety disorder is characterized by restlessness E. Generalized anxiety disorder is characterized by the need for repeated reassurance.

A nurse is caring for a client who has avoidant personality disorder. Which of the following statements should the nurse identify as characteristic for a client who has this disorders? 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.

A. I'm scared that you're going to leave me Rationale: Clients who have avoidant personality disorder often have fear of abandonment. This type of statement is expected.

A nurse is reinforcing teaching with the partner of a client who has moderate Alzheimer's disease and is to be discharged to home care. 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 childproof door locks. B. Place rugs over electrical cords C. Mark cleaning supplies with colored tape D. Place the client's mattress on the floor E. Install light fixtures above stairs.

A. Install childproof door locks. D. Place the client's mattress on the floor E. Install light fixtures above stairs. Rationale: A. Door locks that are difficult to open are appropriate to reduce the risk of the client wandering outside without supervision D. Placing the client's mattress on the floor reduces the risk for falls out of bed. E. Stairs should have adequate lighting to reduce the risk for falls.

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. The nurse should identify that which of the following client statements indicates 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 obse.

A. Life isn't worth living if I gain weight Rationale: The statement reflects the cognitive distortion of catastrophizing, because the client's perception of her appearance or situation is much worse than her current condition

A nurse is reinforcing teaching for a client who is begin ECT treatments. Which of the following assessments should the nurse instruct the client to expect following the procedure? Select all that apply. A. Measurement of the blood pressure for hypertension. B. Palpation of the abdomen for tenderness. C. Use of percussion hammer for hyperrelexia D. Questions to determine the presence of memory loss and confusion. E. Auscultation of the breath sounds for lower lob concern

A. Measurement of the blood pressure for hypertension. D. Questions to determine the presence of memory loss and confusion. Rationale: A. Following ECT, the client's blood pressure is expected to be elevated. The nurse should tell the client to expect blood pressure measurement following ECT. D. The client is at risk for memory loss following ECT. The nurse should tell the client to expect to be questioned about her short term memory following the procedure.

A nurse is collecting data from a client who has illness anxiety disorder. Which of the following findings should the nurse expect? Select all that apply A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of health care providers. D. Depressive disorder E. Narcissistic personality

A. Obsessive thoughts about disease B. History of childhood abuse C. Avoidance of health care providers. D. Depressive disorder Rationale: A. Obsessive thoughts about disease is an expected finding in a client who has illness anxiety disorder. B. A history of childhood abuse is an expected finding in a client who has illness anxiety disorder C. Avoidance of health care providers is an expected finding in client who have illness anxiety disorder of the care-avoidant type D. A depressive disorder is an expected finding in a client who has illness anxiety disorder

A nurse is communicating with a client who was just 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 atenntively D. Giving information

A. Offering advice Rationale: Offering advice to a client is a barrier to therapeutic communication that the nurse should avoid using. Advice tends to interfere with the client's ability to make personal decisions and choices.

A nurse in an acute mental health facility is assisting with the admission of a client who has major depressive is order and anxiety disorder. Which of the following actions is the nurse's priority? A. Placing the client on one-on-one observation B. Assisting the client to perform ADLs C. Encouraging the client to participate in counseling D. Reinforcing teaching with the client about medication adverse effects.

A. Placing the client on one-on-one observation Rationale: The greatest risk for a client who has MDD and anxiety is injury due to self-harm. The highest priority intervention is placing the client on one-to-one observation.

A nurse is assisting with the plan of care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse recommend? A. Reinforcing ways to use new behaviors B. Practicing new problem-solving skills C. Developing goals D. Establishing boundaries

A. Reinforcing ways to use new behaviors Rationale: Reinforcing ways for the client to incorporate new health behaviors into life is a correct task for the termination phase.

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements 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

A. Tell me about how you are feeling right now. Rationale: Asking an open-ended question is therapeutic and assists the client in identifying anxiety.

A nurse is told during change-of-shift report that a client is stuporous. When evaluating the client, which of the following findings should the nurse expect? A. The client arouses briefly in response to a sternal rub. B. The client has a Glasgow Coma Scale score less than 8. C. The client exhibits decorticate rigidity. D. The client is alert but disoriented to time and place.

A. The client arouses briefly in response to a sternal rub. Rationale: A. A client who is stuporous requires vigorous or painful stimuli to elicit a response.

A nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated 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.

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. Rationale: A. Counting backward by sevens in an appropriate technique to check a client's cognitive ability. B. Observing a client's facial expression is appropriate when checking affect. C. Writing a sentence is an indication of language ability.

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. Dysphagia E. Neck pain

A. Voice changes D. Dysphagia E. Neck pain Rationale: A. Voice changes are a common adverse effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx. D. Dysphagia is a potential adverse effect of VNS. This usually subsides with time. E. Neck pain is potential adverse effect of VNS. This usually subsides with time.

A nurse is preparing to collect data from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse ask the client? Select all the 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 your appearance?

A. What is your relationship like with your family C. Would you describe your current eating habits? E. Can you discuss your feelings about your appearance? Rationale: A. When collecting data from a client who has anorexia nervosa the nurse should ask about the client's family and interpersonal relationship C. When collecting data from a client who has anorexia nervosa, the nurse should ask about the client's current eating habits E. When collecting data from a client who has anorexia nervosa, the nurse should ask about the client's perception of the issue.

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 statement should the nurse make? Select all that apply A. When did you start hearing voices? 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 telling you to hurt yourself? E. Why are the voices talking to only you?

A. When did you start hearing voices? C. It must be scary to hear voices D. Are the voices telling you to hurt yourself? Rationale: A. The nurse should ask the client directly about the hallucination. C. The nurse should focus on the client's feelings rather than agreeing with the client's hallucination. D. The nurse should monitor for command hallucinations and the clients's risk for injury to self or others.

A nurse is assisting with the care of a group of clients. Which of the following clients should a nurse consider for referral to a Program of Assertive Community Treatment (PACT) group? A. A client in an acute care mental health facility who has fallen several times while running down the hallway B. A client who lives at home and says he keeps forgetting to come in for his monthly antipsychotic injection for schizophrenia C. A client in a day treatment program who says he is becoming more anxious during group therapy. D. A client in a weekly grief support group who says she still misses her deceased husband who has been dead for 3 months

B. A client who lives at home and says he keeps forgetting to come in for his monthly antipsychotic injection for schizophrenia Rationale: A PACT group works with clients who are non adherent with traditional therapy, such as the client in a home setting who keeps forgetting his injection.

A nurse is discussing the risk 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 disorders C. Female gender D. Coronary artery disease E. Obesity

B. Anxiety disorders C. Female gender Rationale: B. Anxiety disorder is a risk factor for somatic symptom disorder C. Female gender is a risk factor for somatic symptom disorder

A client who has schizophrenia 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

B. Ask the client, Are you seeing something on the ceiling Rationale: The nurse should ask the client directly about the hallucination to identify client needs and determine if there is a potential risk for injury.

A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply) A. Client ate most of his breakfast. B. Client was offered 8oz water every hour C. Client shouted obscenities at assistive personnel D. Client received chlorpromazine 15mg by mouth at 1000 E. Client acted out after lunch

B. Client was offered 8 oz water every hour C. Client shouted obscenities at assistive personnel D. Client received chlorpromazine 15mg by mouth at 1000 Rationale: B. How much water was offered and how often it was offered is objective data that the nurse should document when caring for a client in mechanical restraints C. A description of the client's verbal communication is objective data that the nurse should document when caring for a client in mechanical restraints. D. The dosage and time of medication administration is objective data that the nurse should document when caring for a client in mechanical restraints.

A nurse is assisting in planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial 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.

B. Define the purpose of the group C. Discuss termination of the group E. Establish an expectation of confidentiality within the group. Rationale: B. During the initial phase, the nurse should identify the purpose of the group. C. During the initial phase, the nurse should discuss termination of the group E. During the initial phase, the nurse should set the tone of the group including an expectation of confidentiality.

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

B. Denial Rationale: This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.

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

B. Depressed immune system C. Increased blood pressure E. Unhappiness Rationale: B. a depressed immune system is an indicator of acute stress C. Increased blood pressure is an indicator of acute stress E. Unhappiness is an indicator of acute stress

A nurse is reinforcing teaching about relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include? Select all that apply A. Use caffeine in moderation to prevent relapse B. Difficulty sleeping can indicate a relapse C. Begin taking 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

B. Difficulty sleeping can indicate a relapse D. Participating in psychotherapy can help prevent a relapse E. Anhedonia is a clinical manifestation of a depressive relapse Rationale: B. The client should be aware of sleep disturbances, which can indicate a relapse. D. The client who has bipolar disorder should participate in psychotherapy to help prevent a relapse E. The client who has bipolar disorder should be aware of manifestation, including anhedonia, which is a depressive characteristic that can indicate a relapse.

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 with the client? Select all the 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.

B. Discuss prior use of coping mechanisms with the client D. Demonstrate a calm manner while using simple and clear directions. Rationale: B. Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressors. D. 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.

A nurse is reinforcing teaching to the family of a client who has a substance use disorder. Which of the following statements by a family member indicates understanding? Select all that apply A. We need to understand that she is responsible for her disorder B. Eliminating any codependent behavior will promote her recovery C. She should participate in an Al-Anon group to help her recover D. The primary goal of her treatment is abstinence from substance use E. She needs to discuss her feelings about substance use to help her recover.

B. Eliminating any codependent behavior will promote her recovery D. The primary goal of her treatment is abstinence from substance use E. She needs to discuss her feelings about substance use to help her recover. Rationale: B. Families should be aware of codependent behavior, such as enabiling, that can promote substance use rather than recovery D. Abstinence is primary treatment goal for a client who has a substance use disorder E. Clients ust acknowledge their feelings about substance use as part of a substance use recovery program.

A nurse places a client 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

B. False imprisonment Rationale: 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, such as a seclusion room, if the reason for such confinement is for the convenience of staff.

A nurse is collecting data from a client who has alcohol use disorder and is experiencing withdrawal. Which of the following finding should the nurse expect? Select all the apply A. Bradycardia B. Fine tremors of both hands C. Hypotension D. Vomiting E. Restlessness

B. Fine tremors of both hands D. Vomiting E. Restlessness Rationale: B. Fine tremors of both hands is an expected finding of alcohol withdrawal. D. Vomiting is an expected finding of alcohol withdrawal. E. Restlessness is an expected finding of alcohol withdrawal.

A nurse is collecting data from a newly admitted client who has bulimia nervosa with purging behavior. Which of the following findings should the nurse expect? Select all that apply A. Amenorrhea B. Hypokalemia C. Mottling of the skin D. Slightly elevated body weight E. Presence of lanugo on the face.

B. Hypokalemia D. Slightly elevated body weight Rationale: B. Hypokalemia is an expected finding of purging-tpe bulimia nervosa D. Most clients who have bulimia nervosa maintain a weight within a normal range or slightly higher

A nurse is caring for 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 responses should the nurse make? A. Why do you think you feel the need to give money away? B. I am here to care for you and cannot accept your money C. i can request that your case manager discuss local charity options with you D. You should know that giving away your money is not allowed

B. I am here to care for you and cannot accept your money Rationale: This statement is matter-of-fact, concise and a therapeutic response to a client who has bipolar disorder.

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 monster pinching me all over D. I know that you are stealing my thoughts

B. I am no one and everyone is me Rationale: B. This comment indicates the client is experiencing a loss of identity of depersonalization

A nurse is preparing to assist with the care of a client who has benzodiazepine toxicity due to an overdose. Which of the following actions should the nurse plan to take first? A. Administer flumazenil B. Identify the client's level of orientation C. Infuse IV fluids D. Prepare the client for gastric lavage

B. Identify the client's level of orientation Rationale: B. When taking the nursing process approach to client, the initial step is collecting data. Identifying the client's level of orientation is the priority action

A nurse in an outpatient mental health clinic is preparing to assist with an initial client interview. hen conducting the interview, which of the following actions should the nurse identify as the priority? A. Assist with the coordination of holistic care with social services. B. Identify the client's perception of her mental health status. C. Include the client's famil in the interview. D. Reinforcing teaching with the client about her current mental health disorder.

B. Identify the client's perception of her mental health status. Rationale: B. Data Collection is the priority action when using the nursing process approach to client care. Identifying the client's perception of her mental health status provides important information about the client's psychosocial history

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her, Kill your doctor. Which of the following actions should the nurse take first? A. Use therapeutic communication to discuss the hallucination with the client. B. Initiate one-to-one observation of the client C. Focus the client on reality D. Notify the provider of the client statement

B. Initiate one-to-one observation of the client Rationale: 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

A nurse is assisting with a family therapy group session. The adolescent son tells the nurse that he plans ways to make his sister look bad so his parents will think he's the better sibling, which he believes will give him more privileges. The nurse should identify this dysfunctional behavior as which of the following? A. Placation B. Manipulation C. Blaming D. Distraction

B. Manipulation Rationale: Manipulation is the dysfunctional behavior of dishonesty to support an individual agenda

A nurse is providing preoperative teaching for a client who was just informed that she requires 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 iddentify that the client is experiencing which of the following levels of anxiety? A. Mild. B. Moderate C. Severe D. Panic

B. Moderate Rationale: Moderate anxiety decreases problem-solving and can hamper the client's ability to understand information. Vital signs can increase somewhat, and the client is visibly anxious.

A nurse is contributing to the plan of care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan? Select all the apply A. Provide flexible client behavior expectation B. Offer concise explanations C. Establish consistent limits D. Disregard client complaints E. Use a firm approach with communication

B. Offer concise explanations C. Establish consistent limits E. Use a firm approach with communication Rationale: B. Offering concise explanations improves the client's ability to focus and comprehend the information C. Establishing consistent limits decreases the risk for client manipulation E. Using a firm approach with client communication promotes structure and minimizes inappropriate client behavior

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

B. Splitting Rationale: B. Splitting 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.

A nurse is assisting in a serious and prolonged mass casualty incident at an acute care facility. Which of the following strategies should the nurse use 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. Hold emotions in check in the days following incident E. Take advantage of offered counseling

B. Take breaks during the incident for food and water. C. Debrief with others following the incident E. Take advantage of offered counseling Rationale: B. Taking breaks and remembering to drink water and eat nutritious foods while working during a traumatic incident can help prevent development of a trauma-related disorder. C. Debriefing with others following a traumatic incident can help prevent development of a trauma-related disorder E. Taking advantage of counseling offered by an employer or others can help prevent development of a trauma-related disorder

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 manaterm-10ger. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

B. Tell the nurse to stop discussing the behavior. Rationale: The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. The first action the nurse should take is to tell the newly licensed nurse to stop discussing the client's hallucinations in a public location.

A nurse is assisting with a peer group discussion about the 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 harmacological treatment for mental health disorders. D. The DSM-5 assist nurses in planning care for client's who have mental health disorder. E. The DSM-5 indicates expected findings of mental health disorders.

B. The DSM-5 establishes diagnostic criteria for individual mental health disorders. D. The DSM-5 assist nurses in planning care for client's who have mental health disorder. E. The DSM-5 indicates expected findings of mental health disorders. Rationale: B. The DSM-5 establishes diagnostic criteria for mental health disorders. D. Nurses use the DSM-5 to assist in planning, implementing and evaluating care for clients who have mental health disorders. E. The DSM-5 identifies expected findings for mental health disorders.

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? A. The client asks the nurse whether she will go out to dinner with him. B. The client accuses the nurse of telling him what to do just like his ex-girlfriend. C. The client reminds the nurse of a friend who died from a substance overdose. D. The client becomes angry and threatens harm to himself.

B. The client accuses the nurse of telling him what to do just like his ex-girlfriend. Rationale: When a client views the nurse as having characteristics of another person who has been significant to his personal life, such as his ex-girlfirend, this indicates transference.

A nurse is reinforcing teaching with a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statement 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.

B. The therapist will focus on my past relationships during our sessions. Rationale: Classical psychoanalysis places a common focus on past relationship to identify the cause of the anxiety disorder.

A client says she is experiencing increased stress because, "my significant other 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

B. Use assertiveness techniques. Rationale: B. Assertive communication allows the client to assert her feelings and then make a change in the situation

A nurse is caring for a client who has imld Alzheimer's disease and a new prescription for donepezil. The nurse should include which of the following statements when reinforcing teaching about the medication? A. You should avoid taking OTC acetaminophen while on donepezl B. You can expect the progression of cognitive decline to slow with donepezil C. you will be screened for underlying kidney disease prior to start donepezil D. You should stop taking donepezil if you experience nausea or diarrhea

B. You can expect the progression of cognitive decline to slow with donepezil Rationale: B. Donepezil slows the cognitive deterioratoin of Alzheimer's disease

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 himself.

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

A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when she demonstrates which of the following actions? A. Observes group techniques without interfering with the group process B. Discusses a technique and then directs members to practice the technique C. Asks for group suggestions of techniques and then supports discussion D. Announces the agenda to the group at the beginning of the meeting

C. Asks for group suggestions of techniques and then supports discussion Rationale: Democratic leardership supports group interaction and decision-making to solve problems

A community mental health nurse is assisting with a plan of care to address the issue of depression among older adults clients in the community. Which of the following interventions should the nurse recommend as a method of tertiary prevention? A. Assisting in the education of clients on health promotion techniques to reduce the risk of depression. B. Assisting with screenings for depression at community health programs. C. Assisting in establishing rehabilitation programs to decrease the effects of depression. D. Assisting with providing support groups for clients at risk for depression

C. Assisting in establishing rehabilitation programs to decrease the effects of depression. Rationale: C. Rehabilitation programs are an example of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness. extra info- Health promotion education is an example of primary prevention. Depression screen is an example of secondary prevention Support groups for at risk clients are examples of primary prevention.

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. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

C. Attempt to reduce anxiety Rationale: Clients who have OCD demonstrate repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety.

A nurse is assisting with a court-ordered evluation 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. Has difficulty making even simple decisions C. Attempts to convince other clients to give him their belongings D. becomes agitated if his personal area is not neat and orderly E. Blames others for his past and current problems

C. Attempts to convince other clients to give him their belongings E. Blames others for his past and current problems Rationale: C. Exploitation and manipulation of others is an expected finding of antisocial personality disorder E. Failure to accept personal responsibility is an expected finding of clients who have antisocial personality disorder

A nurse is collecting data from a client who has lost his job and states he is under alot of stress right now. The nurse should recognize that which of the following statements by the client indicates the presence of a protective factor against stress? A. i doubt that I can get another job soon B. I am being treated for bacterial pneumonia C. I spend some time praying everyday. D. My friends live several hundred miles away in my home town.

C. I spend some time praying everyday. Rationale: Practicing spiritual or religous beliefs, such as meditating or praying is a protective factor against stress.

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

C. Attending a partial hospitalization program Rationale: A day-evening treatment/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

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

C. Bipolar disorder with rapid cycling Rationale C. ECT is indicated for treatment of bipolar disorder with rapid cycling

A nurse is working with an established group and identifies various members roles. which of the following should the nurse identify as an individual role? A. Praising input from other members B. Following the direction of other members C. Bragging about accomplishments D. Evaluating the group's performance toward a standard.

C. Bragging about accomplishments Rationale: An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals.

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. Bupropion C. Disulfiram D. arbamazepine

C. Disulfiram Rationale: C. the nurse should expect to administer disulfiram to help the client maintain abstinence from alcohol.

A nurse is reinforcing teaching to a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. 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

C. ECT is effective for clients who are experiencing severe mania Rationale: ECT is appropriate for the treatment of severe mania associated with bipolar disorder

A nurse is assisting with systematic desensitization 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 he begins 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 his anxiety response diminishes.

C. Gradually expose the client to an elevator while practicing relaxation techniques. Rationale: Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure relaxation techniques suppress the anxiety response.

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 over the past 6 months C. Hallucinations D. Altered level of consciousness E. Restlessness

C. Hallucinations D. Altered level of consciousness E. Restlessness Rationale: C. The client who has delirium can have perceptual disturbances (hallucinations, illusions) D. The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate E. The client who has delirium commonly exhibits restlessness and agitation

A nurse in an outpatient mental health clinic is reinforcing teaching with a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching? A. I can expect my problems with PMDD to be the worst when I'm menstruating. B. I will use light therapy 30 minutes a day to prevent further recurrences of PMDD 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

C. I am aware that my PMDD causes me to have rapid mood swings. Rationale: C. A clinical finding of PMDD is emotional lability. The client can experience rapid changes in mood.

A nurse is collecting data from a client who has factitous disorder imposed on another. Which of the following client statements should the nurse expect? A. I had to pretend I was injured in order to get disability benefits B. I know that my abdominal pain is caused by a malignant tumor C. I needed to make my son sick so that someone else would take care of him for a while D. I became deaf when i heard that my wife has having an affair with my best friend

C. I needed to make my son sick so that someone else would take care of him for a while Rationale: 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 nurse is discussing the care of a client who has a personality disorder with a newly licensed nurse. Which of the following statement by the newly licensed nurse indicates understanding? A. I can promote my client's sense of control by establishing a schedule. B. I should encourage clients who have 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.

C. I should practice limit-setting to help prevent client manipulation Rationale: When caring for a client who has a personality disorder, limit-setting is appropriate to help prevent client manipulation.

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse that she is afraid she is going to gain weight 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, try to focus other problems at this time C. I understand you have concern 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.

C. I understand you have concern about your weight, but first let's talk about your recent accomplishments Rationale: 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 nurse is assisting in planning care for 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

C. Implement seizure precautions Rationale: C. The greatest risk to the client is injury. Implementing seizure precautions is the priority intervention

A nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include? Select all that apply A. The needs of both participants 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.

C. It is goal-directed. D. Behavioral change is encouraged. E. A termination date is established. Rationale: C. A therapeutic nurse-client relationship is goal-directed. D. A therapeutic nurse-client relationship encourages positive behavioral change. E. A therapeutic nurse-client relationship has an established termination date.

A nurse is talking with a client who is at risk for suicide following the death of his partner. Which of the following statements should the nurse make? A. I feel very sorry for the loneliness you must be experiencing 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 a loved one.

C. Losing someone close to you must be very upsetting Rationale: This statement is an empathetic response that attempts to understand the client's feeling.

A nurse is assisting in planning a staff education program on substance use in older adults. Which of the following information should the nurse plan to include in the presentation? A. Older adults require higher doses of a substance to achieve a desired effect B. Older adults commonly use regression 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 manifestation of dementia

C. Older adults are at an increased risk for substance use following retirement Rationale: Retirement and other life change stressors increase the risk for substance use in older adults, especially if there is a prior history of substance use

A nurse is assisting with the admission of a 25-year-old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect? A. Wide fluctuations in mood B. Report of minimum of five clinical findings of depression C. Presence of manifestations for at least 2 years. D. Inflated sense of self-esteem

C. Presence of manifestations for at least 2 years. Rationale: Manifestation of dysthymic disorder last fr at least 2 years in adults.

A nurse is making a home visit to a client who has severe Alzheimer's disease. The client's partner, who is 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 C. Provide information on resources for respite care D. Schedule the client for placement of an enteral feeding tube

C. Provide information on resources for respite care Rationale: C. Providing information on resources for respite care is an appropriate action to provide the client's partner with a break from care giving responsibilities.

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, because he is threatening me." Which of the following actions should the nurse take? A. Reassure the client that staff members will keep him safe. B. Monitor the behavior of the client and his roommate closely. C. Report the client's statement to the health care team. D. Place the client's roommate in seclusion as punishment for making threats.

C. Report the client's statement to the health care team. Rationale: The information presented by the client is a serious safety issue that the nurse must report to the health care team.

A 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 week of an MDD episode D. Medication and psychotherapy are most effective during the acute phase of MDD

C. The client is at greatest risk for suicide during the first week of an MDD episode Rationale: C. The client is at greatest risk for suicide during the first week of an MDD episode

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 explains that her body seems to be floating above the ground B. The client has the idea that someone is trying to kill her and steal her money 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.

C. The client states that the furniture in the room seems to be small and far away. Rationale: Stating that one's surroundings are far away or unreal in some way is an example of derealization.

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demostrates 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 her own personal feelings about clients who have anorexia nervosa. C. The nurse asks the client about her body image perception D. The nurse assists in presenting an educational session about anorexia nervosa to a large group of adolescents.

C. The nurse asks the client about her body image perception Rationale: The nurse's one-on-one communication with the client is an example of interpersonal communication.

A nurse is orienting a new client to a mental health unit. When explaining the unit's community meeting, which of the following statement should the nurse make? 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

C. You and the other clients will meet with staff to discuss common problems. Rationale: Community meeting are an opportunity for clients to discuss common problems or issues affecting all members of the unit.

A nurse is assisting with the care of several clients who are attending community-based mental health programs. Which of the following clients should the nurse plan to visit first. A. a client who recently burned her arm while using a hot iron at home. B. A client who requests that her anti-psychotic medication be changed due to some new adverse effects. C.A client who says he is hearing a voice that tells him he is not worth of living anymore. D. A client who tells the nurse he experienced manifestation of severe anxiety before and during a job interview

C.A client who says he is hearing a voice that tells him he is not worth of living anymore. Rationale: The client's report of an auditory hallucinations stating he is not worth of living anymore indicates that this client is at greatest risk for self-harm. Therefore, the nurse should visit this client first.

A nurse is contributing to the 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 his 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

D. Discuss alternative coping strategies with the client Rationale: The nurse should discuss alternative coping strategies with the client

A nurse working on an acute mental health unit assists with a client group focusing on self-management of medication. At each of the meeting, two of the members use the opportunity to discuss their common interest in gambling on sports. This is an example of which of the following concepts? A. Triangulation B. Group process C. Subgroup D. Hidden agenda

D. Hidden agenda Rationale: A hidden agenda is when some group members have a different goal than the stated group goals. The hidden agenda is often disruptive to the effective functioning of the group

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

D. I am your nurse. Let's walk together to your room Rationale: D. It is appropriate for the nurse to introduce herself with each new interaction and to promote reality in a calm, reassuring manner

A nurse is reinforcing teaching about free assoication as a therapeutic tools 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 may begin to associate my therapist with important people in my life. C. I can learn to express myself in non aggressive manner. D. I should say the first thing that comes to my mind.

D. I should say the first thing that comes to my mind. Rationale: Free association is the spontaneous, uncensored verbalization of whatever comes to a client's mind.

A nurse is caring for the parents of a child who has demonstrated recent changes in behavior and mood. When the mother of the child asks the nurse for reassurances about her son's condition, which of the following responses should the nurse make? A. I think your son 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 wrong. Have you asked the doctors your concerns? D. I understand you're concerned. Let's discuss what concerns you specifically.

D. I understand you're concerned. Let's discuss what concerns you specifically. Rationale: The therapeutic response reflects upon, and accepts, the mother's feelings and it allows her to clarify what she is feeling.

A nurse is reinforcing teaching with a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following statements indicates understanding? A. It is common to treat depression with ECT before trying medications. B. I can have my depression cured if I receive a serious 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.

D. I will receive a muscle relaxant to protect me from injury during ECT. Rationale: A muscle relaxant, such as succinylcholine, is administered to reduce the risk for injury during induced seizure activity.

A nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? A. TMS is indicated for clients who have schizophrenia spectrum disorders. B. I will provide post anesthesia C. TMS treatments usually last 5 to 10 minutes D. I will schedule the client for daily TMS treatments for the first several weeks.

D. I will schedule the client for daily TMS treatments for the first several weeks. Rationale: D. TMS is commonly perscribed for 4 to 6 weeks

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

D. Implement one to one observation during meal times. Rationale: The nurse should closely monitor the client during and after meals to prevent purging

A nurse is assisting in conducting a class on therapeutic communication to 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

D. Intonation Rationale: The nurse should identify intonation as a component of verbal communication. Intonation is the tone of one's voice and can communicate a variety of feelings.

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

D. Monitor for adverse effects of medications. Rationale: D. Monitoring for adverse effects of medications is an example of psychobiological intervention.

A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following actions is the nurse's priority? A. Set consistent limit for expected client behavior B. Administer prescribed medications as scheduled C. Provide step-by-step instructions during hygiene activities. D. Monitor for escalating behavior

D. Monitor for escalating behavior Rationale: Monitoring for escalating behavior addresses the client's need for safety. Therefore, this is the nurse's priority action

A nurse working in a mental health clinic is reinforcing teaching with a client who has generalized anxiety disorder and a new prescription for diazepam. Which of the following information should the nurse reinforce? A. 3 to 6 weeks of treatment is required to achieve therapeutic benefit B. Combining alcohol with diazepam will produce a paradoxical response C. Diazepam has a lower risk for dependence than other antianxiety medications D. Report confusion as a potential indication of toxicity

D. Report confusion as a potential indication of toxicity Rationale: D. Confusion is a potential indication of diazepam toxicity that the client should report to the provider.

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

D. Restating Rationale: Restating allows the nurse to repeat the main idea expressed.

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

D. Stay with the client, and remain quiet Rationale: During a panic attacked, the nurse should quietly remain with the client. This promotes safety and reassurance without additional stimuli.

A nurse is collecting data from a client who has acute stress disorder (ASD). Which of the following findings 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 states he first noticed manifestations of the disorder 6 weeks after the traumatic incident occurred D. The client expresses a sense of unreality about the traumatic incident

D. The client expresses a sense of unreality about the traumatic incident Rationale: The client who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality.

A nurse is caring for a client who states, I'm so stressed at work because of my coworker. He expects em to finish his work because he's too lazy!. When discussing effective communication, which of the following statements by the client to his coworker indicates client understanding? A. You really should complete 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.

D. When I have to pick up extra work, i feel very overwhelmed. I need to focus on my own responsibilities. Rationale: D. This response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change.

A nurse in an acute mental health facility is contributing to the plan of care for a client who had dissociative fugue. Which of the following interventions should the nurse include? A. Encourage the client to recognize how to stress brings on a personality change in the client. B. Repeatedly present the client with information about past events C. Make decisions for the client regarding routine daily activities D. Work with the client on grounding techniques

D. Work with the client on grounding techniques Rationale: Grounding techniques (stomping feet, clapping hands, touching physical object) are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization.