Mental Health Disorders and Addictions
A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 2 years 6 years 6 months 1 to 3 months
2 years By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.
The nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? Being physically immobile Sobbing for no apparent reason Reporting great difficulties falling asleep Startling easily to loud noises and being touched
Being physically immobile Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.
A client is admitted to the mental health hospital with the diagnosis of major depression. What is a common problem that clients experience with this diagnosis? Loss of faith in God Visual hallucinations Decreased social interaction Feelings about the future are absent
Decreased social interaction Depressed clients demonstrate decreased social interaction because of a lack of psychic or physical energy. They tend to withdraw, speak in monosyllables, and avoid contact with others. Loss of faith and visual hallucinations are not commonly associated with the diagnosis of major depression. Hallucinations are associated with schizophrenic disorders. Depressed clients are commonly negative and pessimistic, especially regarding their future.
Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing? Illusion Delusion Confabulation Hallucination
Delusion A delusion is a fixed false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client's attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.
A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? Depressed mood Paranoia Euphoria Satisfaction
Depressed mood A sense of being out of control accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one's self. Paranoia is associated with paranoid schizophrenia, not with bulimia nervosa. After bingeing, a person with bulimia nervosa usually feels depressed rather than euphoric or satisfied and an awareness that the eating pattern is abnormal.
A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? Chronic confusion Disordered thinking Defined personal boundaries Violence directed toward others
Disordered thinking The schizophrenic individual has neurobiological changes that cause disorders in thought process and perceiving reality. Chronic confusion and disorientation are not usually associated with this disorder. Illogical thinking and impaired judgment are associated with schizophrenia. Individuals with the diagnosis of schizophrenia often have personal boundary difficulties. They lack a sense of where their bodies end in relation to where others begin. Loss of ego boundaries can result in depersonalization and derealization. Most clients with schizophrenic disorders are not violent.
A client arrives at the mental health clinic complaining about feelings of extreme terror when attempting to ride in an elevator and feelings of uneasiness in large crowds. He reports that these fears are interfering with his concentration at work. What does the nurse identify as the source of these symptoms? Conflict with society, resulting in an obsession Depression about life events, resulting in unreasonable fears Generalized anxiety about conflicts, resulting in unreasonable fears Repression of a terrifying incident in an elevator, resulting in a phobia
Generalized anxiety about conflicts, resulting in unreasonable fears Phobias are specific fears that often serve as a means of coping with generalized anxiety. Conflicts with society do not result in phobias. Although depression is related to phobias, finding a direct connection to life events is difficult. Repression of a terrifying incident in an elevator does not result in a phobia. Repression is utilized as a coping mechanism to protect the client's conscious mind from thoughts or events that will cause them anxiety.
What is the prognosis for a normal, productive life for a child with autism? Dependent on an early diagnosis Often related to the child's overall temperament Ensured as long as the child attends a school tailored to meet needs Guarded because of interference with so many parameters of function
Guarded because of interference with so many parameters of function Research studies have shown that the prognosis for normal, productive function in autistic people is guarded, particularly if there are delays in language development. Accurate diagnosis and early interventions have not been shown to promote a normal, productive life; however, early intervention may help individuals maximize their abilities. Although temperament may affect the child's response to treatment, it does not affect prognosis to any extent. Stating that success is ensured as long as the child attends a school tailored to meet needs is false reassurance and is not helpful.
A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? Crying Self-mutilation Immobile posturing Repetitive activities
Immobile posturing Clients with catatonia exhibit rigidity and posturing behaviors. Most clients with catatonic schizophrenia are unable to express feelings. Self-mutilation is associated with depression. Repetitive activities are associated with obsessive-compulsive disorders.
A child would be demonstrating outwardly focused anger or aggression in an overt manner when engaging in which behavior? Dominating a class discussion Intentionally forgetting to do homework Scribbling on a classmate's art assignment Crying when told he or she must wait his or her tur
Scribbling on a classmate's art assignment Overt anger is demonstrated obviously or in an unconcealed manner that is hurtful, such as in damaging the artwork of another student. Examples of passive outwardly focused anger would be in dominating conversations or intentionally forgetting to do something that is required. Crying is a demonstration of inwardly focused anger that is objectively displayed.
A 5-foot 5-inch (165 cm) 15-year-old girl who weighs 80 lb (36.3 kg) is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes what factor as the most likely cause of her problem? A desire to control her life The wish to be accepted by her peers The media's emphasis on the beauty of thinness A delusion in which she believes that she must be thin
A desire to control her life Eating and weight loss become the means of control to decrease anxiety related to perfectionist thinking. Controlling one's self within the family seems to be more important than peer group acceptance. Although it is true that the media celebrates thinness, the response of the client with anorexia nervosa falls outside the usual range. Although fear of weight gain in the client with anorexia nervosa sometimes reaches delusional proportions, it is based on a belief that being fat is the problem that must be controlled.
The practitioner prescribes a diet high in vitamin B 1 (thiamine) for a client with a long history of alcohol abuse. The nurse concludes that the client understands the teaching about foods high in thiamine when the client makes which statement? "I'll choose fish, aged cheese, and breads." "I'll choose lean beef, organ meat, and nuts." "I'll choose poultry, milk products, and eggs." "I'll choose green vegetables, lentils, and citrus fruits."
"I'll choose lean beef, organ meat, and nuts." Lean beef, organ meats, and nuts all provide high levels of thiamine; other sources include legumes, whole and enriched grains, and lean pork. Of fish, aged cheese, and bread, only fish is considered a source of thiamine. Of poultry, milk products, and eggs, only eggs are considered a source of thiamine; this list contains sources of protein. Of green vegetables, lentils, and citrus fruits, only lentils (legumes) are considered a source of thiamine; most vegetables contain only traces of thiamine, and citrus fruits provide vitamin C.
A female accountant comes to the health clinic for a preemployment physical. During the health history the new employee frequently states, "I feel so nervous about starting this job." She is able to connect with her feelings, thoughts, and actions but constantly focuses her attention on starting the new job. What does the nurse determine that the client is exhibiting? A moderate level of job-related anxiety A severe level of anxiety related to new situations An inappropriate response to handling new situations An ineffective coping mechanism in handling job-related stress
A moderate level of job-related anxiety The ability to connect feelings, thoughts, and actions, plus inattention to all but the anxiety-causing subject, is associated with a moderate level of anxiety. Severe anxiety is related to dissociation, selective inattention, and an inability to connect feelings, thoughts, and actions. The development of mild or moderate anxiety is common in new situations because of apprehension related to the unknown. There is insufficient information for the nurse to come to the conclusion that the client is exhibiting an ineffective coping mechanism in handling job-related stress.
A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism? Daily administration of disulfiram Individual or group psychotherapy Admission to an alcoholic unit in a hospital Active membership in Alcoholics Anonymous
Active membership in Alcoholics Anonymous Members find empathy, patience, and understanding in Alcoholics Anonymous (AA). They are able to have their dependence needs met while helping others who are even more dependent. Individual or group psychotherapy is helpful, but it does not have the success rate of AA. Admission to an alcoholic unit in a hospital is important for the detoxification stage, not for overall therapy. Daily administration of disulfiram may be helpful for some clients, but it does not have the success rate of AA.
Clients with eating disorders often exhibit similar symptoms. What should the nurse expect an adolescent with anorexia nervosa to exhibit? Affective instability Repetitive motor mechanisms Depersonalization and derealization Disheveled and unkempt physical appearance
Affective instability Individuals with anorexia often display irritability, hostility, and a depressed mood. Repetitive motor mechanisms are associated with autism. Depersonalization and derealization are associated with individuals with schizophrenia. Clients with eating disorders are usually meticulous about dress and physical appearance; a disheveled appearance is associated with dementia or depression.
A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? Slow pulse, mild weight loss, and alopecia Compulsive behaviors, excessive fears, and nausea Amenorrhea, excessive weight loss, and abdominal distention Excessive activity, memory lapses, and an increase in the pulse rate
Amenorrhea, excessive weight loss, and abdominal distention In anorexia nervosa, weight loss is excessive (15% of expected weight); nutritional deficiencies result in amenorrhea and a distended abdomen. Although pulse irregularities and alopecia are associated with anorexia, weight loss is excessive, not mild. Although compulsive behaviors are common, excessive fears and nausea are not associated with anorexia nervosa. Memory lapses are not associated with anorexia nervosa; excessive exercising and pulse irregularities are.
What are the "four As" for which nurses should assess clients with suspected Alzheimer disease? Amnesia, apraxia, agnosia, aphasia Avoidance, aloofness, asocial, asexual Autism, loose association, apathy, affect Aggressive, amoral, ambivalent, attractive
Amnesia, apraxia, agnosia, aphasia Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposeful movements (apraxia), and comprehension of visual, auditory, and other sensations (agnosia). Avoidance, aloofness, asocial, and asexual are characteristics of the schizoid personality. Autism, loose association, apathy, and affect are characteristics of schizophrenia. Aggressive, amoral, ambivalent, and attractive are characteristics of an antisocial personality.
A young adolescent is found to have anorexia nervosa. What does the nurse understand probably precipitated the anorexia nervosa? The acting out of aggressive impulses, resulting in feelings of hopelessness An unconscious wish to punish a parent who tries to dominate the adolescent's life The inability to deal with being the center of attention in the family and a desire for independence An inaccurate perception of hunger stimuli and a struggle between dependence and independence
An inaccurate perception of hunger stimuli and a struggle between dependence and independence Inaccurate perception of hunger stimuli and a struggle between dependence and independence are theoretical explanations for the development of anorexia nervosa[1][2]. Acting-out and the wish to punish a domineering parent do not play a role in the development of anorexia nervosa. The inability to be the center the family's attention has not been correlated with anorexia nervosa.
What is a major recognizable difference between anorexia nervosa clients and bulimia nervosa clients? Anorexia nervosa clients tend to be more extroverted than clients with bulimia. Anorexia nervosa clients seek intimate relationships, whereas clients with bulimia avoid them. Anorexia nervosa clients are at greater risk for fluid and electrolyte imbalances than are clients with bulimia. Anorexia nervosa clients deny the problem, whereas clients with bulimia generally recognize that their eating pattern is abnormal.
Anorexia nervosa clients deny the problem, whereas clients with bulimia generally recognize that their eating pattern is abnormal. The client with anorexia nervosa denies the illness; the client with bulimia nervosa hides the behavior because she recognizes that the behavior is a problem. Clients with anorexia nervosa are more introverted and tend to avoid relationships. Clients with bulimia are at a greater risk for fluid and electrolyte problems because of the purging; clients with anorexia nervosa are at greater risk for severe nutritional deficiencies.
A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing? Fixed delusion Magical thought Pathological regression Command hallucination
Command hallucination Command hallucinations are auditory hallucinations that give verbal messages to do harm either to the self or others; giving an identity to the hallucinated voice increases the risk of compliance. A delusion is a false belief held to be true even with evidence to the contrary. In magical thinking, the individual believes that thinking about something can make it happen. Magical thinking is common in young children. The data do not indicate that the client has regressed to a prior level of development.
An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. What specific outcome criterion is unique to adolescents with this problem? Increased impulse control Identification of two positive personal attributes Demonstration of respect for the rights of others Age-appropriate play activities with at least one peer
Demonstration of respect for the rights of others Demonstrating respect for the rights of others is a specific outcome criterion for children with a risk for violence directed at others; children with the diagnosis of conduct disorder typically present with a repetitive and persistent pattern of behavior that violates the basic rights of others or major age-appropriate societal norms or rules. Increased impulse control is a short-term goal for children with a variety of mental disorders of childhood such as attention deficit-hyperactivity disorder and oppositional defiant disorder. Identifying two positive personal attributes is a short-term goal for children who have disturbed self-esteem. Using age-appropriate play activities with at least one peer is a short-term goal for children who have impaired social interaction.
What characteristic of an adolescent girl suggests to the nurse that she has bulimia? History of gastritis Positive self-concept Excessively stained teeth Frequent re-swallowing of food
Excessively stained teeth Dental enamel erosion occurs with repeated self-induced vomiting. History of gastritis is not associated with bulimia. Often body image is disturbed and there is low self-esteem. Habitual regurgitation of small amounts of undigested food (rumination) and re-swallowing of food are not associated with bulimia; emptying of the stomach contents through the mouth (vomiting) is associated with bulimia
A nurse plans to give greater responsibility for self-control to clients with a long history of alcohol abuse who are about to enter a detoxification program. What should the nurse plan to do? Tell them about the detoxification program. Help them adopt more healthful coping patterns. Confront them with their history of substance abuse. Administer their medications in accordance with the prescribed schedule.
Help them adopt more healthful coping patterns The client must learn to develop and use more healthful coping mechanisms if drinking is to be stopped; the responsibility lies with the client because the client must do the changing. Telling the clients about the detoxification program will tell them what to expect but will not instill responsibility for change. Confronting them with their history of substance abuse will place clients on the defensive; it usually does not foster the development of a trusting relationship. Medications may decrease withdrawal symptoms, but they do not provide the motivation for change; this must come from within.
A nurse working on a substance abuse unit knows that the individual uses opioids most commonly for what reason? Desires independence Is trying to reduce stress Wants to fit in with the peer group Enjoys the social interrelationships that occur
Is trying to reduce stress Individuals often take drugs because they cannot deal with the pain of reality; the drug blurs the pain and reduces anxiety. Drugs increase dependency rather than foster independence. Although the individual wanting to fit in with the peer encourages initial use by some adolescents, it is not the most common reason for opioid use. The use of drugs fosters social isolation.
Clients addicted to alcohol often use the defense mechanism of denial. What is the reason that this defense is so often used? It reduces their feelings of guilt. It creates the appearance of independence. It helps them live up to others' expectations. It makes them look better in the eyes of others.
It reduces their feelings of guilt. Alcoholic clients often use denial as a defense against feelings of guilt; this reduces anxiety and protects the self. Denial may make a client seem more stable to others, not independent. Denial deals more with a client's own expectations. Looking better in the eyes of others may be part of the reason, but the bigger motivating factor is to ease guilt feelings.
A client is admitted to an alcohol rehabilitation center. On the fourth day after admission, the nurse detects a strong odor of alcohol on the client's breath. What is the nurse's first action? Asking where the client got the alcohol Locating and removing the alcoholic substance Conveying the staff's disappointment in this behavior Documenting and notifying the practitioner of the client's drinking
Locating and removing the alcoholic substance The nurse should remove the substance before the client or other clients have an opportunity to consume more alcohol. The primary concern is not where the alcohol was obtained but instead protecting the client from consuming more. Making the client feel guilty could increase the desire for more alcohol. The client may drink the remaining alcohol while the nurse documents the information and notifies the practitioner.
During an interview a 32-year-old man describes symptoms of decreased appetite, insomnia, anhedonia, and feelings of worthlessness that have been present for the past few weeks. He reports having had a few episodes of feeling depressed in the past but says that the feelings subsided. Recently he has felt worse, and he is now concerned that his symptoms are negatively affecting his job performance and fears he may lose his job "if someone doesn't help me soon." The nurse suspects these symptoms are related to which disorder? Schizophrenia Bipolar disorder Dysthymic disorder Major depressive disorder
Major depressive disorder The client is describing symptoms of major depressive disorder. Symptoms include depression that has lasted at least 2 weeks, that has resulted in a change in previous function, and that can impair important areas of function such as work performance. The client does not describe feeling depressed for most of his life. There are no symptoms of paranoia or psychosis that would be present in schizophrenia. For bipolar disorder to be considered, symptoms of mania would need to be included in the findings. With dysthymic disorder, depressive symptoms are chronic and present for 2 years or longer. Because of its chronic nature, dysthymia is difficult to distinguish from the person's usual pattern of function.
What should the nurse teach parents about childhood depression? May appear as acting-out behavior Looks almost identical to adult depression Does not respond to conventional treatment Is short in duration and has an early resolution
May appear as acting-out behavior Children have difficulty verbally expressing their feelings; acting-out behaviors, such as temper tantrums, may indicate an underlying depression. Many conventional therapies for adults with depression, including medication, are effective for children with depression. Adult and childhood depression may be manifested in different ways. Childhood depression is not necessarily short and requires treatment.
A nurse is caring for a client with the diagnosis of bulimia nervosa. What does the nurse understand to be the function of food for individuals with bulimia? Gain attention Control others Avoid growing up Meet emotional needs
Meet emotional needs Clients with bulimia[1][2] eat to blunt emotional pain because they frequently feel unloved, inadequate, or unworthy; purging is precipitated to relieve feelings of guilt for bingeing or out of fear of obesity. The bingeing and purging are usually done alone and in secret. Clients with bulimia often feel out of control and perform their behaviors in secret. A protest against growing up is one of the psychodynamic theories regarding anorexia nervosa, not to bulimia nervosa.
A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? Mild Panic Severe Moderate
Mild A person with mild anxiety has a broad perceptual field and increased problem-solving abilities. Panic is characterized by a completely disruptive perceptual field. With severe anxiety, the perceptual field is reduced, as is the ability to focus on details. A moderately anxious person shuts out peripheral events and focuses on central concerns but has a decreased ability to problem solve.
An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? Mild Panic Severe Moderate
Moderate The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety. Mild anxiety is the level at which the individual is cognizant of all aspects of reality but has a "jumpy feeling" and "butterflies in the stomach." Panic is the level at which the individual is no longer in contact with reality, is unable to make decisions, has impaired judgment, and is dysfunctional. Severe anxiety is the level at which individuals lose touch with reality and have a feeling of impending doom, which tends to immobilize them.
What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol? Motivational readiness Availability of community resources Accepting attitude in the client's family Qualitative level of the client's physical state
Motivational readiness Intrinsic motivation, stimulated from within the learner, is essential if rehabilitation is to be successful. Often clients are most emotionally ready for help when they have "hit bottom." Only then are they ready to face reality and put forth the necessary energy and effort to change behavior. The availability of community resources and the qualitative level of the client's physical state are important factors, but neither is the most important one. An accepting attitude on the part of the client's family is an important factor and a helpful one, but not the most important one.
During an assessment interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing? Insomnia Narcolepsy Sleep terror Sleep apnea
Narcolepsy Narcolepsy is overwhelming sleepiness that results in irresistible attacks of sleep, loss of muscle tone (cataplexy), and hallucinations or sleep paralysis at the beginning or end of sleep episodes; the person usually awakens from the sleep feeling refreshed. Insomnia is difficulty initiating or maintaining sleep. Sleep terrors are recurrent episodes of abrupt awakening from sleep accompanied by intense fear, screaming, tachycardia, tachypnea, and diaphoresis with no detailed dream recall. Sleep apnea is a breathing-related sleep disorder caused by disrupted respirations or airway obstruction; sleep is disrupted numerous times throughout the night.
A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" What does the nurse determine that the client is exhibiting? Echolalia Neologism Concretism Perseveration
Neologism Neologisms are words that are invented and understood only by the person using them. Echolalia is the verbal repeating of exactly what is heard. Concretism is a pattern of speech characterized by the absence of abstractions or generalizations. Perseveration is a disturbed system of thinking manifested by repetitive verbalizations or motions or by persistent repetition of the same idea in response to different questions.
A mother brings her 5-year-old daughter to the children's clinic after teachers report that the girl is disobedient and hostile. The child has a negative attitude and argues often with her teachers. At this time she has not violated the rights of other students. The mother reports that she has also noticed this behavior at home. The nurse suspects that the behavior described is associated with what disorder? Anxiety disorder Conduct disorder Major depressive disorder Oppositional defiant disorder
Oppositional defiant disorder Oppositional defiant disorder usually becomes evident before 8 years of age. Affected children do not violate the rights of others. They do not see themselves as defiant but feel that they are responding to unreasonable demands or situations. Children who are anxious or depressed may exhibit some disobedience during the school day but do not exhibit the argumentative and hostile behavior pattern seen with oppositional defiant disorder. Conduct disorder is characterized by a pattern of behavior in which the rights of others and social norms or rules are violated. There is a lack of guilt or remorse for inappropriate behavior, and blame is placed on others.
A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? Ideas of grandeur Confusing illusions Persecutory delusions Auditory hallucinations
Persecutory delusions The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.
What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit? Projection Regression Repression Rationalization
Regression Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid type, in which the delusional system is well systematized. Repression, or unconscious forgetting, is not a major defense used by clients with schizophrenia; if it were, they would not need to break with reality. Rationalization, in which the individual blames others for problems and attempts to justify actions, is seldom used by clients with schizophrenia.
A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When the client sets outcomes, what need is it important for him to understand? Plan to avoid people who drink. Accept that he is a fragile person. Develop new social drinking skills. Restructure his life without alcohol.
Restructure his life without alcohol. Clients must learn new lifestyles and coping skills[1][2] to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option.
A client who has been experiencing excessive stress is hospitalized because of an inability to walk. After a physiologic cause for the problem is ruled out, a diagnosis of somatoform disorder, conversion type, is made. What does the nurse conclude is the cause of the client's paralysis? Nondisabling illness Way to get attention Loss of contact with reality Result of intrapsychic conflict
Result of intrapsychic conflict In situations in which a client may experience a high level of anxiety and psychic pain, a physical reason for not acting may unconsciously be used to limit negative feelings. Somatoform disorders are disabling; the client truly believes that the symptoms are real. These individuals do not enjoy their illness; their anxiety is relieved by it. These individuals are in contact with reality.
While a nurse is assisting with morning care for a client with the diagnosis of schizophrenia, the client suddenly throws off the covers and starts shouting, "My body is disintegrating! I'm being pinched." What term best describes the client's behavior? Somatic delusion Paranoid ideation Loose association Ideas of reference
Somatic delusion A somatic delusion is a false feeling about the physical self that is caused by a loss of reality testing. Paranoid ideations are beliefs that the individual is being singled out for unfair treatment. Loose associations are verbalizations that are difficult to understand because the links between thoughts are not apparent. Ideas of reference are false beliefs that the words and actions of others are concerned with or are directed toward the individual.
What is a priority nursing intervention in the care of a drug-dependent mother and infant? Supporting the mother's positive responses toward her infant Requesting that family members share responsibility for infant care Keeping the infant separated from the mother until the mother is drug free Helping the mother understand that the infant's problems are a result of her drug intake
Supporting the mother's positive responses toward her infant A nurse should attempt to support the mother-child relationship; the mother is experiencing a developmental crisis while coping with drug addiction and possibly guilt. It is the client's right to decide who will share in the care of her child. The client needs contact with her new infant to facilitate bonding. Helping the mother understand that the infant's problems are a result of her drug intake will make the client feel guilty and will not facilitate positive action at this point.
A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Which data are the cause of the nurse's concern? Select all that apply. Tremors in both hands make it difficult for the client to hold a cup. The client's systolic blood pressure has dropped 6 points over last 6 hours. The client was observed falling asleep while talking on the telephone to family. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television.
Tremors in both hands make it difficult for the client to hold a cup. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television. Diaphoresis and tremors are physical characteristics of alcohol withdrawal. Agitation is a psychosocial characteristic of alcohol withdrawal. Systolic blood pressure would rise rather than fall if the client were experiencing alcohol withdrawal. Insomnia, rather than drowsiness, is a physical characteristic of alcohol withdrawal.
When planning care for a client who has just completed withdrawal from multiple-drug abuse, what reality in relation to the client should the nurse take into consideration? Unable to give up drugs Unconcerned with reality Unable to delay gratification Unaware of the danger of drug addiction
Unable to delay gratification A person with an addictive personality is unable to delay gratification; drugs help blur reality and ease frustration. Giving up drugs is possible but not easy; it requires a change in attitude and a deconditioning process. Users of drugs are concerned with reality, and their drug use is an attempt to blur the pains of reality. Intellectually these people may be aware of the dangers of drug addiction, but emotionally they cannot buy into the reality that it can happen to them.
For what most common characteristic of autism should a nurse assess a child in whom the disorder is suspected? Responds to any stimulus Responds to physical contact Unresponsiveness to the environment Interacts with children rather than adults
Unresponsiveness to the environment Poor interpersonal relationships, inappropriate behavior, and learning disabilities prevent autistic children from emotionally adapting or responding to the environment even when the intelligence level is high. It is the lack of response to stimuli that is the clue that the child may have autism. Children with autism have an aversion to physical contact; they also have impaired interpersonal relationships regardless of the age of the other person.
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? Select all that apply. Describes how others have caused the addiction Verbalizes difficulty identifying personal strengths Expresses uncertainty about meeting with the nurse Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress
Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress Looking at one's strengths in addition to areas that need growth is difficult work, and sharing this difficulty demonstrates that the client is willing to work with the nurse to address personal issues. When he is willing to address cause and effect issues of personal behavior, the client is in the working phase of a therapeutic relationship. When people in a therapeutic relationship are able to address how their behavior affects others, they are taking the first step toward taking responsibility for their actions. The use of projection is a defense from taking responsibility for the addiction; this will impair the effectiveness of a working therapeutic relationship. Ambivalence about working with the nurse usually occurs during the introductory phase of the nurse-client relationship.
A client with a history of alcohol abuse says to the nurse, "Drinking is a way out of my depression." Which strategy will probably be most effective for the client at this time? A self-help group Psychoanalytical therapy A visit with a religious advisor Talking with an alcoholic friend
A self-help group Members of self-help groups, particularly Alcoholics Anonymous, are living with the problem themselves; therefore problem identification and self-responsibility are emphasized, and manipulation is limited. Long-term therapy tends to increase anxiety until resolution occurs; level of commitment and duration of therapy render it a less desirable choice for substance abusers. Depending on the client's feelings about religion, talking with a religious advisor may or may not be helpful. Whether talking with an alcoholic friend will be useful depends on the friend's drinking status; it may be helpful or harmful. These variables negate the effectiveness of this choice.
On the third day of hospitalization, a client with a history of heavy drinking begins experiencing delirium alcohol withdrawal syndrome. What is the most appropriate response by the nurse when the client begins experiencing hallucinations? Withholding intervention, because the client may be having vivid dreams Asking the client to describe the hallucinations and explaining that they are not real Administering the prescribed medication to the client to subdue the agitated behavior Pretending to visualize the imaginary things the client is describing to foster acceptance
Administering the prescribed medication to the client to subdue the agitated behavior The nurse must administer the prescribed medication to the client to subdue the agitated behavior in this life-threatening situation. The client's central nervous system (CNS) is overstimulated, and seizures and death can occur. CNS-depressant medications, usually benzodiazepines, are needed to blunt the withdrawal effects. The client needs intervention because the hallucinations are not dreams. Focusing on the sensations associated with the withdrawal syndrome is not therapeutic; it is not helpful to tell the client that the hallucinations are not real, because they are real to the client. Validation reinforces the client's distorted perceptions of reality, is not helpful, and may be unsafe.
A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test? "Do you feel that you are a normal drinker?" "Have you ever felt bad or guilty about your drinking?" "Are you always able to stop drinking when you want to?" "How often did you have a drink containing alcohol in the past year?"
"Have you ever felt bad or guilty about your drinking?" The CAGE screening test for alcoholism contains four questions, corresponding to the letters CAGE: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (as an " Eye-opener") to steady your nerves or get rid of a hangover? "How often did you have a drink containing alcohol in the past year?" is one of the 10 questions on the Alcohol Use Disorders Identification Test (AUDIT). "Do you feel that you are a normal drinker?" and "Are you always able to stop drinking when you want to?" are two of the 26 questions on the Michigan Alcohol Screening Test (MAST).
A nurse in an outpatient mental health setting has been assigned to care for a new client who has been found to have an antisocial personality disorder. What does the nurse expect to observe in the client during the assessment? Pays great attention to detail and demonstrates a high level of anxiety Has scars from self-mutilation and a history of many negative relationships Displays charm, has an above-average intelligence, and tends to manipulate others Demonstrates suspiciousness, avoids eye contact, and engages in limited conversation
Displays charm, has an above-average intelligence, and tends to manipulate others A client with an antisocial personality disorder is charming on first contact, but this charm is a manipulative ploy. These clients usually are bright and use their intelligence for self-gain. Paying great attention to detail and demonstrating a high level of anxiety are traits of an individual with an obsessive-compulsive personality disorder. The client with a borderline personality disorder self-mutilates when under stress; there is a fear of abandonment so that any relationship is better than no relationship. Demonstrating suspiciousness, avoiding eye contact, and engaging in limited conversation resembles the behavior of an individual with a paranoid personality, which includes suspiciousness and lack of trust.
A nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? Strong desire to improve her body image Close, supportive mother-daughter relationship Satisfaction with and desire to maintain her current weight Low level of achievement in school and little concern for grades
Strong desire to improve her body image Clients with anorexia nervosa[1][2] have a disturbed self-image and always see themselves as fat and needing further weight loss. The mother-daughter relationship is usually not supportive; it is disturbed. Usually there is dissatisfaction with one's weight and a desire to lose more. Usually the client is a high achiever who is concerned about grades.
A nurse is working with clients with a variety of eating disorders. Which characteristic unique to bulimia nervosa differentiates this disorder from anorexia nervosa? The client is obese and attempting to lose weight. The client behaves appropriately and looks normal. The client has a distorted body image and sees the body as fat. The client is struggling with a conflict of dependence versus independence.
The client behaves appropriately and looks normal. Bulimic clients hide much of their bingeing and purging behaviors and, unlike clients with anorexia, may have near-ideal body weights. Clients with bulimia nervosa[1][2] are usually not obese. Distorted body image and conflict of dependence versus independence are associated with both anorexic and bulimic clients.
