Evolve: Foundations and Practice of Mental Health
The grieving spouse of a client who has just died says to the nurse, "We should have spent more time together. I always felt that my work came first." What should the nurse conclude that the spouse is experiencing?
Feelings of guilt
The nurse explains to a nursing assistant that behavior usually is viewed and accepted as normal if it:
Fits within standards accepted by one's society
A nurse understands that when a client is a member of a different ethnic community it is important to:
Offer a therapeutic regimen compatible with the lifestyle of the family
What should the nurse do to develop a trusting relationship with a disturbed child who acts out?
Offer support and encourage safety during play activities
A client begins fighting and biting other clients. The practitioner prescribes a stat injection of haloperidol (Haldol). How should the nurse implement this prescription?
Quickly, with an attitude of concern
A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse?
"Does it help to joke about your illness?"
A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want her to know about the diagnosis." How should the nurse respond?
"Let's talk about how you're feeling about your child's diagnosis."
A nurse is interviewing an 8-year-old girl who has been admitted to the pediatric unit. Which statement by the child needs to be explored?
"Those boys are so cute. I hope their room's next to mine!"
A nurse enters the room of an agitated, angry client to administer the prescribed antipsychotic medication. The client shouts, "Get out of here!" The nurse's best approach is to:
Say, "I'll be back in 15 minutes, and then we can talk."
A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug?
The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks.
The parents of an adolescent who engages in self-injurious cutting behavior ask the nurse why their child self-mutilates. What should the nurse give as the reason for the cutting?
Way to manage overwhelming feelings
While caring for a client, a nurse notes that the client has begun to create new words. What term does the nurse use to document this finding?
Neologism -Neologism is the invention of new words with meanings understood only by the client.
Which tool is used to standardize and measure nursing treatments?
Nursing Interventions Classification (NIC) -Nursing Interventions Classification (NIC) is a tool that helps to define nursing interventions, as well as helps to standardize and measure the nursing care provided.
A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention?
Obtaining information about her perception of the incident
A nurse is teaching clients about dietary restrictions during monoamine oxidase inhibitor (MAOI) therapy. What response does the nurse tell them to anticipate if they do not follow these restrictions?
Occipital headaches -Occipital headaches are the beginning of a hypertensive crisis resulting from an excess of tyramine
Methylphenidate (Ritalin) is prescribed to treat a 7-year-old child's attention deficit-hyperactivity disorder (ADHD). The nurse understands that methylphenidate is used in the treatment of this disorder in children for its:
Paradoxical effect
A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse?
"Being incapacitated is difficult for you."
A client who appears dejected, barely responds to questions, and walks very slowly about the mental health unit tells the nurse in a barely audible voice that life is no longer worth living. What is the most therapeutic response to this statement by the nurse?
"Have you been thinking about suicide?"
Which statement by the client indicates to the nurse that the teaching about taking an antidepressant medication has been understood?
"I need to take every dose of my medication as prescribed."
A husband is upset that his wife's alcohol withdrawal delirium has persisted for a second day. What is the most appropriate initial response by the nurse?
"I see that you're worried. We're using medication to ease your wife's discomfort." -Recognizing the spouse's feelings and giving simple factual information help to allay anxiety.
In response to a question posed during a group meeting, the nurse explains that the superego is that part of the self that says:
"I shouldn't want that."
When speaking with a client who has schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. How should the nurse reply?
"I'd like to understand what you're saying, but I'm having trouble following you."
A client on the psychiatric unit sits alone most of the day. The nurse approaches the client. As the nurse gets approximately 3 feet away, the client lets out a string of profanity and shouts, "Leave me alone; I don't want to talk to you!" What is the most appropriate response by the nurse?
"I'll leave for now, but I'll be back later."
What statement by a 45-year-old woman scheduled for an abdominal hysterectomy and bilateral salpingo-oophorectomy should alert the nurse to the potential for postoperative coping difficulties?
"I'm not the least bit worried." -Not being worried indicates potential denial and possible failure to address the problem emotionally.
A nurse leads an assertiveness training program for a group of clients. Which statement by a client indicates that the treatment has been effective?
"It annoys me when people call me 'sweetie,' so I told him not to do it anymore."
A client has been taking escitalopram (Lexapro) for treatment of a major depressive episode. On the fifth day of therapy the client refuses the medication, stating, "It doesn't help, so what's the use of taking it?" What is the best response by the nurse?
"It can take 1 to 4 weeks to see an improvement."
A client who has recently been found to be infected with HIV comments to the nurse, "There are so many terrible people around. Why couldn't one of them get HIV instead of me?" What is the best response by the nurse?
"It seems unfair that you should have this disease."
A client is extremely depressed, and the practitioner prescribes a tricyclic antidepressant, imipramine (Tofranil). The client asks the nurse what the medication will do. The nurse responds:
"It will help increase your appetite and make you feel better."
During a group meeting a client tells everyone, "I'm about to be discharged from the hospital, and I'm afraid." What is the most appropriate response by the nurse facilitator?
"Maybe others in the group have similar feelings that they would share."
A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy?
"Negative thoughts can precipitate anxiety."
A parent who is visiting a hospitalized adolescent gets into an argument with the adolescent. Leaving the adolescent's room in tears, the parent meets the nurse and relates the argument, saying, "I can't believe I got so angry that I could have hit her." What is the most therapeutic response by the nurse?
"Sometimes we find it difficult to live up to our own expectations of ourselves."
A 6-year-old child is found to have type 1 diabetes. In light of the child's cognitive developmental level, which explanation of the illness is most appropriate?
"Taking insulin for your diabetes is like getting new batteries for your superhero toys."
A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent?
"Tell me again how your child fell down the stairs."
After a child's visit to a health care provider, the parent tells the nurse, "I'm so upset! The doctor prescribed an antidepressant!" What is the best response by the nurse?
"Tell me more about what's bothering you."
A client asks the nurse how psychotropic medications work. The nurse correctly replies:
"These medications affect the chemicals used in communication between nerve cells."
During a phone conversation to a crisis hotline a client states, "I'm falling apart and can't put myself together. This goes on and on." What is the most therapeutic response by the nurse?
"What's happening right now that prompted you to call?"
A client is dying. Hesitatingly, his wife says to the nurse, "I'd like to tell him how much I love him, but I don't want to upset him." Which is the best response by the nurse?
"Why don't you share your feelings with him while you can?" -It is difficult to work through a loss; however, encouraging the sharing of feelings helps both parties to feel better about having to let go.
As depression begins to lift, a client is asked to join a small discussion group that meets every evening on the unit. The client is reluctant to join because, she says, "I have nothing to talk about." What is the best response by the nurse?
"You feel you won't be accepted unless you have something to say?" -The statement about the client's feelings of acceptance is a reflective statement that allows the client to either validate the statement or correct the nurse
A woman who is frequently physically abused tells the nurse in the emergency department that it is her fault that her husband beats her. What is the most therapeutic response by the nurse?
"You say that it was your fault—help me understand that."
A nurse determines that confrontation is an appropriate tool for use with a client. What is an example of therapeutic confrontation?
"You say you're not a good parent, but you were effective when you were talking with your son today."
A female client undergoing presurgical testing before a possible colon resection and colostomy says to the nurse, "If I have to have this surgery, I know that my husband will never come near me again." What is the most therapeutic response by the nurse?
"You're concerned about how your husband will respond to your surgery."
During a group discussion regarding the unexpected suicide of a young female client who was on a weekend pass, one of the other clients stands up and shouts, "Oh, I know what you're all thinking. You think that I should've known that she was going to kill herself. You think I helped her plan this." What is the most therapeutic response by the group leader?
"You're upset because you think we're blaming you for her death?"
A nurse counseling a female client on the inpatient psychiatric unit responds to a statement made by the woman by stating, "I'm confused about exactly what is upsetting you. Would you go over that again, please?" The nurse is using:
1 Clarifying
A person mowing a lawn is badly disfigured by the lawnmower blade. According to Erikson's theory, which age at the time of injury will be associated with the greatest risk of long-term psychological effects?
11 years
An older adult living in a long-term care facility has been receiving lithium 600 mg twice a day for 3 weeks to ease manic behavior. The client is experiencing nausea and vomiting, diarrhea, thirst, polyuria, slurred speech, and muscle weakness. What is the most appropriate nursing intervention?
1 Withholding the next dose of lithium and drawing blood to test it for toxicity
Certain questions are applicable in determining nursing negligence. (Select all that apply.)
1 "Was reasonable care provided?" 2 "Was there a breach of nursing duty?" 3 "Was there an act of omission that resulted in harm? 4 "Except for the nurse's action, would the injury have occurred?"
A client with a history of aggressive, violent behavior is admitted to the psychiatric unit involuntarily. The nurse, who understands the need to use deescalation approaches during the preassaultive stage of the violence cycle, monitors the client's behavior closely for progression of signs of impending violence. List these client behaviors in order of escalating aggression, from the lowest risk to the highest.
1 Increasing tension in facial expression 2 Having difficulty waiting to take turns during a group project 3 Pacing in the hall 4 Engaging in verbal abuse toward the nurse 5 Pushing another client while waiting in line to the dining room
A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? (Select all that apply.)
1 Meditation 2 Mental imagery 5 Deep-breathing exercises
A nurse is caring for clients with a variety of psychiatric illnesses. For which diagnoses is the establishment of a psychiatric advance directive (PAD) most beneficial? (Select all that apply.)
1 Bipolar Disease 2 Paranoid schizophrenia -Individuals with manic-depressive illness may have psychotic episodes during which they are unable to perceive and respond to reality appropriately. Mania diminishes judgment and insight, which in turn reduces a client's ability to make decisions. Individuals with paranoid schizophrenia may have psychotic episodes during which they are unable to perceive and respond to reality appropriately. Paranoia makes a client overly suspicious, which diminishes judgment and insight. Individuals with narcissistic personality disorder are usually in contact with reality and able to make reasonable decisions.
An adult who has been in a gay relationship for 3 years arrives at the emergency department in a state of near-panic. The client says, "My partner just left me. I'm a wreck." What should the nurse do to help the client cope with this loss? (Select all that apply.)
1 Identify the client's support systems 4 Encourage the client to talk about the situation
When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? (Select all that apply.)
1 Projection 5 Rationalization
Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? (Select all that apply.)
1 Rigidity 2 Tremors 5 Bradykinesia
A nurse is caring for a man who has inoperable cancer of the pancreas. His wife is trying to cope with the diagnosis. Place the wife's statements in order as the woman progresses through the grieving process, from the first stage to the last:
1. "I want him to get a second opinion." 2. "He shouldn't have gotten this because he doesn't smoke or drink." 3. "His grandchildren need to get to know him." 4. "All I do is cry, because I can't live without him." 5. "If he can't be cured, I just want him to be comfortable."
A parent of four is remanded to the psychiatric unit by the court for observation. The client was arrested and charged with abusing a 2-year-old son, who is in the pediatric intensive care unit in critical condition. The nurse approaches the client for the first time. How should the nurse anticipate that the client will likely respond? (Select all that apply.)
1. By denying beating the son 2. By avoiding talking about the situation 5. Emotional response is inconsistent with degree of injury
When planning nursing care for clients who are grieving the potential death of a family member, it is helpful to draw on the understanding of the five stages of grieving identified and described by Elisabeth Kübler-Ross. Place these stages in order of progression from first to last.
1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
Erik Erikson posited life as a sequence of achievements. Place the levels of development in their order of achievement according to Erikson's theory.
1. Industry vs inferiority 2. Identity vs role confusion 3. Intimacy vs isolation 4. Integrity vs despair 5. Generativity vs. stagnation
A nurse is caring for clients who are undergoing therapy for dependence on alcohol. Which member of the health team has the primary responsibility for their rehabilitation?
2 Client
Before a treatment requiring informed consent can be performed, what information must the client be given? (Select all that apply.)
2 Alternative treatment options 3 The risks and benefits of the treatment 4 The risks involved in refusing the treatment 5 The nature of the problem requiring the treatment
A 44-year-old client has been unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis is this situation?
2 Situational
An adolescent on the psychiatric unit has an angry outburst toward another client who cut in front of people standing in line to get their mail. Later the nurse conducts a one-on-one therapeutic session with the angry client. What is an appropriate short-term goal for the client to strive for?
2 Talking about the situation that precipitated the anger
A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.)
2 "Every time I turn around the kid is falling over something." 4"I can't understand it. He didn't have a problem using the stairs without my help before this."
A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before." What is the best reply by the nurse?
2 "How do you feel about having a male nurse?"
A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? (Select all that apply.)
2 Determining a safe place to go in an emergency 3 Memorizing the domestic violence hotline number
Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? (Select all that apply.)
2 Diaphoresis 3 Hyperrigidity 4 Hyperthermia
An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? (Select all that apply.)
2 Focusing on the child's role in sustaining the injury 3 Changing the story of how the child sustained the injury 5 Giving an explanation of how the injury occurred that is not consistent with the injury
A nurse teaches dietary guidelines to a client who will be receiving tranylcypromine sulfate (Parnate), a monoamine oxidase inhibitor (MAOI). The client compiles a list of foods to avoid. Which foods included on the list indicate that the teaching has been effective? (Select all that apply.)
2 Pepperoni pizza 3 Bologna sandwich
A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client?
3 Boundary violations
A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? (Select all that apply.)
3 "I'd like to end it all with sleeping pills." 4 "The voices say I should kill all prostitutes."
A client is prescribed a monoamine oxidase inhibitor. The nurse teaches the client about what foods to avoid when taking this medication. (Select all that apply.)
3 Aged cheese 4 Ripe avocados 5 Delicatessen meats -Foods high in tyramine, such as aged cheese, should be avoided by anyone taking a monoamine oxidase inhibitor (MAOI). When an MAOI is being taken, tyramine can increase to an unsafe level and cause a life-threatening hypertensive crisis. Foods high in tyramine, such as ripe avocados, should be avoided by people taking MAOIs. Delicatessen meats that are fermented, such as bologna, pepperoni, salami, and sausage, are also high in tyramine and should be avoided by people taking MAOIs. Fresh fish does not need to be avoided by people taking MAOIs; dried, pickled, cured, fermented, and smoked fish should be avoided. Citrus fruits do not need to be avoided by people taking MAOIs. Figs and bananas in large amounts should be avoided.
A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone (Risperdal). Which outcomes indicate that the medication has minimized these symptoms? (Select all that apply.)
3 More interest is shown in unit activities 5 The client performs activities of daily living independently
At what age is a client in Freud's phallic stage of psychosexual development and Erikson's psychosocial phase of initiative versus guilt?
3 to 5years -Three to 5 years is Freud's phallic stage and Erikson's stage of initiative versus guilt. Adolescence is Freud's genital stage and Erikson's stage of identity versus role confusion. Six to 12 years is Freud's latency stage and Erikson's stage of industry versus inferiority. Birth to 1 year is Freud's oral stage and Erikson's stage of trust versus mistrust.
After speaking with the parents of a child dying of leukemia, the practitioner gives a verbal do-not-resuscitate order but refuses to put it in writing. What should the nurse do?
4 Determine whether the family is in accord with the practitioner while following hospital policy
A client has become increasingly depressed, and the practitioner prescribes an antidepressant. After 20 days of therapy, the client returns to the clinic. The client appears relaxed and smiles at the nurse. The most significant conclusion that the nurse can draw from this behavior is that the client:
4 Is responding to the antidepressant therapy
Doxepin (Sinequan) is prescribed for a 74-year-old man for treatment of a depressive episode that has not responded to several other medications. The nurse in the outpatient clinic reviews with the client the side effects of doxepin. The identification of which side effects by the client as needing to be reported to the health care provider allows the nurse to conclude that the teaching has been effective? (Select all that apply.)
4 Retention of urine 5 Thoughts of suicide
How long after the last dose should the nurse schedule to have a client's blood drawn to evaluate the serum lithium level?
8 to 12 hours
The practitioner prescribes valproic acid (Depakene) 750 mg daily to be administered in two divided doses. The medication is supplied as a syrup of 250 mg/5 mL. How many milliliters of solution should the nurse administer per dose? Record your answer using one decimal place. __________ mL
7.5 mL
A client on the psychiatric unit asks a nurse about psychiatric advance directives (PADs). What information should form the basis of the nurse's response?
A client is allowed to consent to or refuse potential psychiatric treatments if a future incapacitating mental health crisis occurs.
An older adult tells the nurse, "I regret so many of the choices I've made during my life." Which of Erikson's developmental conflicts has the client probably failed to accomplish?
Ego integrity versus despair
The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention?
Active participant -To intervene in a crisis the nurse must assume a direct, active role because the client's ability to cope is lessened and help is needed to problem-solve.
Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action?
Administering chlordiazepoxide as indicated by the client's CIWA score
On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery." Which side effect does the nurse suspect that the client is experiencing?
Akathisia -Akathisia , a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation.
In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed?
Antipsychotics
One afternoon a nurse sees a client rushing down the hall of the mental health unit, rapidly tapping his fingers against the wall. What is the most appropriate nursing action at this time?
Approaching the client in a nonthreatening manner to determine the cause of the agitation
A client is scheduled for several diagnostic studies. Which behavior best indicates to the nurse that the client has received adequate preparation?
Arrives early and waits quietly to be called for the tests
The parents of a toddler with recently diagnosed moderate cognitive impairment discuss their child's possibility of future independent function. What should the nurse conclude?
Denial is being used as a defense.
What is the most therapeutic nursing intervention to help a late-middle-aged individual cope with the emotional aspects of aging?
Assisting the individual with plans for the future
An older man is widowed suddenly when his wife is killed in an automobile accident. What should the nurse in the emergency department do first to best help the client at this time?
Assure him that everything possible was done for his wife
The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client:
Attempts to minimize the illness
As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of:
Attitudes and beliefs -Some attitudes and beliefs include reluctance by older people to seek help because of pride in their independence, stoic acceptance of difficulty, unawareness of resources, and fear of being "put away." Although the client mentions "being put away", that is an attitude
A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request?
Autonomy -Autonomy is the ethical principle of respecting the independence and right to self-determination of others. In this situation the nurse focuses on helping the client make a choice.
What developmental task should the nurse consider when caring for toddlers?
Autonomy -Testing the self both physically and psychologically occurs during the toddler stage, after trust has been achieved. Trust is the task of infancy. The task of industry is accomplished between the ages of 6 and 12.
A terminally ill client repeatedly tells the nurse all the details of a daughter's wedding that will take place in 6 months and how important it is for her to attend. What Kübler-Ross stage of grieving does the nurse identify?
Bargaining
A female client in the terminal stage of cancer is admitted to the hospital in severe pain. The client refuses the prescribed intramuscular analgesic for pain because it puts her to sleep and she wants to be awake. One day, despite the client's objection, a nurse administers the pain medication saying, "You know that this will make you more comfortable." The nurse in this situation could be charged with:
Battery -Battery is the intentional touching of one person by another without permission of the person being touched.
A nurse on the psychiatric unit is assigned to work with a male client who appears reclusive and distrustful of everyone. The nurse can help the client develop trust by:
Being prompt for their scheduled meetings -Being prompt for their scheduled meetings helps the client feel important because the nurse remembers their meetings and is on time.
Thirty minutes after administering fluphenazine (Prolixin) to a client, the nurse notes that the client's jaw is rigid, the client is drooling, and her speech is slurred. There are a number of as-needed prescriptions in the client's chart. What should the nurse administer?
Benztropine (Cogentin), 2 mg intramuscularly -Benztropine (Cogentin) is an anticholinergic, antiparkinsonian drug used to treat drug-induced extrapyramidal symptoms associated with phenothiazine therapy; the intramuscular (IM) route will relieve symptoms more rapidly.
A client has recently started taking a new neuroleptic drug, and the nurse notes extrapyramidal effects. Which drug does the nurse anticipate will be prescribed to limit these side effects?
Benztropine mesylate (Cogentin) -Benztropine (Cogentin), an anticholinergic, helps balance neurotransmitter activity in the central nervous system (CNS) and helps control extrapyramidal tract symptoms.
A parent whose daughter is killed in a school bus accident tearfully tells the nurse, "My daughter was just getting over the chickenpox and didn't want to go to school, but I insisted that she go. It's my fault that she's dead." How should the nurse anticipate that perceiving a death as preventable will likely influence the grieving process?
Bereavement may be of greater intensity and duration.
A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client?
Boundary violations
How should a nurse at an assisted living facility encourage a client to effectively complete the tasks of older adulthood?
By fostering a sense of contentment when the client looks back on her achievements
A resident in a nursing home recently immigrated to the United States from Italy. How does the nurse plan to provide emotional support?
By offering choices consistent with the client's heritage
A client's methods of coping are maladaptive. How can the nurse best help the client develop healthier coping mechanisms?
By setting realistic limits on the client's maladaptive behavior
When planning care for an older client, the nurse remembers that aging has little effect on a client's:
Capacity to handle life's stresses
What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?
Channeling unacceptable impulses into socially approved behavior
A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department?
Charming -Abusers are often extremely charming to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. Abusers mask their fears by becoming angry and aggressive. Abusers are not confused; they are manipulative of others. Abusers are rarely indifferent; they tend to be opinionated and demanding.
A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to observe the client for side effects. What is the nurse's initial action?
Checking the client's blood pressure
A nurse is teaching a client about side effects of medications. Which drug will cause a heightened skin reaction to sunlight?
Chlorpromazine -Clients taking chlorpromazine should be instructed to stay out of the sun. Photosensitivity makes the skin more susceptible to burning. Photosensitivity is not a side effect of lithium, sertraline, or methylphenidate.
A recently married 22-year-old woman is brought to the trauma center by the police. She has been robbed, beaten, and sexually assaulted. The client, although anxious and tearful, appears to be in control. The health care provider prescribes alprazolam (Xanax) 0.25 mg for agitation. The nurse should administer this medication when the:
Client requests something to calm her
A client is admitted for treatment of obsessive-compulsive disorder that is interfering with activities of daily living. Which medication should the nurse anticipate the health care provider will prescribe?
Clomipramine (Anafranil)
A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using?
Compensation -By developing skills in one area, the individual compensates for a real or imagined deficiency in another, thereby maintaining a positive self-image.
When a person who is nonathletic and uncoordinated is successful in a musical career, it may be related to the defense mechanism of:
Compensation -Compensation is replacing a weak area or trait with a more desirable one
A client has been prescribed chlorpromazine (Thorazine) for the management of positive symptoms of schizophrenia. When the client reports difficulty sustaining an erection, the nurse:
Consults with his provider regarding alternative medication therapies Although erectile dysfunction can result from conventional antipsychotic medication therapy, the provider is often able to prescribe an alternative medication that will help manage the symptoms but is less likely to cause the dysfunction.
A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. The nurse's behavior reflects:
Countertransference
A nurse is working with a couple and their two children. The 14-year-old son has been in trouble at school because of truancy and poor grades. The 16-year-old daughter is quiet and withdrawn and refuses to talk to her parents. The parents have had severe marital problems for the past 10 years. The priority nursing concern at this time is how the:
Couple's marital problems are affecting their children -The parents' ongoing marital problems appear to have interfered with their parental roles, resulting in their children's behavioral problems. At this time the children need support, not limits. The son's and daughter's behaviors are not the priority nursing concern because there are no data to support these assumptions.
On the first day of the month a practitioner prescribes an antipsychotic medication for a client with schizophrenia. The initial dosage is 25 mg once a day, to be titrated in increments of 25 mg every other day to a desired dosage of 175 mg daily. On what day of the month will the client reach the desired daily dose of 175 mg?
Day 13
A client with type 1 diabetes is found to have a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination?
Decreased control of the diabetes
What can the nurse do to help older adult to successfully complete Erikson's major task of this stage?
Develop a sense of satisfaction when considering past achievements
What is the most difficult initial task in the development of a nurse-client relationship?
Developing an awareness of self and the professional role in the relationship -The nurse's major tool in mental health nursing is the therapeutic use of self. Mental health nurses must learn to identify their own feelings and understand how they affect the situation. Although remaining therapeutic and professional and being able to understand and accept a client's behavior may be difficult, an awareness of self is still the most difficult part of developing a nurse-client relationship. Accepting responsibility for identifying and evaluating the real needs of a client implies that the nurse is working alone in caring for the client.
A child in the first grade is murdered, and counseling is planned for the other children in the school. What should a nurse identify first before evaluating a child's response to a crisis?
Developmental level of the child
A nurse concludes that a client is using displacement. Which behavior has the nurse identified?
Directing pent-up emotions at someone other than the primary source -When acting out against the primary source of anxiety creates even further anxiety or danger, the individual may use displacement to express feelings toward a "safer" person or object
A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do?
Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation
A male long-distance jumper improves his distance by 3½ inches (7 cm) and earns the praise of his coach, but on another day, when he does not reach his mark, he forcefully kicks the door of his locker. What defense mechanism does his outburst demonstrate?
Displacement -Displacement is the discharging of pent-up feelings on a less threatening object, in this case the locker door.
One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. The nurse identifies the defense mechanism that the client is using as:
Displacement -Displacement reduces anxiety by transferring the emotions associated with an object or person to another emotionally safer object or person.
A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example?
Dissociation -Speaking in the third person reflects poor ego boundaries and dissociation from the real self. Transference is the movement of emotional energy and feelings that one has for one person to another person
What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion?
Documenting both the client's behavior and the reason that specific rights were denied
A practitioner prescribes Alprazolam (Xanax) 0.25 mg by mouth three times a day for a client with anxiety and physical symptoms related to work pressures. For what most common side effect of this drug should the nurse monitor the client?
Drowsiness
A nurse is administering hydroxyzine (Vistaril) to a client. For which common side effects of this drug should the nurse monitor the client?
Drowsiness and dry mouth -This drug suppresses activity in key regions of the subcortical area of the central nervous system; it also has antihistaminic and anticholinergic effects
A client is scheduled for a 6-week electroconvulsive therapy (ECT) treatment program. What intervention is important during the course of treatment?
Elimination of benzodiazepines for nighttime sedation -The use of benzodiazepines can raise the seizure threshold, which is counterproductive.
In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. This technique is known as:
Empathy
What characteristic is most essential for the nurse caring for a client undergoing mental health care?
Empathy
The day after the birth of their baby, the parents are upset to learn that the baby has a heart defect. At this time it is most helpful for the nurse to:
Encourage the expression of their feelings
A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks?
Fluphenazine -Fluphenazine can be given intramuscularly every 2 to 3 weeks to clients who are unreliable about taking oral medications; it allows them to live in the community while keeping the disorder under control. Lithium is a mood-stabilizing medication that is given to clients with bipolar disorder. This drug is not given for schizophrenia. Diazepam (Valium) is an antianxiety/anticonvulsant/skeletal muscle relaxant that is not given for schizophrenia. Fluvoxamine (Luvox) is a selective serotonin reuptake inhibitor; it is administered for depression, not schizophrenia.
A client is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. The client's anxiety level is approaching a panic level, and the client's ritual is interfering with work and daily living. Which selective serotonin reuptake inhibitor (SSRI) should the nurse anticipate that the health care provider may prescribe?
Fluvoxamine (Luvox) -Fluvoxamine (Luvox) inhibits central nervous system neuron uptake of serotonin but not of norepinephrine. Haloperidol (Haldol) is not an SSRI; it is an antipsychotic that blocks neurotransmission produced by dopamine at synapses. Imipramine (Tofranil) is a tricyclic antidepressant, not an SSRI. Benztropine (Cogentin) is an antiparkinsonian agent, not an SSRI.
After a traumatic event, a client is extremely upset and exhibits pressured and rambling speech. What therapeutic technique can the nurse use when a client's communication rambles?
Focusing
A nurse encourages a client to attend Alcoholics Anonymous (AA) meetings after discharge. What do self-help groups such as AA help their members do?
Foster changes in behavior
A client is admitted to the emergency department after ingesting a tricyclic antidepressant in an amount 30 times the daily recommended dose. What is the immediate treatment anticipated by the nurse?
Gastric lavage with activated charcoal and support of physiological function -Gastric lavage with charcoal may help decrease the level of tricyclic antidepressant overdose. Supportive measures such as mechanical ventilation may be needed until the medical crisis passes.
According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to the earlier developmental stage of:
Generativity versus stagnation -Erikson theorized that how well people adapt to the current stage depends on how well they adapted to the stage immediately preceding it—in this instance, adulthood. Although Erikson believed that the strengths and weaknesses of each stage are present in some form in all succeeding stages, their influence decreases with time
A nurse is caring for a 20-year-old client. According to Erikson's developmental psychosocial theory, what is expected by 20 years of age?
Having a coherent sense of self and plans for self-actualization
Imipramine (Tofranil), 75 mg three times per day, is prescribed for a client. What nursing action is appropriate when this medication is being administered?
Having the client checked for increased intraocular pressure and teaching about symptoms of glaucoma
A client on the psychiatric unit is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT). Because of the client's profoundly depressed behavior, the nurse doubts that the client can provide informed consent. What should the nurse's initial intervention be?
Having the client verbalize her understanding and the outcomes of the procedure
A disturbed client who has been out of touch with reality has been hospitalized for several weeks. One day the nurse notes that the client's hair is dirty and asks whether the client wants to wash it. The client answers, "Yes, and I'd like to shower and change my clothes, too." What can the nurse conclude about the client in relation to this response?
He has some feelings of self-worth.
What is most important for the nurse to do to assist a couple to cope with their feelings about the husband's terminal illness?
Helping the couple express to each other their feelings about his terminal illness
A client in the hyperactive phase of a mood disorder, bipolar type, is receiving lithium. A nurse sees that the client's lithium blood level is 1.8 mEq/L. What is the most appropriate nursing action?
Holding the drug and notifying the health care provider (prescribing provider) immediately because the blood lithium level may be toxic -The lithium level should be maintained between 0.5 and 1.5 mEq/L. The lithium level is currently unsafe but does not need to drop to 0.5 mEq/L before being resumed. Continuing the drug and asking the health care provider to prescribe a higher dosage are both unsafe options.
A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency department." What does the nurse consider this statement to represent?
Hospital policy
The nurse should teach a client receiving isocarboxazid (Marplan) that failure to adhere to the necessary dietary restrictions can result in:
Hypertensive crisis -Monoamine oxidase uptake is inhibited by the medication, increasing concentrations of endogenous epinephrine, norepinephrine, serotonin, and dopamine in central nervous system storage sites; high levels of these transmitters in the presence of tyramine (e.g., cheeses, herring, wine, sausages) can cause hypertensive crisis.
A health care provider refers a 52-year-old man to the mental health clinic. The history reveals that the man lost his wife to colon cancer 6 months ago and that since that time he has seen his health care provider seven times with the concern that he has colon cancer. All tests have had negative results. Recently the client stopped seeing friends, dropped his hobbies, and stayed home to rest. Which disorder should the nurse identify as consistent with the client's preoccupation with the fear of having a serious disease?
Hypochondriac disorder -Preoccupation with fears of getting or having a serious disease is called hypochondriasis. The condition usually exists for 6 months or longer, persists despite negative medical tests and reassurance, and results in social or occupational impairment. Conversion disorder is characterized by the presence of one or more symptoms related to a neurological problem that has no organic cause. Somatization disorder is characterized by the reporting of many physical problems by the client, usually beginning before age 30; physical problems may include pain, gastrointestinal symptoms, sexual or reproductive problems, and at least one symptom that suggests a neurological disorder. Body dysmorphic disorder is characterized by preoccupation with some imagined defect in appearance that causes marked distress and significant impairment in social and occupational function.
To therapeutically relate to parents who are known to have maltreated their child, the nurse must first:
Identify personal feelings about child abusers
A nurse in the mental health clinic concludes that a client is using confabulation when:
Imagination is used to fill in memory gaps
A female client in the mental health clinic has pressured speech and mumbles incoherently. What is the most appropriate nursing intervention?
Indicating to the client that she needs to slow down because what she says is important and cannot be understood
The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the best response by the nurse?
Informing him that he should seek emergency intervention for his wife -The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention. The wife, not the husband, is the priority at this time.
A nurse concludes that a 6-year-old child who has attained an acceptable level of psychosocial development has achieved Erikson's developmental conflicts related to trust, autonomy, and:
Initiative
A woman with five children comes to the emergency department with multiple facial injuries. The client says, "My husband is an alcoholic, and he just beat me up." The nurse concludes that the client appears to be a victim of abuse. What should the nurse do next?
Inquire about her and the children's safety -The safety of the victim and the children must be determined, because research shows that children of an alcoholic parent are frequently abused. If the nurse suspects child abuse, a report must be made to child protective services.
A 65-year-old man is admitted to the hospital with a history of depression. The client, who speaks little English and has had few outside interests since retiring, says, "I feel useless and unneeded." The nurse concludes that the client is in Erikson's developmental stage of:
Integrity versus despair
An older retired client is visiting the clinic for a regularly scheduled checkup. The client tells the nurse about the great life he has lived and the activities that he enjoys at the senior center. According to Erikson, what developmental conflict has been resolved by this client?
Integrity versus despair
A client with diabetes mellitus is able to discuss in detail the diabetic metabolic process while eating a piece of chocolate cake. What defense mechanism does the nurse identify when evaluating this behavior?
Intellectualization -Intellectualization is the avoidance of a painful emotion with the use of a rational explanation that removes the event from any personal significance.
Which goal specific to a client with impaired verbal communication related to a psychological barrier should be documented in the client's clinical record?
Interacting appropriately with others in the therapeutic milieu -Interacting appropriately with others in the therapeutic milieu is a goal related to the identified problem and is appropriate and measurable.
To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors the central factors that influence development?
Interpersonal theory -The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachments and a longing to meet biological and psychological needs are two dimensions associated with this theory.
According to Erikson, a young adult must accomplish the tasks associated with the stage known as:
Intimacy versus isolation
A nurse is evaluating a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group?
Intimacy versus isolation The major task of young adulthood is centered on human closeness and sexual fulfillment; lack of love results in isolation.
A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse's questions factually in a soft voice with a composed manner. This behavior may indicate that the client:
Is controlling the expression of feelings
Survivors of a major earthquake are being interviewed on admission to the hospital. The nurse notes that they exhibit a flattened affect, make minimal eye contact, and speak in a monotone. These behaviors are indicative of the defense mechanism known as:
Isolation
A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine (Cogentin) or trihexyphenidyl in conjunction with the phenothiazine derivatives neuroleptic medications?
It combats the extrapyramidal side effects of the other drug.
When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, the nurse should:
Listen to what the client is saying
The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is:
Lorazepam (Ativan)
A nurse is caring for a client who is angry and agitated. What is the best approach for the nurse to use with this client?
Maintaining a calm, consistent approach with the client
A client with schizophrenia is started on an antipsychotic/neuroleptic medication. The nurse explains to a family member that this drug primarily is used to:
Make the client more receptive to psychotherapy -Antipsychotic/neuroleptic medications help control anxiety, improve cognition, and decrease acting-out behavior, rendering the client better able to participate in therapy. Although the medication may keep the client quiet and relaxed, control the client's behavior and reduce stress, or prevent the need for restraints, none of these is the primary purpose of administration.
A nurse administers prescribed anxiolytics to clients with severe emotional disorders. What is the goal of this treatment?
Makes the client more amenable to psychotherapy
A health care provider prescribes divalproex (Depakote). What does the nurse consider an appropriate indication for the use of this drug?
Management of manic episodes of bipolar disorder
A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of:
Manipulating the environment to benefit the client
Which nursing intervention involves providing, structuring, and maintaining a safe and therapeutic environment in collaboration with patients, families, and other health care providers?
Milieu therapy
A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client?
Mydriasis
The nurse should first discuss terminating the nurse-client relationship with a client during the:
Orientation phase, when a contract is established
A nurse notes that haloperidol (Haldol) is most effective for clients who exhibit behavior that is:
Overactive
A young client who has become a mother for the first time is anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect?
Primary prevention -Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems. There is no category of prevention called therapeutic prevention.
A client who is taking lithium arrives at the mental health center for a routine visit. The client has slurred speech, has an ataxic gait, and complains of nausea. The nurse knows that these signs and symptoms are:
Probably associated with a toxic level of lithium
A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." The nurse concludes that the client is using:
Projection
A client with the diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine drug. The daycare center is planning a fishing trip. It is important that the nurse:
Provide the client with sunscreen
A young female client admitted to the trauma center after being sexually assaulted continues to talk about the rape. Toward what goal should the primary nursing intervention be directed?
Providing a safe environment that permits the ventilation of feelings
A 13-year-old girl is brought to the emergency department by her mother, who tells the nurse that she just found out that her daughter has been sexually abused by her grandfather for almost 2 years. What is the nurse's priority intervention?
Providing a safe, nonjudgmental environment
A client says, "Since my husband died I've got nothing to live for. I just want to die." The nurse hears the nursing assistant say, "Things will get better soon." The nurse identifies this response as:
Providing false reassurance
Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings?
Psychoanalytical model -The psychoanalytical model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. The psychobiological model views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. The social-interpersonal model affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.
A client in the mental health clinic who has concerns about getting married says to the nurse, "I guess I'd better get married. All the plans are made and paid for, and the invitations have all been mailed." What defense mechanism is the client using?
Rationalization
A client who is being treated in a mental health clinic is to be discharged after several months of therapy. The client anxiously tells the nurse, "I don't know what I'll do when I can't see you anymore." The nurse determines that the client is:
Reacting to the planned discharge
What should a nurse ensure when creating an environment that is conducive to psychological safety?
Realistic limits are set.
A health care provider writes a prescription of "Restraints PRN" for a client who has a history of violent behavior. What is the nurse's responsibility in regard to this order?
Recognizing that PRN orders for restraints are unacceptable
A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should:
Refer the mother to the psychiatrist -It is the responsibility of the psychiatrist, who is the primary care provider, to discuss the test results with the mother. Explaining to the mother the results of the tests is beyond the scope of the nurse's role. The mother should be referred to the psychiatrist, not the psychologist, because the psychiatrist is the leader of this health team. Teaching about the tests should have been done before, not after, the tests were administered.
A client has just spent five minutes complaining to the nurse about numerous aspects of the client's hospital stay. Which is the best initial response by the nurse?
Refocus the conversation on the client's fears, frustrations, and anger about the client's condition
A client sits huddled in a chair and leaves it only to assume the fetal position in a corner. The nurse, observing this, identifies the behavior as
Regressive
An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance?
Reinforcing routines and supporting her usual habits
A client is to begin lithium carbonate therapy. The nurse should ensure that before the drug's administration the client has baseline:
Renal Studies -Because of the severity of side effects and the stress lithium places on the renal and cardiovascular systems, its administration is contraindicated in clients with renal or cardiovascular disease. Baseline renal studies can be used for comparison in the future.
After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client?
Repression
Incidences of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation?
Repression
Three days after a stressful incident a client can no longer remember why it was stressful. The nurse, in relating to this client, can be most therapeutic by identifying that the inability to recall the situation is an example of the defense mechanism of:
Repression
What is the priority goal in the planning of care for a client in crisis?
Restoring the client's psychological equilibrium
An older client whose family has been visiting on the psychiatric unit is visibly angry and says to the nurse, "My daughter-in-law says they can't take me home until the doctor lets me go. She doesn't understand how important this is to me; she's not from our culture." What should the nurse do?
Say, "You feel she doesn't want you at home."
The nurse is explaining the Client Bill of Rights to a female client whose psychiatrist has admitted her to an inpatient facility. Her admission is voluntary. The statement that is not a client right is the right to:
Select health team members -Clients may not select the members of the health care team when admitted to an inpatient setting that delivers care 24 hours a day, 7 days a week.
In addition to hallucinating, a client yells and curses throughout the day. The nurse should:
Seek to understand what the behavior means to the client -All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client.
After caring for a terminally ill client for several weeks, a nurse becomes increasingly aware of a need for a respite from this assignment. What is the best initial action by the nurse?
Seeking support from colleagues on the unit -Talking with colleagues who face or who have faced the same problems may provide constructive help with the situation
A nurse is caring for a client who has abruptly stopped taking a barbiturate. What should the nurse anticipate that the client may experience?
Seizures
What is the basic therapeutic tool used by the nurse to foster a client's psychological coping?
Self -The self is often the most important tool available to the nurse to help a client cope; to be therapeutic, the nurse must be present, actively listening, and attentive.
A psychiatric client recently admitted to the inpatient unit has a history of angry outbursts. The client's anger appears to be escalating, although the client still appears to be in control. What should the nurse do first to prevent an incident from developing?
Set a contract with the client to verbalize frustrations before acting out
Olanzapine (Zyprexa) is prescribed for a client with bipolar disorder, manic episode. What cautionary advice should the nurse give the client?
Sit up slowly. -Olanzapine (Zyprexa), a thienobenzodiazepine, can cause orthostatic hypotension. Blurred, not double, vision may occur. Decreased salivation is an effect of Olanzapine. It may also cause nausea and other gastrointestinal upsets and should be taken with fluid or food.
When working with clients who use manipulative socially acting-out behaviors, the nurse should be:
Sincere, cautious, and consistent
What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position?
Sitting down in a chair by the client and saying, "I'm here to spend time with you."
After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty?
Social interaction
A health care provider prescribes haloperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication?
Staying in the sun
A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense is the client using when identifying the other clients thusly?
Splitting -Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others.
The emergency department nurse is conducting an interview and assisting with the physical examination of a female sexual assault victim. What is most important for the nurse to document on this client's record?
Statements by the client about the sexual assault and the rapist
A 19 year-old, arrested for assault and robbery, has a history of truancy and prostitution but is unconcerned that her behavior has caused emotional distress to others. The diagnosis of antisocial personality disorder is made. According to psychoanalytical theory, the client's lack of remorse and repetitive behavior probably are related to an underdeveloped:
Superego
A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group?
Support
A mother and her 5-year-old daughter have been referred to a child advocacy center for a forensic pediatric sexual examination. Before the child is examined or interviewed, the mother gives a detailed history, relaying her suspicion that the child's maternal grandfather sexually assaulted her. As the interview progresses, the mother suddenly says, "My father sexually molested me when I was a child, but I try not to think about it." What defense mechanism does the nurse recognize that the mother's statement demonstrates?
Suppression
An executive, busy at work, receives a phone call from a friend relating bad news. The woman makes a conscious effort to put this information out of her mind and continues to work at the task at hand. The next day she remembers that her friend telephoned her but is unable to recall the message. Which defense mechanism does this behavior represent?
Suppression
A nurse is caring for a client who is experiencing a crisis. Which nervous system is primarily responsible for the clinical manifestations that the nurse is likely to identify?
Sympathetic nervous system
A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again?
Take a dose as soon as possible, up to 2 hours before the next dose.
A client has been taking prescribed risperidone (Risperdal) 3 mg twice a day for the past 8 days. A friend brings the client to the outpatient clinic. The client reports tremors, shortness of breath, a fever, and sweating. What should the nurse do?
Take the client's vital signs and arrange for immediate transfer to a hospital
What is an initial client objective in relation to anger management?
Taking responsibility for the hostile behavior -Before progress can be made in treating anger, the client needs to take responsibility for the behavior. As long as the client blames others, there will be no motivation to change. The client may express remorse but continue to blame others and not feel the need for change. Developing alternative methods to release feelings is a worthwhile goal that is more appropriate later in therapy; it is not an initial goal. The client's own behavior needs to change; it is not appropriate in this situation to teach others to change.
A client with the diagnosis of schizophrenia is given one of the antipsychotic drugs. The nurse understands that antipsychotic drugs can cause extrapyramidal side effects. Which effect is cause for the greatest concern?
Tardive dyskinesia
A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client?
Tardive dyskinesia -Tardive dyskinesia occurs as a late and persistent extrapyramidal complication of long-term antipsychotic therapy. It is most often manifested by abnormal movements of the lips, tongue, and mouth.
A client with a history of violence is becoming increasingly agitated. Which nursing intervention will most likely increase the risk of acting-out behavior?
Teaching relaxation
A clinic nurse observes a 2-year-old girl sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her top away. Is it something I've done?" What is the most therapeutic initial response by the nurse?
Telling the father that it is nothing he has done and sharing the nurse's observations of the child
The nurse refers a client to a self-help group. What does the nurse anticipate that a self-help groups such as Alcoholics Anonymous (AA) will help its members learn?
That their problems are not unique -Sharing problems with others who have similar problems can help one explore feelings and begin to enhance coping abilities. The Twelve Steps of AA guide alcoholics to seek help from a higher power, which may be religious, based in nature, or the group itself. Problem drinking usually is caused by how the drinker feels about him- or herself. Although AA is a support group, it is a self-help support group. The only one who can stop someone from drinking is the person who is drinking.
In which situation is the use of seclusion contraindicated?
The client has expressed severe suicidal thoughts.
Which is the most important information for a nurse to gather from the client in crisis?
The client's perception of the circumstances surrounding the crisis
A nurse is aware that a co-worker's mother died 16 months ago. The co-worker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior?
The co-worker may need help with grieving.
A nurse plans to use family therapy as a means of helping a family cope with their child's terminal illness. The nurse bases this choice on the principle that:
The entire family is involved because what happens to one member affects all
A recently hired nurse is caring for several clients on a mental health unit at a local community hospital. The nurse manager is evaluating the nurse's performance. What situation indicates that the nurse-client boundaries of the recently hired nurse are appropriate?
The nurse shares with the entire treatment team vital information the client disclosed in a private session.
What is the most important tool a nurse brings to the therapeutic nurse-client relationship?
The self and a desire to help
A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary?
Undoing
On which principle should the nurse's role be based in the maintenance or promotion of the health of older adults?
There is a strong correlation between successful retirement and good health.
What is the planned effect of naloxone when it is administered for a heroin overdose?
To compete with opioids for receptors that control respiration
A nurse is caring for several clients who have severe psychiatric disorders. What is the major reason that a health care provider prescribes an antipsychotic medication for these clients?
To reduce the positive symptoms of psychosis
Which individual is coping with issues concerning dependence versus independence?
Toddler -The toddler is learning autonomy, but because of the nature of development there is still physical and emotional dependence on the parents. The major task during infancy is the development of trust. School-aged children cope with the task of industry and developing skills for working in and relating to the world. Preschool-aged children cope with developing a sense of initiative.
A nurse reminds a client that it is time for group therapy. The client responds by shouting, "You're always telling me what to do, just like my father!" What defense mechanism is the client using?
Transference
Amitriptyline (Elavil) is an antidepressant medication used to treat anxiety disorders. Which class of antidepressant medications does it belong to?
Tricyclics -Amitriptyline (Elavil) is one of several tricyclic antidepressants used to treat anxiety disorders .
According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?
Trust Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child.
A client's hands are raw and bloody from a ritual involving frequent handwashing. Which defense mechanism does the nurse identify?
Undoing
A nurse administers an antipsychotic medication to a client. For which common manageable side effect should the nurse evaluate the client?
Unintentional tremor
A client receiving the medication buspirone hydrochloride (Buspar) is admitted to the hospital with the diagnosis of possible hepatitis. The nurse identifies that the client's sclerae look yellow. What should be the nurse's initial action?
Withhold the medication
For which adverse effect should the nurse continually observe a client who is receiving valproic acid (Depakene)?
Yellow sclerae -Yellow sclerae are a sign of jaundice; pancreatitis and hepatic failure are life-threatening adverse effects of valproic acid (Depakene).
A client with schizophrenia is actively psychotic, and a new medication regimen is prescribed. A student nurse asks the nurse, "Which of the medications will be the most helpful against the psychotic signs and symptoms?" What response should the nurse give?
Ziprasidone (Geodon) -Ziprasidone (Geodon) is a neuroleptic, which will reduce psychosis by affecting the action of both dopamine and serotonin.
