HESI Review Psych

The police accompany a client to the emergency department after the client tried to jump off a bridge. Which question is most important for the practical nurse (PN) to ask the client during admission to the mental health unit? a. Is the client having hallucinations to harm other people? b. Where does the client usually seek health care treatment? c. Are there any incidents of aggression in the client's history? d. Does the client have a history of depression?

a. Is the client having hallucinations to harm other people? Rationale: The priority is to determine the presence of hallucinations, which may be encouraging the client to harm self or others.

The nurse will be assisting with electroconvulsive therapy (ECT) for a client who is extremely suicidal. The nurse should provide which priority intervention during the therapy? a. Keep suction equipment available if the client vomits. b. Restrain the client's extremities to prevent injury. c. Apply heart monitoring devices before the treatment. d. Reassure the client that memory loss is usually short-term.

a. Keep suction equipment available if the client vomits. Rationale: Airway management is the priority. Nausea is common after the procedure and vomiting by the client who is unconscious can lead to aspiration. It is unsafe to restrain the client's extremities during a seizure (convulsion) because the strong muscle contractions can cause a fracture if the extremities are restrained. In addition, restraints are rarely necessary because a short-acting neuromuscular medication is usually administered to prevent muscle movements or damage. Heart monitoring is crucial, but remember the phase "Airway, Breathing, Circulation" or "ABCs." After the procedure it is important to reassure the client that memory loss is short term, but the priority action is preventing aspiration.

A client admitted with extensive burns cries during a dressing change and says, "Why are you all torturing me like this? I just want to die." Which response by the PN is best? a. These treatments are painful and necessary to prevent a terrible infection. b. These treatments must seem like torture to you, but we want to help you recover. c. You have so much to live for, and all of your family members want you to live. d. Would you like me to call the chaplain so that you can privately discuss your feelings?

b. These treatments must seem like torture to you, but we want to help you recover. Rationale: Acknowledging that the treatment is painful offers an empathetic response without sounding patronizing. The client is not asking for information as much as pleading for understanding.

A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and, using the right arm, throws a hairbrush against the wall. How should the PN respond? a. "I will return to talk to you when you are calm again." b. "Since you are upset, let's play some soft music." c. "I can see you are upset. I want you to know I am a good listener." d. "I hear that you are very upset. Let's try some deep breathing exercises."

c. "I can see you are upset. I want you to know I am a good listener." Rationale: The client is angry and the PN recognizes this anger and offers an opportunity to discuss feelings.

A client with schizophrenia tells the nurse, "Cannot you hear that buzzing sound? It's the sound CNN makes when it's putting bad thoughts in my head." Which is the most appropriate response to make to this client? a. "I will close the door to your room so you can think of something else." b. "I will need to report that you are still having those hallucinations." c. "I do not hear any buzzing sounds. You are safe here in the hospital." d. "I do not understand why CNN would choose you for their bad thoughts."

c. "I do not hear any buzzing sounds. You are safe here in the hospital." Rationale: The nurse needs to stress reality by informing the client that the nurse does not hear any buzzing thoughts. The nurse also needs to help the client feel safe and supported when they are experiencing hallucinations. The nurse should not leave the client to think of something else. The client is hearing sounds that seem very realistic. The nurse should not threaten the client (Option B) or argue with the client (Option D).

A 53-year-old client with a known history of heavy alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The practical nurse (PN) should observe for which symptoms are early indications of alcohol withdrawal? a. Tachycardia, tachypnea, hypotension, and pale and clammy skin b. Leg cramps, abdominal cramping, diarrhea, diaphoresis, and rhinorrhea c. Elevated blood pressure, anxiety, transient hallucinations, tremors, and restlessness d. Increasing demands for narcotic medication for postoperative pain management

c. Elevated blood pressure, anxiety, transient hallucinations, tremors, and restlessness Rationale: A client experiencing alcohol withdrawal will demonstrate symptoms within 6 to 12 hours of cessation of drinking and initially demonstrates restlessness, anxiety, tremors, transient hallucinations or illusions, tachycardia, and hypertension that may progress to delirium tremens. The PN should also reassess the client's pain.

A client diagnosed with schizophrenia who has been taking the antipsychotic agent clozapine for the past 3 weeks has a low-grade fever. Which nursing finding would have the greatest implications for this client's care? a. Difficulty with constipation b. 5-pound weight gain c. Dry mouth d. Leukopenia

d. Leukopenia Rationale: Any sign of infection could be an indication of hematologic conditions and would have the greatest implication for this client's care. Agranulocytosis and leukopenia are the adverse reactions of clozapine; therefore, the WBC and differential count should be closely monitored during treatment.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. What is the best response by the practical nurse (PN)? a. "Tell me how you think this might affect your present sexual activity." b. "How active is your current sex life?" c. "How has your sex life changed as you have become older?" d. "Tell me about your sexual needs as an older adult."

a. "Tell me how you think this might affect your present sexual activity." Rationale: Asking how the client's current sexual activity will be affected offers an open-ended question most relevant to the client's statement

Which client requires the most immediate intervention by the practical nurse? a. Client expressing inability to do anything worthwhile b. Client experiencing sudden onset of confusion and disorientation c. Client unable to correctly demonstrate changing a dressing d. Client with T score of −2.5 on a bone density test

b. Client experiencing sudden onset of confusion and disorientation Rationale: Disorientation and confusion are indicative of delirium and requires prompt intervention to maintain client safety, prevent injury as well as treatment to prevent permanent damage.

The practical nurse (PN) observes a client who is sitting alone and mumbling. How should the PN document this finding? a. Appears to experience hallucinations. b. Sits alone and mumbles to self. c. Possible medication noncompliance. d. Refuses participation in milieu.

b. Sits alone and mumbles to self. Rationale: Chart documentation is best done objectively, so describing that the client is sitting alone and mumbling is preferred.

A family has just learned that a member of the family has been given a terminal diagnosis. They are very upset and are loudly expressing their anger in the hall. Which action should the nurse take first? a. Describe the signs and symptoms of impending death. b. Direct family to the chapel in the hospital. c. Guide the family to an empty room for privacy. d. Explain that there is no curative treatment available.

c. Guide the family to an empty room for privacy. Rationale: The family needs time to cope with the diagnosis; therefore, providing privacy will help the family gain composure.

A client who became agitated an hour previously is now pacing the hallway and asking to leave the mental health unit. What action should the practical nurse (PN) take first? a. Allow the client to continue pacing. b. Confine the client to an observation room. c. Encourage the client to attend group therapy. d. Call security for possible assistance.

a. Allow the client to continue pacing. Rationale: First, the PN should encourage the client to continue pacing until agitation decreases; however, if the client becomes more agitated or becomes a danger to self or others, other actions such as medication administration may be required.

The nurse is caring for several clients diagnosed with eating disorders. Which implementations are most likely to be effective for clients with eating disorders? (Select all that apply.) a. Behavior modification and family therapy. b. Praise the client for every meal consumed at 75% or more. c. Assess for the client taking large amounts of water before weighing. d. Weight the client while the client stands with the back to the standing scale. e. Encourage the client with anorexia nervosa to prepare food for the unit party. f. Check under food trays, pockets, and trashcans after meals for discarded food items.

a. Behavior modification and family therapy. c. Assess for the client taking large amounts of water before weighing. d. Weight the client while the client stands with the back to the standing scale. f. Check under food trays, pockets, and trashcans after meals for discarded food items. Rationale: Behavior modification and family therapy are effective when treating eating disorders. The client should be assessed for water loading before weighing session. The client should be faced with the back to the standing scale to prevent arguing about weight. The area around the client should be checked for discarded food items. The client should be praised for weight gain, not for specific food intake. The client with anorexia nervosa should not be allowed to prepare food for others, because the person often gains pleasure from providing food for others to reinforce the client's perception of self-control.

The daughter of an older adult who is confused asks the practical nurse (PN) for guidance regarding the use of alternative dietary supplements to treat Alzheimer disease. Which information should the PN provide? a. Carefully review information regarding research findings. b. Avoid dietary supplements because they interact with drugs. c. Recommend specific dietary supplements that are safe. d. Refer to a health food store for more complete information.

a. Carefully review information regarding research findings. Rationale: Some dietary supplements may be helpful, whereas others may not, so the family should carefully review current research findings regarding the supplements they are considering.

A caregiver wishes to discuss end-of-life issues with the nurse. The caregiver asks the nurse to explain what DNR means. What information is most important for the nurse to provide? a. DNR means that no attempts to perform cardiopulmonary resuscitation will be done. b. DNR gives the caregiver permission to make decisions regarding the client's care. c. DNR is a code for classifying illnesses according to diagnosis and treatment requirements. d. DNR is a living will that allows a person to specify what treatments they would want given under certain conditions.

a. DNR means that no attempts to perform cardiopulmonary resuscitation will be done. Rationale: No cardiopulmonary resuscitation will be implemented which is expressed in terms that the client can understand.

A tornado has destroyed most of a small, rural town last night, killing several children and firefighters. The nurse is assisting those who are seeking attention for their mental health needs regarding their immediate crisis. Which actions will be most effective for the nurse to implement now? (Select all that apply.) a. Help those affected to identify their own support systems in the community. b. Explain to those affected the goal of care is to improve their lives permanently. c. Assist those affected to identify their own effective coping skills used in other situations. d. Assist in educating those affected on the weather systems that cause tornados to start. e. Explain that the nurse will be approaching local county officials to improve warning systems.

a. Help those affected to identify their own support systems in the community. c. Assist those affected to identify their own effective coping skills used in other situations. Rationale: The nurse will be most effective when meeting the most immediate needs of those affected by the crisis. It will be most helpful for the nurse to help those affected to identify their own support systems available in the community. The nurse can also assist those affected to identify and use coping skills which have been effective in the past. The goal of care is to return the individual to the pre-crisis level of functioning; it is not likely possible to improve their lives at this time. The individual in crisis does not need information on how the tornado occurred or how the nurse will advocate for better warning systems in the future.

The nurse working in the community health clinic is assessing risk factors that can decrease medication effectiveness for clients diagnosed with schizophrenia. Which client behavior is likely to decrease the effectiveness of psychotropic medications? a. Smokes at least 20 cigarettes daily. b. Misses a medication appointment at the clinic. c. Hears voices more often than usual. d. Takes a morning medication later in the day.

a. Smokes at least 20 cigarettes daily. Rationale: Smoking more than 10 cigarettes daily and drinking more than 250 mg of caffeine can decrease the effectiveness of antipsychotic and antianxiety medications.

A depressed client whose judgment is poor and whose thoughts are disorganized tells the practical nurse (PN) they insist on leaving the hospital 1 day after admission. Which documentation in the client medical record suggests that the client is unable to safely care for basic needs? a. The client forgot to turn off the stove several times in the last month. b. The client reported feeling dissatisfied with their ability to clean house. c. The client has missed several days of work due to stress and illness. d. The client forgot to keep the last two scheduled clinic appointments.

a. The client forgot to turn off the stove several times in the last month. Rationale: The client forgetting to turn off the stove demonstrates the client's inability to safely care for self.

During an admission interview, a client reports using alcohol and other illegal drugs every day for the last 3 years. What question is most important for the practical nurse (PN) to ask this client? a. "What happened to make you decide to get help?" b. "When did you last use alcohol or any other drug?" c. "Have you ever had any withdrawal symptoms?" d. "Do you have anyone to help you stay clean?"

b. "When did you last use alcohol or any other drug?" Rationale: To assess for the onset of withdrawal symptoms, it is most important to determine when the client last ingested any alcohol or other drug.

In evaluating a client's response to an antidepressant medication, which statement should the practical nurse (PN) expect to hear from a client who has been taking the medication for 10 days? a. Reports feeling good about lifetime achievements. b. Describes only awakening occasionally during the night. c. Says that mood is better now than in the past few years. d. Talks about going dancing for the first time in years.

b. Describes only awakening occasionally during the night. Rationale: Antidepressants take approximately 2 to 4 weeks to take effect, and improvement in the vegetative symptoms of depression such as sleep disturbance is the usual initial response to these drugs.

A client experiencing the manic phase of bipolar disorder has lost 4 pounds (1.8 kg) due to constant activity and an inability to sit still for a meal. What intervention will be most effective for this client? a. Administer a prescribed antianxiety medication. b. Offer the client foods such as cheese sticks and frozen fruit juice cups. c. Provide three full meals a day and sit with the client while the meal is served. d. Challenge the client to compete with other clients to see who can eat the most food.

b. Offer the client foods such as cheese sticks and frozen fruit juice cups. Rationale: The client should be offered "finger foods," foods that can be eaten while moving around. Antianxiety meds will not likely improve the client's nutritional status because of the sedative effects. Even if the nurse sat with the client, it is not likely the client would sit through three full meals. The client in the manic phase should not participate in competitive games. Forcing food down could also be harmful.

An older adult female client diagnosed with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the practical nurse (PN) to provide? a. Orient the client to time, place, and person. b. Tell the client that the nurse is there and will help her. c. Remind the client that her mother is no longer living. d. Explain the seriousness of her injury and the need for hospitalization.

b. Tell the client that the nurse is there and will help her. Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The PN should use the techniques of "offering self" and "talking to the feelings" to provide reassurance.

A client is admitted to the psychiatric inpatient unit with a diagnosis of major depression after retirement from work. The initial nursing care plan includes the goal that the client will identify psychosocial stressors that may have a negative impact on the client's depression and begins to modify them. What is the practical nurse's (PN) expectation of the client related to this goal? a. This goal is not appropriate regarding depression. b. The depression is retirement related and will dissipate once the client adjusts to the life changes and developmental tasks. c. Depressed clients are often unaware of underlying feelings and should be encouraged to explore self-awareness. d. The treatment team should approve nursing goals before they are initiated.

b. The depression is retirement related and will dissipate once the client adjusts to the life changes and developmental tasks. Rationale: Clients who make life changes such as retirement experience feelings of stress because they are no longer active in the work environment. They have to adjust to a new role in the home and family. Awareness is the first step in dealing with feelings, so the practical nurse's (PN's) efforts should be directed toward increasing the client's awareness of feelings.

The nurse working at a mental health crisis center receives several phone calls during the shift. Which phoned in comment requires the most immediate response? a. "My wife left me, and I have no reason to keep on living." b. "I keep hearing voices telling me to walk into a busy street." c. "I have a loaded pistol in my room, and I know how to use it." d. "I can get hold of 6 acetaminophen tablets with hydrocodone"

c. "I have a loaded pistol in my room, and I know how to use it." Rationale: All these statements indicate a seriously depressed and potentially suicidal individual. However, the individual describing having a loaded pistol available, along with weapon knowledge, requires the most immediate response.

The practical nurse (PN) is monitoring a client with alcohol dependency who is admitted for detoxification. The client complains of a headache, and the vital signs are as follows: blood pressure, 149/96 mm Hg; pulse, 104 beats/min; and temperature, 100.9° F. What action should the PN implement? a. Reassess the client in an hour. b. Offer the client prescribed PRN ibuprofen 200 mg. c. Administer prescribed lorazepam 2 mg. d. Encourage frequent rest periods.

c. Administer prescribed lorazepam 2 mg. Rationale: The client's elevated vital signs are indicative of alcohol withdrawal; therefore, lorazepam should be administered.

An older adult client who is recently transferred from the critical care unit suddenly begins hallucinating, and becomes disoriented, and fearful. The practical nurse (PN) should expect to implement which interventions? (Select all that apply.) a. Move all monitoring machines from the client's bedside. b. Allay fears by teaching the client about cause of disease. c. Cluster care to maximize rest periods during the day. d. Encourage visitation by friends and family members. e. Reorient client to changes between day and night.

c. Cluster care to maximize rest periods during the day. d. Encourage visitation by friends and family members. e. Reorient client to changes between day and night. Rationale: The best intervention is to provide the client with rest periods. In the critical care unit, many lifesaving treatment modalities overload the client with an array of auditory, visual, and even painful stimuli as well as deprivation of changes from day to night. These stressors, plus the environmental transfer from one unit to another, can result in confusion and psychotic symptoms. Family visits are supportive that can stimulate reassurance, relaxation, and sensory orientation.

A client has phenelzine, a monoamine oxidase inhibitor (MAOI) prescribed for depression that has not been treated successfully with other antidepressants. The nurse has reinforced teaching regarding dietary restrictions required with this drug to avoid a severe hypertensive crisis caused by a food/drug interaction. The nurse realizes teaching has been effective if the client selects which item from the snack cart? a. Yogurt mixed with raisins b. Chocolate covered banana c. Popcorn with salt and butter d. Sharp cheddar cheese sticks

c. Popcorn with salt and butter Rationale: The client should be educated to select meal and snack items that are low in tyramines. Items high in tyramines can interact with the MAOI class of antidepressant drugs and cause a severe, potentially fatal hypertensive crisis. The client should NOT eat foods with high tyramine content such as aged cheese or avocados, red wine, beer, yeast, yogurt, raisins, soy sauce, chocolate, or bananas.

While sitting at a table talking to the practical nurse (PN), the client leans over and begins hyperventilation. What action should the PN initiate? (Select all that apply.) a. Take the client to the self-esteem group. b. Find a peer to remain with the client. c. Reassure the client by encouraging slow deep breathing. d. Refocus the client's attention to television. e. Assess the client for physical symptoms. f. Remove client to a quiet area.

c. Reassure the client by encouraging slow deep breathing. e. Assess the client for physical symptoms. f. Remove client to a quiet area. Rationale: The PN should remain quiet and calm and should assess the client's physical symptoms. If there are no physical symptoms associated with the hyperventilation, encourage to breathe slowly and deeply to diminish the hyperventilation, provide reassurance, and move the client to a quiet area to minimize environmental stimuli.

A male client diagnosed with an antisocial personality is complimenting the female nurse about her hair, soft skin, and beautiful eyes in a group meeting. What action should the practical nurse (PN) take? a. Calmly request the client to leave the group meeting. b. Ignore the client's comments and continue with the group. c. Tell the client that the client is being inappropriate and to please stop. d. Thank the client for the compliment and ask why the client is acting this way.

c. Tell the client that the client is being inappropriate and to please stop. Rationale: The PN should tell the client to stop making the comments. The nurse's role is to set limits, present reality, and help the client realize that there are consequences to behavior.

A client is being treated in the emergency department, stating his arms do not move anymore. He calmly says "I guess I will just have to learn to live without using them." Upon further data collection, the client reports a fire in his back yard which killed his beloved dogs. Because of the extreme, sudden heat and flames, he was unable to save the dogs. The nurse discusses the situation with the health care team. The plan of care involves treatment for which disorder? a. Malingering b. Secondary gain c. Munchausen syndrome d. Conversion reaction

d. Conversion reaction Rationale: The client is experiencing "La belle indifference" or beautiful indifference. The client is not experiencing the normal type of concern expected when losing function of the arms. This is characteristic of a conversion reaction. Malingering occurs when a client creates complaints for secondary gain, such as not having to report to work or school. Secondary gain describes gains the client obtains from the sick role such as extra attention, sympathy, or release from responsibilities. Munchausen syndrome is a severe type of factitious disorder that results in severe self-harm that may require invasive treatment.

The nurse in a pediatric clinic is assisting with data collection for a 7-year-old child being evaluated for possible autism spectrum disorder. Which symptom reported by the caregiver is most closely associated with this disorder? a. The child steals items from the caregiver, fights with others, and lies frequently. b. The child frequently defies rules and the caregiver's authority, uses curse words. c. The child shows no remorse for hurting others, but acts charming to get own way. d. The child becomes upset when a minor change is made in the home furnishing.

d. The child becomes upset when a minor change is made in the home furnishing. Rationale: The child who becomes upset when a minor change is made in the home furnishing is exhibiting behavior associated with the autism spectrum disorder. Lying, stealing, and fighting with others are symptoms associated with conduct disorder. The child who frequently defies rules and the caregiver's authority is showing oppositional defiant disorder. Not showing remorse but acting charming to get their way is common with antisocial personality disorder.

The nurse is reviewing medical records for a client with generalized anxiety disorder (GAD). The nurse is most likely to note which characteristic described? a. The client has had anxiety lasting 3 weeks. b. The client is anxious about work and talks about it excessively. c. The client states sometimes the anxiety helps with getting more school assignments done. d. The client mentions using their usual coping mechanism of prayer and talking to family does not help at all.

d. The client mentions using their usual coping mechanism of prayer and talking to family does not help at all. Rationale: The client with generalized anxiety disorder usually describes being unable to use their usual coping mechanisms to deal with this anxiety. Generalized anxiety disorder exists when a client has unrealistic anxiety or worrying lasting 6 months or longer. In addition, the client with GAD worries about multiple life circumstances, not just about work. A client with mild anxiety can sometimes have more motivation to learn.

The nurse is caring for a seriously depressed client. At 0930, the nurse finds the client curled up on the bed, facing the wall. The client has an appointment with the therapist at 0945. What is the most appropriate statement for the nurse to make? a. "It's almost time for your visit with the therapist; I'll walk with you to her office." b. "I can tell you're tired right now, I'll tell your therapist you do not want to see her." c. "You have every right not to visit with your therapist, but you will not feel better." d. "If you do not participate with the therapy, your insurance company will not pay."

a. "It's almost time for your visit with the therapist; I'll walk with you to her office." Rationale: The nurse should strongly encourage the client to participate in necessary activities and do not give the client a choice about participating in these activities. In option A, the nurse offers to walk with the client to the therapist's office. The nurse should not use threatening comments such as not feeling better if they do not see the therapist, or insurance companies not paying for treatment.

An older adult with a 30-year history of bipolar disorder presents at the psychiatric outpatient clinic with diarrhea and confusion. What information is most important for the practical nurse to obtain? a. Medications taken during the last week b. Average length of time spent outdoors daily c. Amount of table salt used daily d. History of flu immunization

a. Medications taken during the last week Rationale: The client's symptoms may suggest lithium toxicity and result in life-threatening conditions such as a cardiac arrhythmia and sudden death. Therefore, a medication history is a priority assessment for any client diagnosed with a psychiatric disorder.

The practical nurse (PN) is interviewing a client who reports having angry outbursts and difficulty controlling mood changes and denies hearing voices or having suicidal ideas. What information is most important for the practical nurse (PN) to obtain? a. Available community resources b. Use of medications or substances c. Family history of mental illness d. Past academic achievements

b. Use of medications or substances Rationale: Assessing for the use of psychotropic medications and/or substances is most important, because the nurse should gather data about medication as well as the possibility of consumption of alcohol or other substances.

A client is admitted to the hospital with the diagnosis of schizophrenia. Which finding should the practical nurse (PN) recognize as the most characteristic of the mental status of a client diagnosed with schizophrenia? a. Mood swings b. Extreme sadness c. Manipulative behavior d. Incongruent affect

d. Incongruent affect Rationale: Facial expressions that are not in keeping with the person's thought content are referred to as incongruent; incongruent affect is most commonly seen in early-onset schizophrenia.

A client who becomes angry while waiting for a supervised smoke break loudly insists on going outside now. Which intervention is best for the practical nurse to implement? a. Encourage the client to use a nicotine patch. b. Reassure the client that it is almost time for another break. c. Have the client leave the unit with another staff. d. Review the schedule of outdoor breaks with the client.

d. Review the schedule of outdoor breaks with the client. Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule.

A client diagnosed with schizophrenia refuses to take a shower, stating that the CIA has planted cameras in the bathroom. Which should be the nurse's action? a. Tell the client he must shower because other clients are complaining about the odor. b. Remind the client he can be physically forced to take a shower by security staff. c. Tell the client the CIA has no interest in placing cameras in bathroom stalls. d. Tell the client "These thoughts must feel scary to you, but you are safe here with us."

d. Tell the client "These thoughts must feel scary to you, but you are safe here with us." Rationale: The client is genuinely frightened. The nurse should acknowledge the client's fears, but also assure the patient he is safe.

On admission, a client diagnosed as a substance abuser is described as delusional. The practical nurse (PN) understands that this client is out of contact with reality and is experiencing which symptoms? (Select all that apply.) a. Tactile distortions b. Sensory misperceptions c. Alcohol withdrawal d. Psychotic e. Personality changes

c. Alcohol withdrawal d. Psychotic Rationale: Delusions are false thoughts or beliefs characteristic of psychosis, alcohol delirium tremens, and dementia.

An adult client who is withdrawing from alcohol is observed carrying on a conversation in an empty room while looking under the bed trying to find a neighbor. What interventions should the practical nurse (PN) implement? (Arrange the items in order, with first on top and last on bottom.) Arrange the sequence options in the correct order by assigning each option a number. Review the last medications administered. Report the client's behavior to the charge nurse. Administer prn chlordiazepoxide. Take the client's vital signs. Sit quietly with the client.

1. Take the client's vital signs. 2. Review the last medications administered. 3. Administer prn chlordiazepoxide. 4. Report the client's behavior to the charge nurse. 5. Sit quietly with the client. Rationale: The client is hallucinating and experiencing delirium tremens, so first assess vital signs, which provides data regarding the cardiovascular response to the CNS excitation that occurs during alcohol detoxification. Then the client's medications should be reviewed, administer prn chlordiazepoxide, and report the behavior. Finally, sitting quietly with the client provides an opportunity to observe the client and offer emotional support.

Several days after hospitalization, a client is repeatedly washing the top of the same table. Which intervention should the practical nurse (PN) to implement first to help the client cope with anxiety related to this behavior? a. Administer a prescribed PRN antianxiety medication. b. Assist the client to identify stimuli that precipitate the ritualistic activity. c. Allow time for the ritualistic behavior, and then redirect the client to other activities. d. Teach the client relaxation and thought-stopping techniques.

c. Allow time for the ritualistic behavior, and then redirect the client to other activities. Rationale: Initially, the PN should allow time for the ritual to diminish anxiety.

The nurse is working with a client with schizophrenia. Which "positive" symptom of schizophrenia is the nurse most likely to observe? a. Flat affect b. Hallucinations c. Minimal speech d. Inability to begin activities

b. Hallucinations Rationale: A positive symptoms of schizophrenia are hallucinations and delusions. Negative symptoms are flat affect, poverty of speech, and an inability to begin activities.

A client who is receiving disulfiram for the treatment of alcoholism has been cautioned about the importance of avoiding alcohol, particularly during concurrent treatment with cephalosporin antibiotics, because an Antabuse reaction may be initiated. The nurse realizes teaching has been effective if the client identifies which symptom could indicate the client is experiencing a reaction to disulfiram? a. Diarrhea b. Headache c. Tachycardia d. Hematuria

b. Headache Rationale: Headache, vomiting, and flushing are indicative of a reaction to disulfiram.

The practical nurse (PN) is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the admission to the inpatient unit? a. Monitor appetite and PO intake at meals. b. Maintain safety in the client's milieu. c. Provide ongoing, supportive contact. d. Encourage participation in activities.

b. Maintain safety in the client's milieu. Rationale: Because a very depressed client is at risk for suicide, the most important reason for closely observing the client immediately after admission is to maintain safety.

The nurse is caring for a client with substance abuse disorder. Which client statement corresponds with the use of rationalization as a defense mechanism? a. "My husband is the meanest person alive, you'd drink too if you were married to him." b. "I do not really have a substance abuse problem, I have never been arrested for DUI." c. "Substance abuse is the regular use of psychoactive substances with behavior patterns." d. "I really loved my grandfather, and he drank two shots of whiskey with ice every night."

a. "My husband is the meanest person alive, you'd drink too if you were married to him." Rationale: Rationalization is offering an acceptable explanation to make the behavior seem acceptable. The client who states that her husband is the reason she drinks is using rationalization. The individual who states they do not have a substance abuse problem is using denial as a defense mechanism. The individual giving an advanced statement about the theory or definition of the disorder is using intellectualization as a defense mechanism. Identification is being used by the individual who mentions a much loved grandfather who drank.

The health care provider prescribes clonazepam 1.25 mg. The medication is available in 0.5-mg tablets. What should the nurse administer? a. 3 tablets b. 2.5 tabletsCorrect Answer c. 2 tablets d. 1.25 tablets

b. 2.5 tablets Rationale: 1.25 mg/0.5 mg = 2.5 tablets.

A client who is tearful and experiencing suicidal thoughts associated with memories of childhood abuse is admitted to the mental health unit. The client reports having nightmares, difficulty sleeping, and an inability to cope at work. Which goal is the priority for the practical nurse when implementing the plan of care? a. The client will report 6 hours of sleep nightly. b. The patient will reestablish a relationship with parents. c. The patient will report to staff suicidal thoughts. d. The patient will display adequate coping skills.

c. The patient will report to staff suicidal thoughts. Rationale: Client safety is the priority for this client with suicidal thoughts.

The spouse of a client who has been physically abused refuses to leave the client's room during the admission interview. Which action should the practical nurse (PN) implement? a. Conduct the assessment with the spouse in the room. b. Physically escort the spouse out of the client's room. c. Wait until the spouse leaves the room to assess the client. d. Assist the client to walk to a treatment room on the unit.

d. Assist the client to walk to a treatment room on the unit. Rationale: Escorting the client to a treatment room provides the privacy needed to examine her and talk to her without the spouse in the room. The client may be reluctant to tell the truth with the abusive spouse in the room.

A client diagnosed with Alzheimer disease is wandering the busy halls of the extended care facility and asks the practical nurse (PN), where should I stand for the parade? Which response is best for the PN to provide? a. Anywhere you want to stand, as long as you do not get hurt by those in the parade. b. There is no parade. You are confused because of all the activity in the hall. c. Let's go back to the activity room and see what is going on in there. d. Remember, I told you that this is a nursing home and I am your nurse.

c. Let's go back to the activity room and see what is going on in there. Rationale: It is common for those with Alzheimer disease to use the wrong words. Redirecting the client (using an accepting, nonjudgmental dialogue) to a safer place and familiar activities is most helpful because clients experience short-term memory loss.

A client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. Which statement indicates to the practical nurse (PN) that the client needs continued hospitalization? a. Sometimes I put on my headphones when I hear the voices. b. The voices are louder when I forget to take my medication. c. No matter what I do, I cannot make the voices go away. d. I just try to tell the voices to stop when they bother me.

c. No matter what I do, I cannot make the voices go away. Rationale: Hospitalization is needed to maintain the client's safety because the client continues to hear voices telling the client to do things that can cause self-harm.