Mental Health 3

The client with depressive disorder, is in alcohol withdrawal and reports a recent job loss. Which of the following should be the priority nursing intervention? A. Determine the presence and degree of suicidal risk. B. Assist the client to identify negative effects of chemical dependency. C. Identify support groups in the community for long term treatment. D. Refer client to a mental health care provider for evaluation and treatment.

A - Maslow's hierarchy is the priority for this client so ensuring safety is the first nursing action. The other options would be part of the plan of care at some point but are not the priority in this situation.

Which of the following are expected findings in the client with obsessive compulsive disorder (OCD)? Select all that apply. A. Difficulty relaxing B. Irrational fear of certain objects C. Rule-conscious behavior D. Unaware of compulsions E. Perfectionist behavior

A is correct as OCD causes high levels of stress and anxiety. C is correct as OCD clients have increased anxiety when rules are not followed. E is correct as OCD clients strive for perfection and have increased anxiety if it is not attained. B describes phobias. Clients with OCD are aware of their compulsions.

Which statement indicates concrete thinking in the client who has schizophrenia? A. I am aware that each problem has only one solution. B. I am a prophet of God. C. The voices tell me to avoid large crowds. D. I know you're trying to poison me and you can't convince me otherwise.

A is correct as it refers to the client's inability to think abstractly. B is an example of delusion and grandiosity. C is an auditory hallucination, and D describes paranoia.

A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following is the highest priority? A. Protecting the client from injury B.Determining the cause of the client's anxiety C.Ensuring that the client feels safe D.Identifying the client's coping skills.

A is correct as the greatest risk is harm to self or others. The other options are an important part of crisis intervention but not the highest priority.

A nurse is admitting a client who is in the manic phase of bipolar disorder. the nurse should recognize that it is appropriate to admit this client to which of the following? A. A private room in a quiet location on the unit B. A semi-private room with a roommate who has a similar problem C. A private room close to the nursing station D. A seclusion room until the activity level becomes more subdued

A is correct. The client could be easily overstimulated by the number of activities and people on the unit so a private room away from the nursing station is better. The private room can be used for a time-out during the day and to settle down at night. A client with the same problem would be too stimulating for both of them. Legal and ethical guidelines require the least restrictive setting. Seclusion requires a doctor's order.

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate? A. Ask her if she has a plan to commit suicide. B. Recognize the attempt at manipulation and escort her back to her activity. C. Assist her to her room and allow her to rest before resuming activity. D. Notify her family and request a visitor to stay with her until thoughts of suicide are gone.

A is correct. The nurse should take seriously all statements regarding suicide. The other options involve not taking her statements seriously.

A nurse in a hospital is caring for a client who has agoraphobia. The nurse should evaluate that the client is making progress when the client is able to attend A. a picnic in a local park B. daily group therapy sessions C. recreational therapy in the day room. D. lunch in the hospital cafeteria with family.

A is the correct response as it demonstrates progress by attending an event outside of the hospital. B, C, and D are incorrect because the client's phobia does not concern exposure to other people.

The client who is bipolar is being discharged on lithium. The nurse understands the lithium toxicity can occur if the client A. engages in strenuous exercise. B. discontinues the drug abruptly. C. increases sodium intake. D. eats food high in tyramine.

A is the correct response. Loss of too much water and sodium with strenuous exercise can lead to lithium toxicity so the client should be instructed to make sure he replaces any water and sodium that have been lost through sweating. D/c'ing the drug abruptly or increasing sodium would cause a drop in the level. Foods high in tyramine should be avoided by those on MAOIs not lithium.

Which of the following findings should the nurse identify as a negative symptom in the client with schizophrenia? A. Affective flattening B. Bizarre behavior C. Illogicality D. Somatic delusions

A is the example of a negative symptom of schizophrenia. B, C, and D are positive symptoms of schizophrenia.

Which of the following would you recognize as manic behavior? Select all that apply. A. Talking in rapid, continuous speech B. Interacting with others in a flirtatious way C. Spending large sums of money D. Sleeping for long periods of time. E. Dressing in black or grey clothing.

A, B, and C are all correct manifestations of the manic phase of bipolar disorder. Excessive sleeping and dressing in dark clothing are manifestations of the depressive phase.

Which of the following is an expected finding for a client with major depressive disorder (MDD)? A. Significant change in weight B. Hyperexcitability C. Exaggerated response of pleasure to stimuli. D. Attention seeking behavior

A, change in weight, either loss or gain, is an expected finding with MDD. Lack of energy, vs hyperexcitability and anhedonia, vs experiencing pleasure, are expected with MDD. D is an expected finding of personality disorders, not MDD.

Which of the following statements indicates a schizophrenic client's understanding for a relapse prevention plan? A. I can remember when my hallucinations first began. B. I know which of my hallucinations trigger a relapse C. I record the number of hallucinations I have each day. D. I will read as much information as I can about schizophrenia.

B demonstrates awareness of triggers, an important component of a relapse prevention plan. A, C, and D indicate understanding of the disorder or desire to gain knowledge, but do not address relapse prevention.

A client is in the manic phase of bipolar disorder and says he is bored. Which of the following activities is appropriate for the nurse to suggest? A. Watching a video in the day room B. Walking with the nurse in the courtyard C. Participating in a basketball game in the gym D. Reading a book in his room.

B is correct as gross motor and physical activities help to expend excess energy. A and D are not appropriate as the client would likely not be able to sit quietly for these activities. Competitive games may increase anxiety and tension, and escalate hyperactivity.

A nurse is caring for a client with obsessive-compulsive disorder. Which of the following actions by the nurse is appropriate? A. Interrupt the compulsive behavior B. Investigate reasons for the behavior C. Encourage avoidance of situations that increase anxiety. D. Provide strict environment that inhibits obsessive-compulsive opportunities.

B is correct as it will help identify the underlying stress. A would lead to increased anxiety. Avoiding anxiety is not realistic. The client needs to learn positive anxiety-reducing behaviors to replace the compulsive behaviors. Strict control increases anxiety in the patient with OCD.

A nurse is developing a plan of care for the client with schizophrenia. Which of the following interventions is appropriate to include in the plan of care? A. Place in seclusion if visual hallucinations are present. B. Limit the number of questions asked during assessments. C. Provide diversion with consistent, stimulating activities. D. Directly tell the client that delusions are not real.

B is correct as minimizing questions will avoid an increase in paranoia. Seclusion would increase the severity of hallucinations. Reducing stimulation is appropriate to decrease anxiety in this patient. Negating the perception of a delusion will increase anxiety and agitation.

The client with chronic anxiety is being discharged. Which of the following should the nurse include in the discharge plan? A. Contact crisis counselor once a week B.identify anxiety-producing situations C. try to repress feelings of anxiety D. eliminate stress and anxiety from daily life.

B is correct as treatment includes helping clients recognize signs that anxiety level is rising and the triggers that cause this reaction. Crisis counselor is only contacted when needed, not a set schedule. Repression of anxiety leads to maladaptive behaviors. It is impossible to eliminate stress and anxiety from daily life.

The client with bipolar disorder states, "I feel like Superman. I can do anything. I can fly home today and then become a US Senator." Which of the following is the client A. flight of ideas B. grandiosity C. reality testing D. derealization

B is correct, as this refers to the client's beliefs that he has special abilities. A is constant disorganized speech, C refers to the client's ability to recognize and correct alterations in thinking and D refers to a client's false belief that changes in the environment are present.

A client with schizophrenia tells the nurse, "They lie about me all the time and they are trying to poison my food.." Which of the following responses is therapeutic? A. You are mistaken. Nobody is lying about you or trying to poison you. B. You seem to be having very frightening thoughts. C. Why do you think you are being lied about and poisoned? D. Who is lying and trying to poison you?

B is correct. You should avoid making statements that directly confront or affirm the delusional beliefs. Respond to the feelings the client is trying to communicate, shifting the focus from the delusional beliefs, which are not real, to the client's fear, which is real. A directly contradicts the client which could make him feel angry and misunderstood. C and D are incorrect because they support the content of the delusional thinking.

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following is an appropriate response by the nurse? A. It might help you feel better if you talk about it. B. I'll just sit here with you for a few minutes then. C. I understand. I've felt like that before, too. D. Why are you feeling so down?

B is the only therapeutic response as it involves offering self, showing caring and concern and availability if the client wants to talk. The other options are communication blocks of giving advice, false empathy, and asking for an explanation.

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following interventions are appropriate? Select all that apply. A. Avoid eye contact to prevent escalation of anxiety. B. Establish rapport with the client C. Identify the cause of the anxiety. D. Validate the client's feelings E. Develop a flexible crisis intervention plan

B, C, D - Avoiding eye contact is incorrect as it inhibits the nurse-client relationship and does not assist in establishing rapport. Establishing rapport, identifying the cause of the anxiety and validating the client's feelings are all correct. A concrete crisis intervention plan, not flexible, is necessary for this patient.

Which of the following diagnoses does the nurse identify as presenting the greatest risk for suicide? A. Premenstrual dysphoric disorder B. Seasonal affective disorder C. Recurrent brief depression D. Minor depression

C - The person with recurrent brief depression experiences periodic major depressive episodes and is at greatest risk for suicide during those times. All depressive disorders have a risk for suicide but the other 3 options are not the diagnoses with the greatest risk.

Which of the following behaviors does the nurse anticipate in a client with schizophrenia? A. Periods of elation with unusual talkativeness B. Preoccupied with folding clothes C. Invents words that have no meaning D. Recurrent thoughts of past trauma

C correctly describes a behavior of the schizophrenic patient. A describes a patient with bipolar disorder. B describes OCD. D describes PTSD.

A nurse overhears a client with schizophrenia talking to herself. The client keeps stating, "The mazukas are coming. The mazukas are coming." The nurse correctly recognizes the use of the word "mazuka" as an example of which of the following alterations in speech? A. echolalia B. clang association C. neologism D. word salad

C is correct as it describes the use of a fictitious word that has meaning only to the client. Echolalia is constant repeating of what another person is saying. Clang association is the use of words that rhyme. Word salad is the use of words that have not logical meaning with one another.

A nurse is caring for a patient with paranoid schizophrenia. Which of the following interventions should be included in the plan of care? A. rotate staff assignments for this client B. use touch to calm the client during periods of anxiety C. Remove medication from sealed packages at the client's bedside D. Assign assistive personnel to feed the client.

C is correct as it helps reduce the client's fear that the medication is poisoned. For this reason the client should also not have someone feeding them. Consistent staffing is beneficial for this type of client. Touch is not appropriate as it can cause them to misinterpret the action, leading to paranoia and/or aggression.

A nurse ic caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following nursing interventions is appropriate? A. Warn the client that further disruption will result in seclusion. B. Ignore the client's behavior, realizing it is consistent with her illness. C. Set limits on the client's behavior and be consistent in approach. D. Ask the client to recommend consequences for disruptive behavior.

C is correct as it is necessary to communicate acceptable behavior to the client and be consistent with negative consequences when the behavior plan is not followed. A does not resolve the current behavior and encourages manipulation. B does not address the needs of the client or other on the unit. D encourages manipulation.

The nurse is caring for a client with depression. He observes an improvement in the client's grooming when she comes to breakfast freshly bathed, wearing clean clothes, with combed and styled hair. Which of the following responses by the nurse is therapeutic? A. Everyone feels better after showering B. You must be feeling better. You look great! C. You look very nice after your bath and shampoo. D. Why are you all dressed up today? Is it a special occasion?

C is correct as it is open-ended and acknowledges and affirms the positive behavior. A is a non-therapeutic cliche. B is condescending, and D asks a "why" question.

The nurse is discussing with a newly licensed nurse the appropriate care for the client with bipolar disorder continuously running around the unit asking people to dance with her. Which statement indicates the new nurse understands the appropriate intervention? A. I will turn on a dance video so she can burn off excess energy. B. I will offer her a low-calorie snack if she stops the behavior. C. I will instruct her to go outside with me and sit in the garden area. D. I will observe her closely for the development of aggressive behavior.

C is correct as it removes the client from the stimulating environment and uses instruction, not bargaining, to decrease the activity level. Constant activity during mania can lead to exhaustion, so A and D are incorrect as they do not address this issue. The client needs high-calorie snacks to replenish burned calories.

Which of the following statements by a client with mood disorder indicates readiness for discharge? A. Right now, I can't bathe myself or dress myself, but I feel good about that. B. Going home will be fun, but if it isn't fun, I can always have my mother to help me. C. I will take my medicines as I should, and know to call the number you gave me if I have bad thoughts. D. Taking care of myself is important, but it's okay if I don't want to do anything.

C is correct as it verbalizes a plan for help and demonstration of care. A identifies an inability to perform ADLs, B identifies a lack of responsibility, and D identifies a lack of understanding of the importance of self-care, all of which do not support readiness for discharge.

A nurse in the emergency department is caring for a client who reports chest pain, headache, and shortness of breath. He continues to state, "I don't know why my wife left me." The client receives a diagnosis of anxiety. His findings support which level of anxiety? A. Mild B. Moderate C. Severe D. Panic

C is correct as the findings described are all associated with severe anxiety. Mild anxiety may produce more mild physical symptoms, moderate anxiety may cause a pounding heart but not the other presenting symptoms, and panic level causes the client to lose touch with reality and is associated with unintelligible speech or inability to speak.

Which of the following supports the admitting diagnosis of acute mania in the client with bipolar disorder? A. The client's spouse reports that the client has recently gained weight. B. The client is dressed in all black. C. The client responds to questions with disorganized speech. D. The client reports that voices are telling him to write a novel.

C is correct, as clients with acute mania exhibit disorganized speech such as flight of ideas. Client with acute mania typically have weight loss and typically present with bizarre, uncoordinated dress. Report of voices is typical of schizophrenia vs acute mania.

The nurse is assisting the client who has schizophrenia to develop a relapse plan. Which statement by the nurse is appropriate? A. You should be aware that excessive sleeping is an early sign of relapse. B. Relapse is an indication that you are not taking your medications properly. C. You should keep your provider's and therapist's number with you. D. Taking an additional does of medication is appropriate as soon as signs of relapse appear.

C is correct, in addition to keeping a written plan available at all times. Difficulty sleeping, vs excessive sleeping, is an early sign. Relapse can occur for several reasons and does not indicate failure on the client's part. They should not change the dosage of a medication without a prescription.

The nurse is caring for a client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse use to handle the client's ritualistic behaviors? A. Isolate the client for a period of time. B. Confront the client about the senseless nature of the ritualistic behaviors. C. Plan the client's schedule to allow time for rituals. D. Set strict limits on the behaviors so the client can conform to the unit rules and schedules.

C is correct. Adequate time to perform the rituals is necessary for the client to be able to handle anxiety in the initial phase of treatment. Isolating will not have a positive effect. Confrontation is non-therapeutic as the client is usually aware that the behaviors are excessive or unreasonable. Setting strict limits will increase anxiety in the initial phase of treatment. At some point a contract with a goal of setting limits will be

A nurse is caring for a client who has depression. After three days of treatment, the nurse notices that the client is suddenly more active and there are not longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care? A. Encourage family to take the client out of the facility for short periods of time. B. Reward the client for her change in behavior. C. Monitor the client's whereabouts at all times. D. Ask the client why her behavior is changed.

C is correct. Clients with depression who exhibit a sudden change in behavior are at risk for suicide and precautions should be included in the plan of care. Options A and B don't recognize the risk associated with this sudden change in behavior. D is asking a "why" questions which fosters a defensive reaction by the patient.

Which of the following is the most common behavioral finding among clients who have depression? A. Focus on past failures B. Slowed body movement C. Lack of energy D. Sleep disturbances.

C is seen in as many as 97% of clients with depression. A, B, and D are all seen with these clients but are not the most common findings.

A nurse is conducting a group therapy session. the group has been laughing at a story one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are all making fun of me." The nurse should be aware that the client is displaying A. flight of ideas B. delusions of grandeur C. loss of reference D. looseness of association.

C is the correct answer describing a type of delusion in which the client believes all events, situations or interactions are directly related to him. A describes rapid movement or constant flow of speech, jumping from one topic to another. B describes attaching special significance to self-stature and having exaggerated sense of importance. D is also known as derailment when ideas jump too rapidly from one unrelated topic to another.

Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors? A. The ritualistic behavior provides sexual satisfaction. B. The client performs ritualistic behavior to boost self-esteem. C. The ritualistic behavior temporarily relieves anxiety. D. The client performs ritualistic behavior to decrease feelings of shame.

C is the correct rationale for the ritualistic behavior in OCD. The behaviors may involve sexuality issues but do not have the purpose of sexual satisfaction. The behaviors typically cause the client to feel humiliation and shame, and do not raise self-esteem.

A client with schizophrenia suddenly states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate? A. You need to tell the voices to leave you alone. B. There are no voices. C. What are the voices telling you to do? D. Why do you think you are hearing the voices?

C is the correct response as it recognizes the risk involved with a command hallucination and asks the client directly about it. This is a therapeutic approach in this situation. A acknowledges the reality of the voices and encourages the client to argue with them, which is nontherapeutic. B negates the client's perception and is also nontherapeutic. D asks a "why" questions and will increase defensiveness.

The client with bipolar disorder approaches the nurse and reveals fresh, self-inflicted superficial cuts going up and down his right arm. Which of the following actions should the nurse perform first? A. Implement the client's behavioral modification plan B. Document the size and location of the cuts C. Inspect the cuts for debris. D. Administer a tetanus antitoxin.

C is the correct response based on the nursing process of assessment and Maslow's Hierarchy of safety. The other actions will be performed but are not the first action.

The nurse observes that the client with schizophrenia consistently does the opposite of what he is told. The nurse recognizes this as which of the following alterations in behavior? A. automatic obedience B. waxy flexibility C. negativism D. impaired impulse control

C is the correct response. A is the performance of simple commands in a machine-like manner. B is the continuation of a posture in a statue-like manner. D is the inability to control impulses.

A nurse on an inpatient mental health unit is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority? A. Home environments B. Support systems C. Suicide risk D. Psychiatric history

C is your priority as the greatest risk to the safety of this client is self-harm. Home environment, support systems and psych history are important but not your priority.

The client with schizophrenia states, "The government is forcing thoughts into my brain through satellites." the nurse should document that the client is experiencing which of the following types of delusions? A. Persecution B. Control C. Erotomanic D. Somatic

Clients with control delusions believe others are trying to control them, so B is correct. A means the person believes others are trying to harm him. C means the person believes someone desires a romantic relationship with him and D believes his body is undergoing unusual or unnatural changes.

The nurse is caring for a new client who exhibits signs of a major depressive episode. The provider states that she wants to rule out medical conditions which could also be linked to the findings. The nurse should expect diagnostic testing for which of the following medical conditions? A. Pancreatitis B. Cholecystitis C. Tuberculosis D. Hypothyroidism

D - Expected findings of hypothyroidism including changes in weight, sleep disturbances, decreased energy and changes in thought process mimic those of a major depressive episode. The other options do not not mimic those symptoms.

A nurse in the psychiatric unit is caring for a client with moderate anxiety disorder. Which measures should the nurse include in the immediate plan of care? A. Circumvent a discussion about concerns. B. Remain near the client C. Encourage the client to sit for a while D. Foresee anxiety-provoking circumstances

D expresses the importance of foreseeing these circumstances to avoid escalation of anxiety. Open communication, not circumventing a discussion is best. Remain with the client when severe, not mild to moderate anxiety exists. Working off excess energy, vs sitting, will help in this situation.

The nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse suspects the client is suffering from post-traumatic stress disorder when he states A. A check any room I enter because the enemy is still after me and could be hiding anywhere B. My child was born with a birth defect I believe is due to an exposure I had overseas. C. I killed four enemy soldiers with my bare hands and saved my entire battalion. D. In my dreams, all I can see are the wounded reaching out and trying to grab me.

D is a correct description of PTSD where the patient repeatedly re-experiences the ordeal in flashbacks, dreams, nightmares or frightening thoughts, esp. when exposed to events or objects reminiscent of the trauma. A describes a paranoid statement not characteristic of PTSD. B is not characteristic of PTSD. C is a grandiose statement more characteristic of bipolar-manic phase.

The client with bipolar in the psychiatric unit comes to the nurses' station at 0300 demanding that the nurse call the provider immediately. Which is the nurse's most appropriate response? A. You are being very unreasonable and I will not call your doctor at this hour. B. Go back to your room and I'll try to get in touch with your doctor. C. I can't call the doctor in the middle of the night unless it's an emergency. D. You must be very upset about something.

D is correct as it shows empathy and allows for further communication and clarification by the client. A, B, and C are examples of communication block by either showing disapproval, putting the client's feelings on hold, or focusing on an inappropriate issue, respectively.

The client exhibiting manic behavior reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action? A. Identifying support systems. B. Assisting the client in identifying coping behaviors C. Encouraging self-care. D. Preventing self-directed violence.

D is correct as prevention of injury addresses the greatest safety risk so is the priority. The other responses are important but don't address the greatest safety risk so are not the priority.

The client with obsessive compulsive disorder (OCD) is constantly picking up after others in the day room. The nurse recognizes the client uses this behavior to do which of the following? A. Limit the amount of time available to interact with others. B. focus attention on meaningful tasks. C. manipulate and control others' behaviors. D. decrease anxiety to a tolerable level.

D is correct, as those with OCD reduce anxiety using compulsive rituals. A is not the etiology of OCD. The repetitive rituals commonly involve meaningless tasks. C describes those with personality disorders, not OCD.

The nurse is assessing a client whose adult daughter states has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse anticipates planning care for managing which of the following phobias?' A. Xenophobia B. Acrophobia C. Mysophobia D. Agoraphobia

D is correct. A = fear of strangers, B=fear of heights, and C= Fear of dirt or germs

Which of the following is an expected finding in the client with posttraumatic stress disorder following a sexual assault? A. Sleeping 12 hours or more each day B. Increasing sense of attachment to others C. constant need to talk about the event D. increasing feelings of anger

D is correct. Anger and irritability are findings associated with PTSD. Insomnia, not excessive sleeping is common, along with detachment and avoidance of relationships. Avoidance of discussing the event is also associated with PTSD.

A nurse is completing an admission assessment for a client who has depression. Findings include an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following is an appropriate intervention to include in the plan of care? A. Discourage rest only at bedtime B. Instruct family to avoid visiting during mealtimes C. Offer frequent low calorie snacks D. Develop a structured routine for the client to follow

D is the best option. This client needs to balance rest and activity since fatigue can increase depression. The family should be encouraged to be present at mealtimes to reinforce caring and self-esteem. Frequent high calorie snacks should be offered as this client is at risk for inadequate intake.

The client with anxiety has a prescription for alprazolam (Xanax) 0.25mg PO every 8 hr. PRN anxiety. Which of the following is an appropriate situation to administer alprazolam to this client? A. The client states, "I see purple bugs crawling on the wall." B. The client describes an increase in pain after receiving meperidine (Demerol). C. The client pretends to be a government agent. D. The client states, "My heart is pounding out of my chest."

D is the correct response as alprazolam is a benzodiazepine which decreases the severity of panic attacks, anxiety and insomnia. A describes hallucinations and C describes delusions of grandeur, both of which are treated with antipsychotic medications, not anxiolytics. While pain can cause anxiety and anxiety can increase pain, unless the nurse notes symptoms of anxiety he should administer a pain med or notify the MD.

The depressed client refuses to participate in group therapy or perform ADLs. Which statement by the nurse is appropriate? A. I will assist you in getting out of bed and getting dressed. B. You can remain in bed until you feel well enough to join the milieu. C. The unit rules state you may not remain in bed. D. If you don't participate in your care, you will not get better.

Meeting physiologic and basic needs directly is best, so A is correct. B is a communication block of ignoring basic needs. C focuses on the rules instead of the client. D is threatening.

Which of the following is an expected finding in the client with a diagnosis of conversion disorder? A. Frequent manic episodes B. Refusal of medication due to paranoia C. constant desire to talk about personal emotions D. involuntary loss of a sensory function

Option D is correct as this is a finding with conversion disorder. Depression, not mania, is a finding associated with conversion disorder, as is medication seeking behavior/dependence. This patient also has the inability to communicate emotional feelings.

A nurse at a walk-in mental health clinic is assessing a client. The client says, "My dad is in town. I am physically ill, haven't been able to sleep, can't concentrate, and have diarrhea, a headache and palpitations. I had to have my husband drive me here today because I didn't trust myself behind the wheel. I was afraid to even come. I just know something bad will happen. My dad can read my thoughts." The nurse should assess the client's anxiety level to be A. mild B. moderate C. severe D. panic

Option D is correct. This scenario describes the panic level of anxiety, highly disorganized, hyperactive and agitated, with somatic symptoms. With mild anxiety, the client has heightened sense of alertness and is able to concentrate. With moderate anxiety the perceptual field narrows but with help the client is able to cope. With severe anxiety, the perceptual field is scattered and the client can't focus on anything except relieving the anxiety.

A nurse in an acute mental health facility is caring for a client receiving treatment for anxiety. The client begins continuous pacing at a rapid rate. Which of the following interventions is most appropriate? A. Instruct her to sit down and quit pacing. B. Take the client to a quiet area C. Administer a PRN anti-anxiety medication D. Talk calmly to the client.

The least restrictive intervention is D, talk calmly to attempt to verbally deescalate the client's behavior. The other options would assist the client but are not the least restrictive.

The client with schizophrenia states he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? A. Command hallucination B. Gustatory hallucination C. Automatic obedience. D. Negativism

The situation describes command hallucination, so A is correct. Gustatory is when the client experiences a taste that is not actually present. C refers to the machine-like performance of simple commands in an otherwise unresponsive client. Negativism is when the client does exactly the opposite of what he is instructed to do.

The nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following is the priority intervention? A. Discuss alternative coping strategies with the client. B. Identify precipitating factors for ritualistic behaviors C. Instruct the client on relaxation techniques for use when anxiety increases D. Provide a structured activity schedule for the client.

Using the nursing process, B is the correct response as it gathers more data about the client. Then the other options can be addressed.