Chapter 8 NCLEX Review (website)

The nurse is teaching family members about the brain's connection to behaviors commonly seen in

A chemical that is released in the brain.

The nurse is observing a client sitting alone in the day room who appears intently focused on the empty chair next to him. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he looks over at the chair, whispers something unintelligible, and shakes his head. Based on this observation the nurse would assess the client's behavior as:

A hallucination

A client, hospitalized for depression after a recent suicide attempt, tells the nurse that she cut her foot and needs a bandage. The client takes off her shoe and reveals a 1 inch by 4 inch bloody rectangle on her right insole that appeared to be a self-inflicted wound with a sharp instrument. Which of the following is the first action the nurse would take?

Ask the client about her feelings.

The nurse is observing a client sitting alone intently focused on the empty chair next to him. Suddenly the client lunges at the chair and yells "Quit talking to me! I told you I wasn't going to listen to you anymore." Which of the following actions should the nurse take? (Select all that apply.)

Ask the client to describe what he is seeing and hearing. Offer to sit with the client and talk about his favorite hobby, bird-watching. Ask the client if he would like to go for a walk.

The nurse is observing a client sitting alone in the day room who appears intently focused on the empty chair next to him. Suddenly the client begins laughing hysterically and making frantic hand gestures at the chair. When the nurse approaches the client, he looks over at the chair, whispers something unintelligible, and shakes his head. Which of the following terms best describes this behavior?

Calmly walk over to the client and say, "Tell me what's going on."

Which of the following behaviors is not generally associated with self-mutilation?

Getting a tattoo

During the initial intake interview, the client exhibits pressured speech and launches into a lengthy explanation of her ability to read "the writing on the wall". She points to certain patterns on the wallpaper and says "This is Hurricane Katrina and this is 9/11. Thousands of people died because I read the writing. I should never have read the writing it was my fault." Which of the following terms best describes this behavior?

Ideas of reference

During a meeting on the unit, a client stands up and begins reciting Bible scriptures. When asked to sit down and focus on the meeting, the client replies "I know that my Redeemer lives. He lives on 1412 Washington Street." She sits down and quietly folds her hands in prayer. Which of the following terms best assesses this behavior?

Religiosity

client has been pacing up and down the hallway for the last hour. He stares at others without blinking, clenches his fists, and mutters to himself. Another client walks down the hall and accidentally bumps into the first client. Before anyone could react, the first client punched the second client in the face and pulled his hair. The team acted quickly to restrain the first client and move him safely to the seclusion room. During a staff review of this critical incident, several alternatives were discussed. Which of the following actions should be taken to prevent a similar incident? Select all that apply.

Restrict other clients from going down the hallway while the client is pacing. Quietly and calmly ask the client if he would rather go to the quiet room or the exercise room. Offer the client a PRN dose of ziprasidone (Geodon) by mouth.

A female client with a history of being sexually abused is hospitalized for depression after a recent suicide attempt. She states that she often cuts her body in hidden places as punishment. "When I see the blood I feel better because then I know I'm alive." Which of the following nursing diagnoses would have the highest priority?

Self-mutilation: Cutting related to feelings of guilt and low self-esteem

Which of the following signs of escalating behaviors, if displayed by a client, requires immediate intervention? (Select all that apply.)

Throwing objects at staff or other clients. Banging one's head against the wall.