Foundations and Practice of Mental Health Nursing; Psychobiological Disorders

A 19-year-old adolescent is admitted to the emergency department with multiple fractures and potential internal injuries. The client's history reveals multiple drug abuse for the past 8 months. When caring for this client, the nurse determines that the most serious life-threatening responses usually result from withdrawal from: 1 Heroin 2 Methadone 3 Barbiturates 4 Amphetamine

barbiturates

How should a nurse characterize a sudden terrorist act that causes the deaths of thousands of adults and children and negatively affects their families, friends, communities, and the nation? 1 Recurring 2 Situational 3 Maturational 4 Adventitious

Adventitious

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory? 1 Subtract serial sevens from 100. 2 Copy one simple geometric figure. 3 State three random words mentioned earlier in the exam. 4 Name two common objects when the nurse points to them

state three random words mentioned earlier in the exam Stating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. Copying one simple geometric figure is a test of visual comprehension. Naming two common objects when the nurse points to them is a test of verbal skills to identify aphasia.

A nurse expects that when an individual successfully completes the grieving process after the death of a significant other, the individual will be able to: 1 Accept the inevitability of death. 2 Go on with life while forgetting the past. 3 Remember the significant other realistically. 4 Focus mainly on the good qualities of the person who died

remember the significant other realistically Successful resolution means being able to remember the good as well as the bad qualities of the deceased and accepting them as part of the deceased's being human. Resolution involves working through feelings, not just accepting what occurred. Resolution does not mean forgetting; rather it means realistically remembering the past. Focusing mainly on the good qualities of the person who died is an unhealthy response that may become pathological as a result of the unresolved feelings about the person's other qualities.

At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse? 1 Reflecting feelings 2 Making observations 3 Seeking consensual validation 4 Attempting to place events in sequence

seeking consensual validation Seeking consensual validation is a technique that prevents misunderstanding so that both the client and the nurse can work toward a common goal in the therapeutic relationship. Reflection of feelings is used to increase client awareness but should not be used when the nurse is unsure of what the client is saying. Making observations refers more to nonverbal than to verbal communication. Placing events in a sequence helps organize content, but ideas should be clarified first by means of validation if the nurse is unsure of the meaning of what is being said.

What is the best response by the nurse to a client prescribed phenelzine (Nardil) who makes the following selections for tomorrow's menu? (See the patient's selections indicated by the checkmarks on the chart). 1 "Your diet tends to be high in cholesterol and fat, so let's discuss some changes." 2 "You've made appropriate choices, but remember your increased need for protein." 3 "You've made wise selections that are healthy and appropriate for your medication." 4 "Your selections show that we need to discuss how to avoid foods that contain tyramine."

you've made wise selections that are healthy and appropriate for your medications

A nurse, planning care for a client who is an alcoholic, knows that the most serious life-threatening effects of alcohol withdrawal usually begin after a specific time interval. How many hours after the last drink do they occur? 1 8 to 12 2 12 to 24 3 24 to 72 4 72 to 96

24 to 72

A client with mild Alzheimer disease has been taking galantamine (Razadyne), and the health care provider prescribes paroxetine (Paxil) for depression. For what effect should a nurse assess the client when these medications are taken concurrently? 1 Allergic 2 Dystonic 3 Additive 4 Extrapyramidal

additive

During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, "Welcome to the funny farm. I'm Jo-Jo, the head yo-yo." Which meaning can the nurse assign to the client's statement? 1 Trying to fill the "life of the party" role 2 Looking for attention from the new staff 3 Unable to distinguish fantasy from reality 4 Anxious over the arrival of new staff members

anxious over the arrival of new staff members

A client with a history of a short temper and physically abusive behavior becomes violent and is admitted to the psychiatric service. At the time of admission the client is extremely anxious. What is the priority nursing action? 1 Sitting quietly with the client 2 Encouraging the client to play video games 3 Introducing the client to several other clients 4 Assigning a staff member to supervise the client

assigning a staff member to supervise the client Assigning a staff member to supervise the client will enable the staff member to respond quickly to any escalation in the client's mood or behavior. Sitting quietly with the client may put the nurse at risk because it may actually make the client more anxious and precipitate violence. The client is too anxious to concentrate on a game or to interact with other people.

What is a primary component of the nursing plan of care for a client with the diagnosis of anorexia nervosa? 1 Observing the client after meals 2 Weighing the client before meals 3 Measuring the client's fluid balance 4 Limiting the client's interaction with peers

observing a client after meals Observing the client after meals is the only way the nurse can be certain that the client does not engage in purging. Weighing will not help the nurse assess the client's electrolyte or nutritional status. An accurate intake and output record is difficult to obtain unless the individual is closely observed throughout the day. There is no need to isolate the client from peers.

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. 1 Jaundice 2 Diaphoresis 3 Hyperrigidity 4 Hyperthermia 5 Photosensitivity

Diaphoresis Hyperridgidity Hyperthermia

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 2 Suppression 3 Sublimation 4 Identification 5 Rationalization

Projection Rationalization

A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action? 1 Setting limits on manipulative behavior 2 Encouraging participation in group therapy 3 Respecting the client's need for social isolation 4 Recognizing that seductive behavior is expected

Respecting the clients need for social isolation These clients are withdrawn, aloof, and socially distant; allowing distance and providing support may foster the eventual development of a therapeutic alliance. Manipulative behavior is typical of clients with the diagnosis of antisocial personality disorder or borderline personality disorder. Group therapy will increase this client's anxiety; cognitive or behavioral therapy is more appropriate. Seductive behavior is associated with clients with the diagnosis of histrionic personality disorder.

A male client with the diagnosis of schizophrenia, paranoid type, often displays overt sexual behavior toward female clients and nurses. What is the nurse's best response when the client engages in sexually explicit behavior? 1 Refusing to speak with the client until he stops the behavior 2 Sending the client to his room when the behavior is observed 3 Ignoring this behavior until the client is more in control of his responses 4 Telling the client in a matter-of-fact manner that his behavior is unacceptable

Telling the client in a matter-of-fact manner that his behavior is unacceptable Telling the client that the behavior is unacceptable rejects the behavior, not the client; it helps separate the client from the behavior. Refusing to speak with the client does not help the client learn self-control; it rejects both the client and the behavior. Isolating the client limits his ability to learn more acceptable responses. Part of recovery is learning acceptable behavior; ignoring inappropriate behavior is not therapeutic

A client on a psychiatric unit who has been hearing voices is receiving a neuroleptic medication for the first time. The client takes the cup of water and the pill and stares at them. What is the most therapeutic statement the nurse can make? 1 "You have to take your medicine." 2 "This is the medication that your doctor ordered." 3 "This will help you not to hear the voices. It will only work if you take it." 4 "There must be a reason that you don't want to take your medicine."

This will help you nor hear the voices. It will only work if you take it.

A practitioner prescribes routine checks of the client's lithium level to be performed. How many hours after the last dose of lithium should the nurse plan to obtain the blood specimen? 1 2 to 4 2 4 to 6 3 6 to 8 4 8 to 12

8 to 12 Lithium absorption and excretion occur 8 to 12 hours after the last dose. Concentrations may be falsely higher at 2 to 4, 4 to 6, or 6 to 8 hours after administration, affecting the reliability of the readings. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A client with a diagnosis of bipolar I disorder with rapid cycling is readmitted 4 months after discharge. On the first day on the unit the client continually interrupts the nurse and is increasingly talkative and loud. What is the most therapeutic response by the nurse? 1 "You seem to have a need to interrupt me." 2 "How's your relationship with your spouse?" 3 "Do you realize that you're talking loud and fast?" 4 "Tell me about the medication you've been taking."

tell me about the medication you've been taking Antidepressants can induce rapidly cycling behavior, or the client may not be taking medications as prescribed; asking the client to talk about the medication will elicit information in a nonchallenging, nonthreatening manner. Observing that the client seems to have a need to interrupt the nurse is challenging and is not focused on assessing the problem. The question "How is your relationship with your spouse?" is not focused on the behavior being manifested. Asking the client whether he realizes that he is speaking loudly and quickly does little to promote discussion.

A client is admitted with a conversion disorder. What is the primary nursing intervention? 1 Talking about the physical problems 2 Exploring ways to verbalize feelings 3 Explaining how stress caused the physical symptoms 4 Focusing on the client's concerns regarding the symptoms

Exploring ways to verbalize feelings

Typically discussions of the topic of suicide are geared to the younger or middle-aged adult, but older adults actually account for 20% of suicide deaths in the United States. What questions should a nurse ask when, during the assessment of an older adult, the nurse suspects suicidal intent? Select all that apply. 1 "Do you think about killing yourself?" 2 "How often do you have these thoughts?" 3 "Do you have the means to kill yourself?" 4 "Have you thought about your loved ones?" 5 "How would you kill yourself if you decided to do it?" 6 "Why do you think you won't be around much longer?"

Do you think about killing yourself? How often do you have theses thoughts? Do you you have the means to kill yourself? How would you kill yourself if you decided to do it?

An agitated, acting-out, delusional client is receiving large doses of haloperidol (Haldol), and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations should alert the nurse to stop the drug immediately? Select all that apply. 1 Jaundice 2 Dizziness 3 Tachycardia 4 Lethargic behavior 5 Extrapyramidal symptoms

Jaundice Tachycardia

A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3 Older single man just found to have pancreatic cancer 4 Middle-age woman experiencing dysfunctional grieving

Older single man just found to have pancreatic cancer

The nurse can best handle personal questions asked by the client in any phase of the nurse-client relationship by: 1 Reviewing the positive and negative aspects of the subject 2 Providing brief, truthful answers and redirecting the focus of conversation 3 Offering an honest, brief expression of personal views on the topic in question 4 Reminding the client gently that the nurse's feelings are not the client's concern

Providing brief, truthful answers and redirecting the focus of conversation Unless the nurse answers the question, the client will continue to focus on the nurse rather than on the self; the nurse can best redirect after a brief answer. Reviewing the positive and negative aspects of the subject moves the focus to the nurse's opinions rather than the client's feelings. Offering an honest, brief expression of personal views on the subject raised moves the focus to the nurse's opinions rather than the client's feelings. Reminding the client gently that the nurse's feelings are not the client's concern is not therapeutic; the client is being asked to share, and the nurse should also be willing to share.

What should the nurse do when determining whether a client is experiencing adverse effects of risperidone (Risperdal)? 1 Monitor for episodes of diarrhea. 2 Test sensation of lower extremities. 3 Question if dizziness is experienced. 4 Auscultate breath sounds to detect wheezing

Question if dizziness is experienced Hypotension and dizziness are adverse effects of risperidone (Risperdal). Risperidone may cause constipation, not diarrhea. It does not affect the neuromuscular or cardiovascular function of the legs; numbness and coldness of the feet do not occur. Risperidone does not cause wheezing or shortness of breath.

A school nurse is teaching a high school health class about inhalant abuse. What serious effect of using inhalants should the nurse discuss? 1 Esophageal varices 2 Acute electrolyte imbalances 3 Extrapyramidal tract symptoms 4 Death in one third of first-time users

death in one third of first-time users Use of inhalants, called "huffing," is most often seen in preadolescent males in rural areas, and it can be lethal in overdose. Esophageal varices are associated with alcoholic cirrhosis. Acute electrolyte imbalances are associated with alcoholic cirrhosis and are related to malnutrition, dehydration, and ascites. Extrapyramidal tract symptoms are associated with typical antipsychotic medications.

For which adverse effect should the nurse continually assess a client who is receiving valproic acid (Depakene)? 1 Yellow sclerae 2 Motor restlessness 3 Ringing in the ears 4 Torsion of the neck

yellow sclerae Yellow sclerae are a sign of jaundice; pancreatitis and hepatic failure are life-threatening adverse effects of valproic acid (Depakene). The client must have frequent liver function tests. Motor restlessness (akathisia) is associated with antipsychotic drugs. Ringing or buzzing in the ears (tinnitus) is associated with aspirin. Torsion of the neck (torticollis) due to contracted cervical muscles is associated with antipsychotic drugs. Test-Taking Tip: Pace yourself during the testing period and work as accurately as possible. Do not be pressured into finishing early. Do not rush! Students who achieve higher scores on examinations are typically those who use their time judiciously.

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. It is most appropriate for the nurse to: 1 Allow the child to change his bed and pajamas. 2 Change the child's bed while he changes his pajamas. 3 Take the child to the bathroom and change his pajamas. 4 Remind the child to call the nurse next time to avoid the need to change his pajamas

Change the child's bed while he changes his pajamas Changing the child's bed while the child changes his pajamas will not call attention to the accident and will minimize the child's embarrassment. The child would probably be unable to change the bed without assistance; failure to complete the task might add to his embarrassment. Taking the child to the bathroom to change his pajamas and reminding the child to call a nurse next time will only add to the child's embarrassment.

The nurse is facilitating group therapy for clients with the diagnosis of chronic undifferentiated schizophrenia. The nurse begins the first meeting with an introduction of all group participants. What should the nurse do next? 1 Ask the clients what they hope to gain from the meetings. 2 Allow the clients to discuss anything they wish to bring up. 3 Have each of the clients identify a specific concern and then discuss each one. 4 Share with the clients the purpose of the meetings and explain the rules of behavior.

Share with the clients the purpose of the meetings and explain the rules of behavior Sharing the purpose of the meeting and explaining the rules is the most therapeutic option because it sets both the parameters of discussion and limits on behavior. Asking clients what they hope to gain, allowing clients to bring up any topic, or having each client express and discuss a concern is not therapeutic for a group of clients with the diagnosis of schizophrenia; because of the disruption of cognitive processes, these clients are unable to make these contributions.

The nurse can identify the most commonly demonstrated comorbid disorders associated with generalized anxiety disorder (GAD) by assessing the client for which of the following? Select all that apply. 1 Obesity 2 Signs of alcohol withdrawal 3 Phobias 4 Impaired cognitive function 5 Suicidal ideations

Signs of alcohol withdrawal Phobias suicidal ideations

A nurse is writing a plan of care in the medical record of a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs. An intermediate goal for this client is: 1 "The client will develop faith in his wife." 2 "The client will develop better self-control." 3 "The client will develop feelings of self-worth." 4 "The client will develop insight into his behavior."

The client will develope feelings of self worth Helping the client develop feelings of self-worth will reduce the client's need to use pathological defenses. Faith in his wife, or the lack of thereof, is not the basic underlying problem, merely a symptom of it. Self-control, or the lack thereof, is not the basic underlying problem, merely a symptom of it. Insight can develop only when the need to use the defense is reduced; this is a long-term goal.

A client with a history of methamphetamine use is admitted to the mental health unit because of aggressive violent behavior. For what clinical manifestations of methamphetamine use should the nurse assess this client? Select all that apply. 1 Bradypnea 2 Tachycardia 3 Hyperthermia 4 Constricted pupils 5 Decreased blood pressure

tachycardia hyperthermia Methamphetamine is a stimulant that causes a surge of dopamine and blocks the reuptake of dopamine. The sympathetic nervous system is activated, resulting in an increase in the heart rate. Because methamphetamine affects the central nervous system, the body temperature will increase, sometimes to dangerous levels. The respirations will increase, not decrease, because of the activation of the sympathetic nervous system. The pupils will dilate, not constrict, because the sympathetic nervous system is activated. The blood pressure will increase, not decrease, because of the activation of the sympathetic nervous system.

A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, the nurse should consider that: 1 Crying relieves depression and helps the client face reality. 2 Crying releases tension and frees psychic energy for coping. 3 Nurses should not interfere with a client's behavior and defenses. 4 Accepting a client's tears maintains and strengthens the nurse-client bond.

Crying releases tension and frees psychic energy for coping. Crying is an expression of an emotion that, if not expressed, increases anxiety and tension; the increased anxiety and tension use additional psychic energy and hinder coping. Crying does not relieve depression, nor does it help a client face reality. It is not universally true that nurses should not interfere with a client's behavior and defenses. In most instances the client's defenses should not be taken away until they can be replaced by more healthy defenses. The nurse must interfere with behavior and defenses that may place the client in danger, but the client's current behavior poses no threat to the client. It is not always true that accepting a client's crying maintains and strengthens the nurse-client bond. Many clients are embarrassed by what they consider a "show of weakness" and have difficulty relating to the individual who witnessed it. The nurse must do more than just accept the crying to strengthen the nurse-client relationship.

A client in the early dementia stage of Alzheimer disease is admitted to a long-term care facility. Which activities must the nurse initiate? Select all that apply. Weighing the client once a week 2 Having specialized rehabilitation equipment available 3 Keeping the client in pajamas and robe most of the day 4 Establishing a schedule with periods of rest after activities 5 Reviewing the client's weekly budget and use of community resources 6 Setting up a plan for weekly entertainment through a senior citizens group

Weighing the client once a week Having specialized rehabilitation equipment available Establishing a schedule with periods of rest after activities

When counseling the 20-year-old parents of a 13-month-old child, the nurse considers that the defense mechanism most often used by physically abusive parents is: 1 Idealization 2 Transference 3 Manipulation 4 Displacement

displacement Displacement is a defense mechanism in which one's pent-up feelings toward others who are a threat are discharged on others who are less threatening. Idealization is attributing overstated positive characteristics to others. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage.

A 65-year-old retired baker is admitted to the hospital with the diagnosis of dementia. The nurse's question that best tests the client's capacity for abstract thinking is: 1 "How are a television and a radio alike?" 2 "Can you give me today's complete date?" 3 "What would you do if you fell and hurt yourself?" 4 "Repeat the following numbers for me: 8, 3, 7, 1, 5."

how are television and radio alike The question "How are a television and a radio alike?" forces the client to find a characteristic common to two things, an ability that is the criterion for abstract thinking. The question "Can you give me today's complete date?" tests orientation, not abstract thinking. The question "What would you do if you fell and hurt yourself?" tests judgment, not abstract thinking. The question "Repeat the following numbers for me: 8, 3, 7, 1, 5" tests short-term memory, not abstract thinking.

An extremely anxious client enters a crisis center and asks a nurse for help. Which initial response best reflects the nurse's role in crisis intervention? 1 "Tell me what you've done to help yourself." 2 "I'll be here for you to help you figure things out." 3 "I understand that in the past you've had problems." 4 "Tell me about the things that are bothering you the most."

ill be here for you to help you figure things out

A nurse on a mental health unit has developed a therapeutic relationship with a manipulative, acting-out client. One day as the nurse is leaving, the client says, "Please stay. I'm afraid that the evening staff doesn't like me. They're always punishing me." What is the nurse's most therapeutic response? 1 "I'll ask the staff not to punish you." 2 "Tell me more about what you're feeling now." 3 "Don't worry. I told you, everything will be all right." 4 "You know I leave at this time. We'll talk about this in the morning."

"You know I leave at this time. We'll talk about this in the morning." Reminding the client that the nurse leaves at this time each day and telling him that they will discuss the issue in the morning demonstrates acceptance of the client and sets limits on the client's manipulative behavior. "I'll ask the staff not to punish you" reinforces the client's belief that the evening staff is punishing him and could result in a split among the staff members. Asking the client to reveal more about what he is feeling now indicates that the nurse has been manipulated by the client. Telling the client not to worry and that everything will be all right is false reassurance; the nurse cannot make everything all right

A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary nurse approaches the client, who appears to be listening to voices, and comments, "You seem to be listening to something. Tell me what you hear." The primary nurse requests feedback from the psychiatric clinical specialist regarding this nursing intervention. How should the clinical specialist respond? 1 By reminding the nurse that once the content is known, there is no need to focus on the hallucinations because doing so reinforces them 2 By giving positive feedback for the nurse's attempt to explore the content of the client's hallucinations and reinforcing the need to continue this approach 3 By recognizing this as a positive intervention and helping the nurse develop a plan of care that calls for a contract to refrain from acting on command hallucinations 4 By suggesting that the nurse use an open-ended approach and asking the nurse to discuss the correlation between positive behaviors observed and prescribed antipsychotics

By reminding the nurse that once the content is known, there is no need to focus on the hallucinations because doing so reinforces them Once the content of the hallucination is known and it is not a command to harm the self or others, focusing on the hallucinations is not therapeutic; recognizing feelings, pointing out reality, and learning to use strategies to push aside hallucinations are therapeutic. Giving positive feedback reinforces the nurse's inappropriate approach with the client; continuing this approach reinforces the value of the hallucinations for the client, which is undesirable. This is a negative, not a positive, intervention; also, no data support the fact that the client is experiencing command hallucinations. Clear, concise, direct communication is more desirable when clients are experiencing hallucinations, which are usually frightening; although positive behaviors are a response to antipsychotic medications, these should not be the primary focus of this supervisory session.

A terminally ill client tells the nurse, "I would love to learn to speak German before I die." The nurse's response to the client's desire to learn a foreign language should be based on an understanding that: 1 Activities that support the client's denial should not be encouraged. 2 Clients should be encouraged to set meaningful goals for themselves. 3 Energies expended on such an activity would not justify the outcome. 4 The client's time should be focused on goals that are easily attainable.

Clients should be encouraged to set meaningful goals for themselves The client's goal is meaningful, and the nurse should do everything possible to help the client achieve it. There is no reason to dissuade the client from a meaningful goal despite its difficulty. The evidence does not demonstrate that the client is in denial. If the client wants to work toward a goal, the energy expenditure is justified. Test-Taking Tip: If you are unable to answer a multiple-choice question immediately, eliminate the alternatives that you know are incorrect and proceed from that point. The same goes for a multiple-response question that requires you to choose two or more of the given alternatives. If a fill-in-the-blank question poses a problem, read the situation and essential information carefully and then formulate your response.

A client is receiving carbamazepine (Tegretol) for the treatment of a manic episode of bipolar disorder. What should the nurse include when planning client teaching about this medication? Select all that apply. 1 "You have to eat a low-sodium diet every day." 2 "You'll have to take a diuretic with this medication." 3 "You'll have to take this medication for the rest of your life." 4 "You may want to suck on hard candy when you get a dry mouth." 5 "We'll need to test your blood often during the first few weeks of therapy."

You may want to suck on hard candy when you get a dry mouth." "We'll need to test your blood often during the first few weeks of therapy." Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. Carbamazepine can cause severe bone marrow depression in the early phase of therapy. Also, the drug level needs to be checked frequently to ensure a therapeutic level. A low-sodium diet is not required; nor is a diuretic. The client may or may not have to take the medication for life.

What clinical manifestation best indicates to the nurse that the mental status of a client with the diagnosis of schizophrenia, paranoid type, is improving? 1 Absence of mild to moderate anxiety 2 Development of insight into the problem 3 Decreased need to use defense mechanisms 4 Ability to function effectively in activities of daily living

ability to function effectively in activities of daily living A person who can handle the activities of daily living and function in society is considered mentally stable. Some anxiety is necessary and unavoidable; anxiety causes problems when it is overwhelming for an extended period. Insight into one's problems is of no use if one is unable to function in society. Everyone uses defense mechanisms; the extent to which they are used helps determine mental health.

What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client? 1 Contradicting the client's persecutory delusions 2 Accepting the client's statements as the client's beliefs 3 Medicating the client when these thoughts are expressed 4 Redirecting the client whenever a negative topic is mentioned

accepting the clients statements as the clients beliefs The nurse must accept the client's statement and beliefs as real to the client to develop trust and move toward a therapeutic relationship. Clients cannot be argued out of delusions. These feelings and thoughts are constant; medicating the client whenever they are expressed could result in an overdose. Redirecting the client's conversation whenever negative topics are brought up may cut off conversation and the development of trust. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel: 1 Angry 2 Dependent 3 Inadequate 4 Ambivalent

angry A person with a condescending, superior attitude frequently evokes feelings of anger in others and will increase their anxiety. It is unlikely that a condescending, superior attitude will produce feelings of dependency, inadequacy, or ambivalence in others

A nurse is admitting a client with a history of bipolar disorder. The nurse determines that the client is in the depressive phase of the disorder. Identify the signs and symptoms that support the nurse's conclusion. Select all that apply. 1 Apathy 2 Hyperactivity 3 Flight of ideas 4 Loss of appetite 5 Sleep disturbances

apathy loss of appetite sleep disturbances When a client is depressed, the mood is sad or flat, which is manifested by apathy. Hyperactivity is a sign of the manic phase of a bipolar disorder. Flight of ideas is a sign of the manic phase of a bipolar disorder. Depressed people do not have an appetite or the energy to eat. Difficulty initiating or maintaining sleep or excessive sleepiness is associated with depression.

An older adult with dementia is admitted to a nursing home. The client is confused, agitated, and at times unaware of the presence of others. What is the best nursing approach to help this client adapt to the unit? 1 Initiating a program of planned interaction 2 Explaining the nature and routines of the unit 3 Exploring in depth the reasons for the admission 4 Arranging for the constant presence of a staff member

arranging for the constant presence of a staff member The presence of staff members will give the client support and provide an opportunity to distract and reassure the client. Continuous supervision is necessary for the safety of the client and others. Although a program of planned interaction has value as a general measure, it is too soon to initiate one; it will not decrease the client's level of anxiety at this time. It is unlikely that the client will comprehend or remember explanations. The client does not have the capacity to explore concerns; in fact, this may be counterproductive and anxiety producing.

Alprazolam (Xanax) is prescribed for a client with the diagnosis of panic disorder. The client refuses to take the medication because he fears addiction. Initially the nurse should: 1 Provide the client information about alprazolam. 2 Assess the client's feelings about alprazolam further. 3 Ask the practitioner about changing the client's medication. 4 Have the practitioner speak with the client about the safety of this medication.

assess the clients feelings about alprazolam further Before deciding how to ease the client's fears of addiction, the nurse must explore the full extent of the client's knowledge and feelings about taking this medication. Information may or may not be helpful; the client's feelings are what must be addressed. Although the nurse may eventually ask the practitioner to consider changing the medication or to speak with the client about its safety, neither is the priority at this time

A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce the use of physical symptoms as a response to stress? 1 Limiting discussions about the problem 2 Providing information regarding medical care 3 Teaching the client how to eliminate stress at home 4 Assisting the client in developing new coping mechanisms

assisting the client in developing new coping mechanisms Until the client learns new ways of coping with anxiety, this pattern of behavior will continue. Learning new ways to operate will break the pattern. Limiting discussion will avoid the problem. Providing information about medical care will reinforce the sick role. A certain amount of stress is present in everyday family situations; the elimination of stress is impossible

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 3 Chronic hypochondriasis 4 Obsessive-compulsive disorder 5 Narcissistic personality disorder

bipolar disease 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

A client is admitted to a psychiatric unit with the diagnosis of schizophrenia, undifferentiated type. When assessing the client, the nurse identifies the presence of the characteristics related to this disorder. Select all that apply. 1 Bizarre behavior 2 Extreme negativism 3 Disorganized speech 4 Persecutory delusions 5 Auditory hallucinations

bizarre behavior disorganized speech auditory hallucinations Bizarre behavior is associated with undifferentiated schizophrenia. Disorganized speech is associated with undifferentiated schizophrenia. Auditory hallucinations are associated with undifferentiated schizophrenia. Extreme negativism is associated with catatonic schizophrenia. Persecutory delusions are associated with paranoid schizophrenia.

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? Select all that apply. 1 Bouts of crying 2 Self-destructive acts 3 Presence of delusions 4 Feelings of worthlessness 5 Intense interpersonal relationships

bous of crying self destruct give acts intense interpersonal relationships Clients who feel depressed and hopeless also tend to show their depression and hopelessness physically through crying. Clients who feel depressed and hopeless may try to commit suicide to end the emotional pain they are suffering. Clients who feel depressed and hopeless also tend to express feelings of worthlessness. Preoccupation with delusions is associated with clients with a diagnosis of schizophrenia, not depression. Clients who feel depressed and hopeless tend to be socially withdrawn and to not have the physical or emotional energy required for intense interpersonal relationships.

A nurse is orienting a new client to the unit when another client rushes down the hallway and asks the nurse to sit down to talk. The client requesting the nurse's attention is manipulative and uses acting-out behaviors when demands go unmet. How should the nurse intervene? 1 By suggesting that the client requesting attention speak with another staff member 2 By leaving the new client, saying, "I'll talk with the other client until things calm down." 3 By introducing the two clients and suggesting that the client join them on a tour of the facility 4 By saying to the interrupting client, "I'll be back to talk with you after I orient this new client."

by saying to the interrupting client, ill be back to talk with you after i orient this new client. "I'll be back to talk with you after I orient this new client" sets realistic limits on behavior without rejecting the client. Suggesting that the client requesting attention speak with another staff member will constitute a rejection of the client rather than the behavior. Leaving the new client, saying, "I'll talk with the other client until things calm down", will encourage further manipulation by the client. The other client is entitled to dedicated time with the nurse; asking the interrupting client to join them is inconsistent limit-setting on the part of the nurse.

A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? Select all that apply. 1 Calm 2 Cheerful 3 Depressed 4 Frightened 5 Matter-of-fact

calm matter of fact The symptoms prevent the individual from being forced to act in relation to a conflict or stressor; the client's symptoms thus reduce anxiety and remove the conflict. The individual demonstrates a lack of concern about the symptoms (la belle indifférence). The individual will not be happy and cheerful, sad and depressed, or frightened. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A nurse receives a change-of-shift report on his clients. One client is on direct observation for acute suicidal ideation. Another client had a blood glucose of 400 mg/dL and was given 8 units of short-acting insulin just before the change of shift. A third client is pacing the unit, threatening staff with physical harm. A fourth client is in a bedroom, responding to internal stimuli. A fifth client is playing cards with another client. List the clients in the order in which they should be assessed by the nurse, from first to last. 1. Client with diabetes 2. Client who is suicidal 3. Client responding to internal stimuli 4. Client playing cards with another client 5. Client exhibiting aggressive behavior

client exhibiting aggressive behaviors the client responding to internal stimuli the client with diabetes client who is suicidal client playing cards with another client The client who is exhibiting aggressive behavior needs to be assessed first to prevent violent behavior against self and others. The client responding to internal stimuli (delusions or hallucinations) should be assessed second. The internal stimuli may precipitate aggressive behavior (e.g., command hallucinations). The client with diabetes who was given insulin should be assessed third. The client's response to the administration of insulin should be assessed. The suicidal client is under constant supervision and therefore is not the priority at this time. This client becomes the priority after the potentially aggressive clients and the physically unstable client are assessed. The client playing cards is in no distress and therefore may be assessed last.

During the eighth session of a therapy group, a member who talks frequently is interrupted by one who doesn't. When the interrupting person is finished talking, the one who usually contributes says, "I'm so glad that you feel like talking today." While saying this, the client sits rigidly and looks angry. How should the nurse respond? 1 Comment on the interrupted client's angry behavior and pleasant words. 2 State that it appears that these members of the group are not getting along. 3 Agree with the interrupted client that it is good to have the quiet client talk. 4 Ignore the comment and speak with the talkative member privately about being hostile

comment on the interrupted clients angry behavior and pleasant words For this to be a growth process for the group, feelings and behaviors must be explored. It is better to focus on behaviors and feelings than on personalities or the fact that they do not get along. Agreement ignores the covert message, which should be explored to help the client and the group. Commenting on the incongruent verbal and nonverbal behavior may lead to a growth experience for the client and the group.

A client with phobias about elevators and large crowds comes to the clinic for help because of feelings of depression related to these fears. What is an appropriate short-term goal for this client? 1 Riding an elevator without anxiety when accompanied by the nurse 2 Describing the thoughts and feelings experienced in terrifying situations 3 Experiencing an elevation of mood and relief from feelings of depression 4 Identifying the early childhood conflicts that resulted in the development of these fears

describing the thoughts and feelings experienced in terrifying situation Describing the thoughts and feelings experienced in terrifying situations is a realistic essential first step. The problem and related feelings must be thoroughly explored before solutions can be developed. Riding an elevator without anxiety when accompanied by the nurse is a long-term goal. Experiencing an elevation of mood and relief from feelings of depression is a long-term goal. Identifying the early childhood conflicts leading to the development of the fears is an inappropriate goal; a direct connection to life events is often difficult to find.

A depressed client is given sertraline (Zoloft) 50 mg at bedtime. For what drug-related side effects should the nurse monitor the client? Select all that apply. 1 Dry mouth 2 Weight gain 3 Constipation 4 Photosensitivity 5 Projectile vomiting

dry mouth constipation Dry mouth is a common side effect of sertraline (Zoloft) that should be shared with the client because measures can be taken to relieve discomfort; this side effect should subside within 2 to 3 weeks after therapy begins. Constipation is a common side effect of sertraline; an increase in fluids and bulk in the diet may minimize this effect. Weight loss, not gain, may occur because of the side effects of anorexia, dry mouth, indigestion, and nausea. Photosensitivity is not a side effect of this medication. Although nausea and vomiting may occur, the vomiting is not projectile vomiting.

A 16-year-old boy with a diagnosis of adolescent adjustment disorder and his family are beginning family therapy. What is the best initial nursing approach? 1 Setting long-term goals for the family 2 Letting the client express his feelings first 3 Having the parents explain their rationale for setting firm limits 4 Encouraging each family member to share how the problem is perceived

encourage each family member to share how the problem is perceived Family therapy must include the whole family. Each member must be considered not just individually from his or her perspective but also as a member of the whole. Identification of the problem by the people involved is the priority. The family, not the nurse, sets goals. The nurse assists the family in setting goals by acting as a facilitator. Feelings should be shared eventually, but this is not the initial focus. Setting limits may or may not be a problem within the family.

A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." The best response response by the nurse is: 1 "Everyone has a bed. This one is yours." 2 "You are not allowed to sleep on the floor." 3 "I don't understand why you're on the floor." 4 "You're a valuable person. You don't need to lie on the floor."

everyone has a bed this one is yours A matter-of-fact approach helps avoid a cycle in which the nurse expresses concern to a client who feels unworthy, which increases feelings of unworthiness. Citing a hospital policy focuses on rules and regulations, which may exacerbate the client's negative personal feelings because he is breaking the rules. "I don't understand why you're on the floor" is a statement that the client may not be able to respond to. Telling the client that he is a valuable person and doesn't need to lie on the floor may increase feelings of unworthiness because it creates a gap between the nurse's estimate of the client and what the client feels.

A client with obsessive-compulsive disorder is working toward discussing how his anxiety influences his feelings and the ability to function. What should the nurse include when planning care for this client? Select all that apply. 1 Identification of manipulative behaviors 2 Exploration of anxiety-provoking situations 3 Introduction of the client to socializing situations 4 Assisting the client in examining personal standards 5 Assess the quality of interpersonal relationships

exploration of anxiety-provoking situations assisting the client in examining personal standards

When having a discussion with a home health nurse, a client states that drinking is a problem. What is the nurse's initial response when the client asks for help? 1 Arranging for the client to be admitted to the hospital detoxification unit 2 Scheduling an appointment for the client at the alcohol rehabilitation center 3 Having the client call Alcoholics Anonymous to find out the schedule of local meetings 4 Recommending that the client discuss the problem with family members before seeking help

have the client call alcoholics anonymous to find out the schedule of local meetings Alcoholics Anonymous is community based and is the most effective intervention for drinking problems. There are no data to indicate that the client requires detoxification. Scheduling an appointment for the client at the alcohol rehabilitation center may come later if further intervention is needed. Recommending that the client discuss the problem with family members before seeking help is not a priority; the client must take the first step toward recovery.

When having a conversation with a nurse, an older client states, "I've lived a good life. I don't want to die, but I accept it as a part of life." What developmental stage, according to Erikson, has the client completed? 1 Identity 2 Integrity 3 Acceptance 4 Generativity

integrity Integrity is the last stage of life, identified by the acceptance of life as lived and the inevitability of death. Identity is a developmental task of adolescence. Acceptance is not a term used by Erikson; it is the final stage of Kübler-Ross' theory of death and dying. Generativity is a developmental task of middle-aged people.

An older client who lost a spouse 20 years ago comes to the community health center with a vague list of complaints and a brief life history. The couple's only child died at birth. The client lives alone and is able to perform all the activities of daily living. The client has had an active social life in the past but has outlived many friends and family members. What is an important question for the nurse to ask when taking this client's health history? 1 "Are you all alone?" 2 "How did your son die?" 3 "Do you still miss your spouse?" 4 "How do you feel about your life now?"

how do you feel about your lift now The answer to "How do you feel about your life now?" will provide the nurse with an idea of the client's hopes and frustrations without being threatening or probing. "Are you all alone?" is probing and provides little information for the nurse to use in planning care. "How did your son die?" and "Do you still miss your spouse?" are both probing, disregard the client's present situation, and provide little information for the nurse to use in planning care. Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures

A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies? 1 "How have you managed your problems in the past?" 2 "What do you feel that you've learned from this suicide attempt?" 3 "How will you manage the next time your problems start piling up?" 4 "Were there other things going on in your life that made you want to die?"

how will you manage the next time things start pilling up? "How will you manage the next time your problems start piling up?" focuses the interaction toward the future and invites the client to explore alternative coping strategies. "How have you managed your problems in the past?" explores past coping strategies and should have been asked as a part of the initial assessment. "What do you feel that you've learned from this suicide attempt?" is an attempt to explore the client's insight into current coping strategies that should have been made before any discussion of the alternatives. "Were there other things going on in your life that made you want to die?" asks the client once more to ensure that all the precipitating stressors have been identified; this should have been done in the initial assessment.

A client with moderate dementia often assaults nursing staff, and the staff members decide to develop a plan to minimize this behavior. What should the plan include? 1 Limiting the time staff and client spend together 2 An outline of the consequences for uncooperative behavior 3 The client's preferences for use as a reward or a punishment 4 Identification of nursing staff members whom the client prefers

identification of nursing staff members whom the client prefers The type of care needed by the client requires trust in the caregiver, which develops more rapidly when there is a cooperative relationship and client input is accepted. Limiting staff time may place the client in jeopardy. The staff should not be put in the position of punishing the client; the client with dementia cannot be held responsible for uncooperative behavior. Clients with moderate dementia will not remember and learn from a reward system.

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. 2 Explore the client's psychotic thoughts 3 Reinforce the client's current self-image. 4 Encourage the client to talk about the situation. 5 Suggest that the client explore personal sexual attitudes.

identify the cieltns support systems encourage the client to talk about the situation A client in crisis needs to rely on available sources of support for assistance; therefore it is vital for the nurse to identify the client's support system. Talking about the situation helps the individual put the crisis in perspective. Nothing in the history indicates that the client is having psychotic thoughts. Nor is there information to indicate that the client has issues with self-image. Suggesting that the client explore personal sexual attitudes will not help the client cope with the loss and may add to the client's anxiety.

A nurse may best assist abusing parents in altering their behavior toward their abused 2-year-old child by helping them: 1 Recognize what behavior is appropriate for a toddler. 2 Learn appropriate ways of punishing a toddler's inappropriate behavior. 3 Identify the specific ways in which the toddler's behavior provokes frustration. 4 Ignore the toddler's negative nondestructive behavior while supporting acceptable behavior.

identify ways in which the toddler's behavior provokes frustration By learning how the toddler's behavior provokes frustration, parents may develop more acceptable ways of responding. Although these parents need to learn what behavior is appropriate for a particular age level, it is most important that they learn how to respond appropriately to their toddler's inappropriate behavior. Punishment is an act of retribution, not an act of discipline. Negative behavior cannot be ignored but should be handled appropriately.

A nurse is caring for a child with autism. Which intervention is most appropriate in an attempt to promote socialization for this child? 1 Encouraging participation in group activities 2 Providing minimal environmental stimulation 3 Holding and cuddling the child for short periods 4 Imitating and participating in the child's activities

imitating and participating in the child's activities

A 4-year-old child is found to have attention deficit-hyperactivity disorder (ADHD). What information about the child's behavior should the nurse expect when obtaining a health history from the parents? Select all that apply. 1 Impulsiveness 2 Excessive talking 3 Spitefulness and vindictiveness 4 Deliberate annoyance of others 5 Playing video games for hours on end 6 Failure to follow through or finish tasks

impulsiveness deliberate annoyance of others playing video games for hours on end failure to follow through or finish tasks Impulsivity, the inability to limit or control words or actions, results in spontaneous, irresponsible verbalizations or behaviors. Hyperactivity occurs with both words and actions. Games that are fun, engaging, and interactive often maintain the focus of a child with ADHD. Inattention and distractibility result in inability to focus long enough to complete tasks. Being spiteful and vindictive toward others is characteristic of oppositional defiant disorder. Annoying others deliberately is associated with oppositional defiant disorder; children with ADHD may be annoying, but their behavior is not deliberate.

A clinically depressed young mother whose husband has been killed tells the nurse that she sees no purpose in life and feels like ending it all. What is the best response by the nurse? 1 "How much consideration have you given to the method you'd use to kill yourself?" 2 "Death is hard on everyone, but people make it through every day. You'll see; things will get better." 3 "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now." 4 "You feel that way now, but you still have your whole life ahead of you. Why don't you try to make a new start?"

it can be hard to lose someone you care about so much it can seem that life isnt worth living right now The response "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now" validates the client's experience and opens a channel of communication for further exploration; empathy helps build trust. Asking how much consideration the client has given to the method she would use to kill herself is premature; the nurse should first explore the client's feelings before discussing thoughts and plans. Telling the client that death is hard on everyone but people make it through every day and that things will get better is false reassurance; it invalidates the client's experience. Telling the client that she has her whole life ahead of her and advising her to make a new start is false reassurance; it invalidates the client's experience.

On the morning of a scheduled visit the parents of a client hospitalized for incapacitating obsessive behavior call to say that they cannot come because of problems with the accountant for their small business. The client appears upset and goes into elaborate detail about the parents' business and the monthly visit of the accountant. What is the best response by the nurse? 1 "It's disappointing to have plans change at the last minute." 2 "Would you like to talk about what you'd planned to do today?" 3 "Would you like to make new plans now that they're not coming?" 4 "It's good that you can recognize that your parents are sometimes busy."

its disappointing to have plans change at the last minute Expressing understanding of the client's disappointment recognizes and supports these justified feelings and provides an opportunity for him to ventilate further. Asking whether the client would like to talk about the now-scuttled plans or would like to make new plans ignores the client's feelings and directs communication away from the emotionally charged area. Complimenting the client for being able to understand that the parents are busy also ignores the client's feelings and directs communication away from the emotionally charged area.

A nurse determines that a client is pretending to be ill. What does this behavior usually indicate? 1 Psychosis 2 Malingering 3 Lack of contact with reality 4 Use of conversion defenses

malingering When an individual consciously pretends to have an illness with no physical basis, it is called malingering. People who are psychotic experience delusions, hallucinations, and disorganized thoughts, speech, or behavior. A person out of contact with reality is unable to pretend to be ill. The use of conversion defenses is not a conscious act.

A client tells a mental health nurse about hearing a man speaking from the corner of the room. The client asks whether the nurse hears him, too. What is the nurse's best response? 1 "What is he saying to you? Does it make any sense?" 2 "No one is in the corner of the room. Can't you see that?" 3 "Yes, I hear him, but I can't understand what he's saying." 4 "No, I don't hear him, but it probably upsets you to hear him."

no i don't hear him but it probably upsets you to hear him The statement "No, I don't hear him, but it probably upsets you to hear him" points out reality, recognizes the client's feelings, and prevents the nurse from becoming involved in the client's hallucination. The response "What is he saying to you? Does it make any sense?" is nontherapeutic; it supports and focuses on the hallucination. The response "No one is in the corner of the room. Can't you see that?" is an attempt to argue the client out of feelings by denying they exist. The response "Yes, I hear him, but I can't understand what he is saying" is nontherapeutic; it supports and focuses on the hallucination.

A client who attempted suicide by slashing her wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implemented when the client arrives on the unit? Select all that apply. 1 Obtaining vital signs 2 Assessing for suicidal thoughts 3 Instituting continuous monitoring 4 Initiating a therapeutic relationship 5 Inspecting the bandages for bleeding

obtaining vital signs assessing for suicidal thoughts instituting continuous monitoring initiating a therapeutic relationship inspecting bandages for bleeding Obtaining vital signs and inspecting the bandages for bleeding are interventions that must be performed in this situation; physiological stability must be maintained. Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress. A therapeutic relationship must be developed so the client can trust the nurse to provide a safe environment and aid her emotional recovery.

Incidences of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation? 1 Isolation 2 Repression 3 Regression 4 Introjection

repression Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress or anxiety, thoughts or feelings surface and come into one's conscious awareness. Isolation is the separation of a thought from a feeling tone. Regression is the use of an unconscious coping mechanism through which a person avoids anxiety by returning to an earlier, more satisfying, or comfortable time in life. Introjection is the integration of the beliefs and values of another into one's own ego structure.

When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response? 1 Stating, "You must take your medicine now." 2 Saying, "I'll be back in a few minutes so we can talk." 3 Explaining why it is necessary to take the medication 4 Withholding the medication before notifying the primary care practitioner

saying ill be back in a few minutes so we can talk. Saying, "I'll be back in a few minutes so we can talk," allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution. Staying and insisting that the client take the medication may provoke increased anger and further loss of control. Clients will not accept logical explanations when angry. Alternative nursing interventions should be attempted before withholding the medication and notifying the practitioner may become necessary. Test-Taking Tip: Survey the test before you start answering the questions. Plan how to complete the exam in the time allowed. Read the directions carefully and answer the questions you know for sure first.

A 32-year-old woman is hospitalized with a diagnosis of a bipolar disorder, manic episode. She becomes loud and vulgar and disturbs the other clients. What is the best reaction by the nurse to this situation? 1 Telling her that she is bothering the other clients 2 Ignoring the vulgar talk because it is part of the illness 3 Segregating the client until this phase of her illness passes 4 Commenting that this kind of talk is not appreciated on the unit

segregating the client until this plase of her illness passess During the manic phase, when clients are unable to control their behavior, they should be protected from embarrassing themselves or harming others. These clients are unable to deal with others' feelings; the client's own feelings are primary at this time. Also, simply telling the client that her behavior is bothersome is too general to communicate which behaviors are dysfunctional. The client's behavior cannot be ignored because the client or others may be hurt if limits are not set. Stating that talk such as the client's is not welcome on the unit is critical of the client, who is unable to respond differently at this time.

A deeply depressed, withdrawn client remains curled up in bed and refuses to talk to the nurse. What should the nurse do initially to break through the client's withdrawal? 1 Sit with the client for set periods each hour. 2 Touch the client gently on the arm when the opportunity arises. 3 Urge the client to participate in simple games with other clients. 4 Inform the client that going to the lounge is required in the daytime

sit with the client for set periods each hour Sitting quietly with a severely withdrawn client can provide an opportunity for nonthreatening interaction. Entering a withdrawn client's body space is intrusive and stressful; it often precipitates a need for further withdrawal. The client is unable to socialize with others at this time. Placing demands on the withdrawn client causes a sense of threat, increased anxiety, and a need for additional withdrawal

Anorexia nervosa follows a cyclical pattern. Place the following statements in order of progression through this cycle, with 1 as the first step and 4 as the last step. 1. Self-esteem increases as weight is lost. 2. Secondary gains reinforce the anorectic client's behaviors. 3. Dieting is an attempt to maintain control. 4. Sociocultural attitudes exert pressure to attain an idolized body.

sociocultural attitudes exert pressure to attain an idolized body dieting is am attempt to maintain control self-esteem increases as weight is lost secondary gains reinforce the anorectic clients behaviors Sociocultural (fashion, "superwoman" issues, and the diet and fitness industry), biological, psychological, and familial factors all influence the development of anorexia nervosa. Dieting, exercise, purging, and laxatives are used to lose weight, with the resulting primary gain of a feeling of control over one's life. As weight is lost, the individual feels a sense of accomplishment and self-esteem increases. Finally, secondary gains such as attention from parents and peers reinforce the behaviors associated with anorexia nervosa.

A nurse, along with an adolescent girl and her parents, set bolstering the adolescent's self-esteem as a high-priority goal. The girl expresses an interest in earning money. What nursing action will contribute to the achievement of this goal? 1 Telling the adolescent how much her parents love her 2 Urging the adolescent to join a neighborhood volunteer group 3 Supporting the adolescent's interest in enrolling in a babysitting course 4 Encouraging the adolescent to talk about feelings of pride in her successful siblings

supporting the adolescents interest in enrolling i a baby sitting course Enrolling in a babysitting course is an achievable action that involves a personal goal; it should also bolster the adolescent's self-esteem. Telling the adolescent how much her parents love her, urging the girl to join a neighborhood volunteer group, and encouraging the adolescent to talk about her pride in her siblings may not improve the adolescent's self-esteem. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes.

A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication? 1 Allows symptom-free termination of opioid addiction 2 Switches the user from illicit opioid use to use of a legal drug 3 Provides postoperative pain control without causing opioid dependence 4 Counteracts the depressive effects of long-term opioid use on thoracic muscles

switches the user from illicit opiod use to the use of a legal drug Methadone may legally be dispensed; the strength of this drug is controlled and remains constant from dose to dose, unlike illicit drugs. Methadone is used in the medically supervised withdrawal period to treat physical dependence on opiates; methadone therapy substitutes a legal for an illegal drug. Methadone may be administered over the long term to replace illegal opioid use. If methadone treatment is abruptly stopped, there will be withdrawal symptoms. Methadone is a synthetic opioid and can cause dependence; it is used in the treatment of heroin addiction but may be prescribed for people who have chronic pain syndromes. It is not used for acute postoperative pain. Methadone is not known to counteract the depressive effects of long-term opioid use on thoracic muscles.

A nurse discusses the plan of care with a depressed client whose husband has recently died. The nurse determines that it will be most helpful to: 1 Involve the client in group exercises and games. 2 Encourage the client to talk about and plan for the future. 3 Talk with the client about her husband and the details of his death. 4 Motivate the client to interact with male clients and the nursing staff

talk with the client about her husband and the details of his death Discussing the partner and the partner's death will help the client work through the grief process. Involving the client in group exercises and games refocuses the client's attention away from addressing feelings; the client probably does not have the physical or emotional energy to get involved with group activities. The client must cope with the past and present before addressing the future. Motivating the client to interact with male clients and the nursing staff refocuses the client's attention away from addressing feelings; the client probably does not have the physical or emotional energy to get involved with others.

A hospitalized client with a mood disorder begins to be less hyperactive and acts calmer. One day the client says to the nurse, "My partner and I have problems getting along. Sometimes we don't see eye to eye." What are the nurse's most therapeutic responses? Select all that apply. 1 "Tell me more about how you see things differently." 2 "It can be very upsetting to be at odds with your partner." 3 "You're showing progress because you appear calmer today." 4 "Let's talk about a specific time when you didn't see eye to eye." 5 "It must be difficult living with a person who doesn't see things your way."

tell me more about how you see things differently it can be difficult to be at odds with your partner lets talk about a specific time when you didn't see eye to eye

A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? Select all that apply. 1 Tremors 2 Anorexia 3 Agitation 4 Delusions 5 Confusion

tremors anorexia Hand tremors, related to dysfunction of the nervous system, are an early sign of withdrawal from alcohol; alcohol depresses the central nervous system, interferes with nerve conduction, and results in peripheral neuropathy. Signs and symptoms of alcohol withdrawal begin within 12 hours of cessation or decrease in alcohol consumption, peak in 48 to 72 hours, and usually begin to ease after 4 or 5 days. Anorexia, nausea, and vomiting are early signs of withdrawal from alcohol; alcohol affects the gastrointestinal system and can cause gastritis, pancreatitis, hepatitis, and cirrhosis. Psychomotor agitation is a late, not an early, sign of alcohol withdrawal. Transient visual, auditory, and tactile hallucinations, rather than delusions, are associated with alcohol withdrawal. Confusion, disorientation, and impaired cognition are not early signs of alcohol withdrawal; alcohol withdrawal delirium occurs in less than 10% of those who experience the alcohol withdrawal syndrome.

A client is pacing the floor and appears extremely anxious. The nurse approaches in an attempt to alleviate the client's anxiety. The most therapeutic initial question by the nurse is: 1 "What's made you so upset?" 2 "Where would you like to walk with me?" 3 "Shall we sit down to talk about your feelings?" 4 "How would you like to go to the gym to work out?"

where would you like to walk with me The nurse's presence may provide the client with support and a feeling of control. The client is too upset to respond; asking what has upset the client may lead to more anxiety. The client is too distraught to sit; to be therapeutic the nurse should walk with the client, thereby demonstrating concern. The client is in a panic; anger is not the primary emotion and there is no need to work off aggression.

A nurse who is assessing a recently hospitalized client with a diagnosis of opioid addiction should look for signs of withdrawal. What are these signs? Select all that apply. 1 Seizures 2 Yawning 3 Drowsiness 4 Constipation 5 Muscle aches

yawning muscle aches Yawning and muscle aches are clinical manifestations of opioid withdrawal, which occurs after cessation or reduction of prolonged moderate or heavy use of opioids. Seizures do not occur with opioid withdrawal. Insomnia, not drowsiness, occurs with opioid withdrawal. Diarrhea, not constipation, occurs with opioid withdrawal