Mental Health Exam 1 Prep-U Ch's 2, 5, 6, 7, 8, 10, 13, 14, 15, 16, 17, 18, 20, 24

A client with bipolar disorder is receiving lithium therapy. The nurse is reviewing the client's serum plasma drug levels and determines that the client's level is therapeutic based on what?

1.0 mEq/L

A nurse is preparing to document information obtained from a client diagnosed with a delusional disorder who is experiencing somatic delusions. Which would the nurse most likely document?

Body complaints

Which sleep pattern is suggestive of a manic episode?

A client stays awake for several days and nights before "crashing" and sleeping for a long period.

Which clinical situation provides an example of transference?

A female client with a history of sexual abuse exhibits a profound mistrust of male caregivers.

Clients diagnosed with myasthenia gravis have a decrease in which receptor?

Acetylcholine

Which diagnosis is associated with a pervasive disregard for and violation of the rights of others? Antisocial personality Borderline personality Passive-aggressive personality Schizoid personality

Antisocial personality Explanation: Antisocial personality disorder is characterized by a disregard for and violation of the rights of others. Antisocial personality disorder is a common diagnosis for those in prison and jails.

The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which would be the priority assessment at this time?

Asking whether the client often feels cold.

Which ethical principle is related to the idea of self-determination?

Autonomy

The nurse is assessing a client with anxiety. What symptom indicates that the the client has adopted a maladaptive behavior in response to stress?

Headache

A nurse is conducting an interview with a psychiatric-mental health client and notices the client is using made-up words. This is known as what?

Neologisms

The causes of anxiety disorders can be best explained by what?

Neurobiologic vulnerabilities and perception of psychosocial stress

Which is not a goal of the working phase of the therapeutic relationship?

Reducing the client's anxieties

Which would be the priority diagnosis for the client in the manic phase of bipolar disorder who is exhibiting aggressive behavior?

Risk for other-directed violence

A college student who was the victim of an attempted sexual assault has sought care due to anxiety that is affecting every aspect of the client's life. Which characteristic of the client's situation and the client's anxiety would suggest a diagnosis of posttraumatic stress disorder (PTSD) rather than acute stress disorder?

The attack took place several months ago, and the client's anxiety has been continuous.

The nurse assesses a client with a history of bipolar disorder. The client tells the nurse that that an intelligence agency has surveillance equipment set up in the client's bathroom. The nurse is observing which thought process or content?

delusional thinking

A nurse shows client advocacy by:

offering a hospice consultation to a client who is terminally ill.

Which statement is the most empathic response to a client's disclosure that the client's father abandoned the family when the client was a young child?

"That must have been terribly hurtful experience for you."

Which statement by the nurse demonstrates an understanding of the role automatisms have in a panic attack?

"The client taps her fingers very rapidly when she is feeling anxious."

A nurse is assessing risk for trauma and stress-related disorders for a child. Which areas are important for the nurse to ask about? Select all that apply.

1. Incarceration of a parent 2. Childhood physical abuse 3. Unexpected death of a family member 4. Childhood exposure to mother experiencing violence

A nurse is caring for a client with acute stress disorder. The main goal of therapy for this client is prevention of the progression of this condition to posttraumatic stress disorder (PTSD). Which therapy would the client most likely be referred for?

Cognitive behavioral therapy

Which is an anticonvulsant used as a mood stabilizer?

Divalproex

A client rings the call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethic

Fidelity

A client with a diagnosis of schizophrenia has a history of auditory and visual hallucinations. Which intervention is most likely to minimize the client's hallucinations?

Provide frequent contact and communication with the client

Nursing students in an ethics class have been asked to define "ethics." What would be the best definition of ethics?

The formal, systematic study of moral beliefs.

What does the nurse find on assessment of the thought processes of a client with obsessive-compulsive disorder (OCD)?

The obsessions become intense as the client tries to stop the behavior.

What is the term for the beliefs held by the individual about what matters?

values

A nurse is interacting with a client who is expressing feelings about the client's child's insensitive behavior. Which statement made by the nurse indicates the nurse is empathizing with the client? Choose the best answer.

"It sounds like this is very difficult for you, I can see why it causes you stress."

Which statement made by the nurse to the family of a client diagnosed with obsessive-compulsive disorder (OCD) demonstrates the best general understanding of the chronic nature of the disorder and its management?

"It's important to know that the symptoms will intensify during periods of stress."

The nurse is working with a client who is suspected of having posttraumatic stress disorder after witnessing a violent crime. What statement by the client's spouse would suggest that the client is experiencing hyperarousal?

"My spouse always seems so irritated now, which isn't like my spouse."

Which statement made by the client demonstrates hardiness when faced with a health issue?

"What do I need to do to manage this illness?"

When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply.

"What is your name?" "Can you tell me where you are?" "What day of the week is it?"

For a person to be diagnosed with antisocial personality disorder, the individual must be a minimum of what age? 7 years 13 years 18 years 21 years

18 years Explanation: Antisocial personality disorder diagnosis is given to individuals 18 years of age or older who fail to follow society's rules—that is they do not believe that society's rules are made for them and are consistently irresponsible.

Because of his fear of poisoning, a client with a diagnosis of schizophrenia has severely limited his food intake over the past several months, causing a weight loss of nearly 40 pounds. What consideration would be the priority in the planning of this client's care? A. The client's nutritional status B. The client's compliance with psychotherapy C. The client's coping skills D. The client's mood and affect

A. The client's nutritional status

When assessing a client with anxiety, the nurse should recognize that anxiety may often be a result of what?

Medications

Which medication classification is considered first-line drug therapy for bipolar disorder?

Mood stabilizers

When assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component?

Physical appearance

A client on the inpatient psychiatric-mental health unit was discovered attempting to asphyxiate himself or herself using a blanket. Which measure should the care team prioritize in the client's immediate care?

Placing the client under constant observation

What kind of behavior does the nurse anticipate observing when treating a client obsessed with blasphemous thoughts?

Praying repeatedly.

The psychiatric mental health nurse has received a referral from a community health nurse regarding a client who appears to have hoarding disorder. When planning this client's care, the nurse should prioritize what consideration?

Promoting the client's safety in the home environment

A nurse is aware that the principle of autonomy is being applied in which situation?

The client has decided to stop chemotherapy treatments.

The nurse is assessing a client with anxiety. Which behavior might indicate that the client has moderate anxiety?

The client is nervous and agitated.

What assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation?

The client is often "staring into space" and has no idea how much time has passed

The nurse is administering a sedative drug to a client before the magnetic resonance imaging (MRI) procedure. What are the possible reasons for which the nurse had to sedate the client? Select all that apply.

The client may have claustrophobia. The client may have severe anxiety.

A nurse is caring for a client with dissociative disorder. The nurse tells the client, "Hello, I'm Robin, your nurse. It is 9 o'clock in the morning now. You are in room number 303. My name is Robin, I'm your nurse." What is the most appropriate reason for the nurse to repeat this statement?

The client may need to be reoriented.

A client with posttraumatic stress disorder (PTSD) has been referred for employment. Why might the nurse fear that the client will not be capable of sustaining the job long term?

The client may not be able to get along with coworkers

An older adult resident of a group home has been receiving treatment for schizophrenia for several decades. The nurse who oversees care at the facility believes that the resident may be developing tardive dyskinesia. What assessment findings would support this suspicion? Select all that apply.

The client often smacks lips when at rest The client makes repetitive movements with the fingers

A client diagnosed with schizoid personality disorder is described by family members as what? Eccentric and a loner Dramatic and emotional Nervous and fearful Tired and sad

Eccentric and a loner Explanation: A client diagnosed with schizoid personality disorder is described by family members as being eccentric and a loner, not dramatic and emotional, nervous and fearful, or tired and sad.

What term is used to describe the speech pattern being used when the client imitates or repeats what the nurse is saying?

Echolalia

In teaching a client who has been prescribed a benzodiazepine for panic disorder, the nurse must be certain to do what?

Educate the client that this medication has a high risk for withdrawal symptoms, and the client should not discontinue without a doctor's supervision.

The family members of a client with posttraumatic stress disorder (PTSD) state that they are "constantly walking on eggshells" because the client reacts so strongly to stressors that seem inconsequential to them. What is the nurse's best response?

Educate the family about the client's hyperarousal

A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client?

Ensuring that the client is not permitted to use anything that would be potentially dangerous.

A client states that the client has just had an argument with the client's spouse over the phone. What can the nurse expect that the client's sympathetic nervous system has stimulated the client's adrenal gland to release?

Epinephrine

A client is prescribed a selective serotonin reuptake inhibitor (SSRI) as treatment for depression. Which would the nurse most likely administer?

Escitalopram

An adult male client with a history of PTSD is brought to the emergency department (ED). The client was startled by a dog while out for a walk and kicked it. He was calm and apologetic when he presented to the triage nurse. Which is a priority nursing intervention?

Identify risks for self-harm and aggression

When providing care for a cognitively impaired client who is strongly tied to the client's culture of origin, the nurse supports these expectations by doing what?

Including family when discussing new medication treatment options

The nurse has been asked to assess a Native American client. The nurse plans additional time to interview the client. Why has the nurse planned the additional time?

Native Americans tend to communicate by telling long stories.

The nurse is dialoguing with a client who has been referred after witnessing a workplace accident several weeks ago that resulted in a coworker's death. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)?

The client states that the client is often "awake for hours and hours each night."

In speaking with a client with moderate anxiety, the client becomes tangential discussing unrelated topics. To help the client's attention from wandering, which is an effective intervention?

The nurse should speak in short and simple sentences.

A nurse is caring for a client experiencing delusions. The client tells the nurse "I am sure my brother has plans to kill me. But I am ready; I will be killing him before he tries to reach me." What is the appropriate action of the nurse in this situation?

The nurse should notify to the primary healthcare provider.

Which best defines the term suicide?

Thinking about and planning one's own death

Which are examples of virtues that can exemplify character and conduct as a professional nurse

• Trustworthiness • Humility • Compassion

A client diagnosed with panic disorder has been receiving medication therapy, which is being discontinued. A nurse would be alert for possible withdrawal symptoms if the client was receiving what?

Lorazepam

A client with severe depression has experienced anhedonia for the past 3 months. The nurse caring for this client understands that this term describes what?

Loss of interest or pleasure

Which ethical principle refers to the obligation to do good?

Beneficence

A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified?

Client will express that the client feels safe on the unit

Which statement regarding gender and suicide is correct?

Females engage in suicidal behaviors more frequently than males.

The nurse knows that the most dangerous time period following a previous suicide attempt is what?

First 3 months

A nursing student reports to the instructor that a medication due at 9 a.m. was omitted. Which of the following principles is the student demonstrating?

Integrity

A Haitian American client has a history of not keeping follow-up appointments for necessary lab work. What intervention should the nurse implement to help the client keep the appointments?

Provide an explanation about the importance of keeping the appointment

The nurse is performing a physical health assessment of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What aspect of this assessment should the nurse prioritize?

Sleep assessment

Which would be an appropriate intervention of a client experiencing a panic attack?

Staying with the client and speaking in short sentences

During an assessment, which would be the most important question topic?

Suicidal ideation

Avoiding which outcome is the primary reason for establishing professional boundaries with clients?

The loss of therapeutic effectiveness

A client expresses worry about the client's child's aggressive behavior. The nurse says "You are in a very challenging situation. Your child's aggressive behavior is very stressful for you, is this correct?" What does this nurse's statement indicate?

The nurse is empathizing with the client.

Which self-reflective question is directed towards understanding the fundamental basis of personal attitudes about people of diverse cultures?

While a child, what attitudes did your family express about other cultures?

A nursing student is studying the principle of autonomy. Which example most accurately depicts this principle?

describing surgery to a client before the consent is signed

The most important tool of psychiatric nursing is the:

self.

What would be an example of the nurse practicing fidelity? The nurse:

stays with the client during his death as promised

When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room?

the anxious client

The nurse is conducting a mental health assessment of a client who has been experiencing low mood, anxiety and loss of pleasure for the past month. The client tells the nurse he comes from a "really big family." Despite this, the client tells the nurse he continues to feel alone. Select the nurse's best response.

" You can have lots of people in your social network and still feel isolated."

A nurse's colleague expresses sympathy for a client who is traumatized following a terrorist attack 1 week earlier. The colleague states, "I'm certain that the client has posttraumatic stress disorder (PTSD)." What is the nurse's best response?

"Acute stress disorder is a possibility, which might develop into PTSD."

The nurse is providing care for a psychiatric-mental health client who has a diagnosis of anxiety. Which statement by the nurse is likely the most therapeutic intervention?

"Anxiety is a feeling that is experienced by everyone at some point and it can never be completely removed from one's life."

A 25-year-old client tells the nurse that the client has been worried and tearful lately because of pressures at work. The client states, "My partner tells me that it's 'stress' and 'anxiety,' but doesn't everyone have that? What is anxiety anyway?" Which response gives the best information about the nature of anxiety?

"Anxiety is a sense of psychological distress."

When a client states, "I will solve my own problems without asking my family for help," which response by the nurse demonstrates a therapeutic use of self?

"Asking for help from those who care about us isn't a sign of weakness."

A nurse receives a referral from a health care provider to assess a male client for posttraumatic stress disorder (PTSD). The client is a military veteran and been deployed on a military assignment. He is currently working as a civilian doing security work. The client is at risk of job loss because they avoid patrolling areas that are reminders of past trauma. When forced to complete these aspects of surveillance work, the client displays hyperarousal including mild aggression. Which question by the nurse is fundamental for the assessment?

"Describe your sleep habits over the past few months"

When conducting a social history with a client diagnosed with a borderline personality disorder (BPD), which question would be most important to ask the client related to impulsivity? "Do you always practice safe sex?" "Are you pleased with your medications?" "Do you think of yourself as physically attractive?" "Are you interested in making your partner happy?"

"Do you always practice safe sex?" Explanation: BPD results in impulsive behavior and often sexual promiscuity; therefore, the most relevant question the psychiatric nurse can ask is whether the client always practices safe sex. Satisfaction with medications, physical attractiveness, or making the partner happy are unrelated to impulsivity.

The nurse is conducting an interview with an adult client who is being treated for major depression. What question should the nurse prioritize in an effort to determine the client's risk for suicide?

"Do you ever feel like your situation is hopeless?"

What question by the nurse is focused on identifying oniomaniac tendencies in a client diagnosed with depression?

"Do you get enjoyment out of all the clothes you buy?"

The nurse is assessing a client who recently experienced their first panic attack while at the grocery store. What question should the nurse ask to identify complications of the disorder?

"Do you have any problems going out alone to public places?"

Which of the nurse's assessment questions would best identify whether the client has insight into the illness?

"Do you think that your illness prevents you from functioning well?"

The nurse is working with a client with schizophrenia who has cognitive deficits. It is time for the client to get up and eat breakfast. Which statement by the nurse would be most effective in helping the client prepare for breakfast?

"First, wash your face and brush your teeth. Then put your clothes on."

A nursing instructor is teaching about using behavioral interventions when caring for clients with borderline personality disorder. Which statement by a student indicates a need for further instruction? "Sometimes it is best to just ignore a client's irritating behaviors." "Sometimes it is best to confront a client about irritating behaviors." "Grossly disrespectful behaviors are better ignored." "In some instances, negative responses can be viewed as positive reinforcement."

"Grossly disrespectful behaviors are better ignored." Explanation: Nurses must decide how to respond to particular behaviors. In some instances, if the behavior is irritating but not harmful, it is best to ignore rather than focus on it. Grossly inappropriate behaviors, however, require confrontation.

A client with generalized anxiety disorder states that the client is worried about the client's job. The client never feels like the client has control over the client's responsibilities, even though the client puts in extra hours. The client adds that the client is afraid the client will be fired. Which response by the nurse is most therapeutic?

"Has something changed at work that is causing you to worry?"

The nurse begins an assessment of an older adult client who was brought to the hospital by her son. The client states, "I don't want your kind of help." What is the nurse's best response?

"Have you had a bad experience in the hospital before?"

A nurse is performing a psychosocial assessment of the client. Which questions asked by the nurse can be identified as open ended? Select all that apply.

"How can we help you?" "How did your problems begin?"

Which question in the assessment of a client with anxiety is most clinically appropriate?

"How do you feel about everything that is happening in your life right now?"

The nurse is performing a psychosocial assessment of a client. Which questions should the nurse ask to assess the client's self-concept? Select all that apply.

"How do you think you look today?" "What do you do when you have a problem?"

The nurse is providing care for a client who deliberately overdosed on acetaminophen several days ago. The nurse should assess the current severity of the client's suicidal ideation by asking what question?

"How often are you having thoughts about suicide this morning?"

Which statement made by a client would indicate that the client has delusions of grandeur?

"I am a magician, and my magic powers are good when the moon is full."

A nurse is caring for a client with depression. The client says that the client cannot stop thinking about the client's dead spouse. Which self-disclosure example given by the nurse is most appropriate?

"I can understand your situation; my cousin lost a spouse a few months ago."

The nurse is caring for a client with schizophrenia. The client tells the nurse, "My dead mother is calling me, I will finally be with her tonight. Please do not tell anyone." What is the most appropriate nursing response?

"I cannot keep this a secret. I will ensure that the staff helps keep you safe."

A client checks and rechecks the lock on the door five times before leaving home. What statement by the client indicates that this behavior is a result of obsessive-compulsive disorder (OCD)?

"I check until my anxiety subsides."

Which statement made by a client diagnosed with posttraumatic stress disorder (PTSD) leads the nurse to believe the client is experiencing dissociative symptoms?

"I describe my feelings like I'm having an out-of-body experience."

Which client statement best demonstrates a healthy relationship with family?

"I feel better after I visit with my Mom."

A nurse is interviewing a client and suspects that the client may have narcissistic personality disorder. Which statement by the client would help support the nurse's suspicions? "I have a very important position in life; everyone I know wants to be like me." "My spouse is poisoning my food to get rid of me and marry my spouse's boss." "I like to work alone because then I can let my thoughts wander." "I'm always the life of the party, making new friends all the time."

"I have a very important position in life; everyone I know wants to be like me." Explanation: Individuals with narcissistic personality disorder are grandiose, have an inexhaustible need for admiration, and lack empathy. These individuals believe that they are superior, special, or unique and that others should recognize them in this way. The statement about having a very important position in life and everyone wanting to be like the client reflects this personality trait. The statement about poisoning the food reflects a paranoid personality trait. The statement about working alone suggests a schizoid personality trait. The statement about being the life of the party suggests a histrionic personality trait.

The nurse is providing education to a client prescribed clomipramine to help with obsessive-compulsive disorder. Which statement by the client indicates the teaching was effective?

"I may have a risk of suicidal thoughts with the medication."

The nurse is teaching a client with obsessive-compulsive disorder about cognitive restructuring. Which client statement best demonstrates effectiveness of teaching?

"I may not always have harmful germs on my hands."

The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse?

"I might. I'll give it some..."

A nurse is assessing a client and suspects that the client may have obsessive-compulsive personality disorder based on which statement? "I need to have everything perfect. My life is organized down to the second." "I don't have any friends and I don't like to do anything socially." "I can't trust anybody that I meet, no matter where it is or who they are." "I am better than everyone and they should emulate me."

"I need to have everything perfect. My life is organized down to the second." Explanation: Behaviorally, individuals with obsessive-compulsive personality disorder are perfectionists, maintaining a regulated, highly structured, strictly organized life. A need to control others and situations is common in their personal and work lives. Therefore, the statement about everything being perfect and life being organized reflects this characteristic. The statement about not having any friends and no social interaction reflects a schizoid personality disorder manifested by introversion and reclusiveness, difficulty making friends, and lack of interest in social activity. The statement about not trusting anyone reflects a paranoid personality disorder. The statement about being better than anyone else reflects a narcissistic personality disorder, characterized by grandiosity and an inexhaustible need for admiration. Individuals are benignly arrogant and feel themselves to be above the conventions of their cultural group.

A nurse is caring for a client diagnosed with borderline personality disorder. The nurse has instructed the client about using the communication triad. The nurse determines that the client has understood this technique when stating what? "I should start by stating my feelings as an 'I' statement." "Maybe I should start by describing the situation that has me upset." "I should first tell the other person what I'd like to be different about the situation." "I should begin by telling the other person what has triggered my emotion."

"I should start by stating my feelings as an 'I' statement." Explanation: The client should begin with an "I" statement and the identification of feelings. Many want to begin with the condition. If the client begins with the condition, the statement becomes accusatory and is likely to evoke defensiveness. The "I" statement is followed by a nonjudgmental statement of the emotional trigger, then followed by what the person would like differently or what would restore comfort to the situation.

A nurse is developing a nurse-client relationship with a client diagnosed with borderline personality disorder (BPD). Which statement by the nurse demonstrates that the nurse understands the client's fears of abandonment and intimacy? "I'm here to help you for as long as I can." "I will be seeing you during the daytime this week." "We will work on things until your physician says you can go home." "Let's see how things go first and then how long you need me."

"I will be seeing you during the daytime this week." Explanation: A key to helping clients with BPD is recognizing their fears of both abandonment and intimacy as they relate to the nurse-client relationship. Informing the client of the length of this relationship allows the client to engage in, and prepare for, termination with minimal pain of abandonment. Therefore the statement about seeing the client during the daytime for a week demonstrates understanding of this concept. The other statements are open ended and do not address the length of the relationship.

The nurse provides care to a client who is prescribed a psychopharmacologic agent and is experiencing xerostomia. After providing education on ways to alleviate this side effect, which client statement indicates a need for additional teaching?

"I will increase the amount of fiber in my diet."

The nurse is caring for a Native American client. After asking the client some questions, the nurse determines that the client closely follows the Native American culture. Which request would be consistent with this culture?

"I would like to use herbs and participate in a pipe ceremony to aid in healing."

The nurse is interviewing a client with a diagnosis of depression and the client states, "Honestly, I know my family would be a lot better off if I wasn't around to be a burden on them. That's just between you and me, though, okay?" What is the nurse's best response?

"I'm obliged to share what we talk about with the other people on your care team."

A client comes to the clinic for an evaluation of headache, fatigue, and an overall feeling of being "down." When assessing the client, which statement by the client would alert the nurse to suspect possible suicide? Select all that apply.

"I've been drinking about three or four more beers every night." "I'm so tired that all I ever want to do is sleep all the time." "Most times, I feel like I'm trapped with no way out."

A nurse completing admission paperwork asks the client about having an advanced directive. The client states, "I do not know, what is an advanced directive?" What is the nurse's best response?

"It is a written document that identifies a person's preferences regarding which medical interventions to use in the event of a terminal condition."

A female psychiatric client is talking to the nurse about her reasons for being hospitalized. The client begins to discuss her relationship with her female significant other. She is describing the things in her relationship that are making her uncomfortable, and she asks the nurse, "Should I break up with my partner?" Which response by the nurse would be most effective in building rapport between the client and nurse?

"It sounds like you're beginning to be uncomfortable in this relationship."

A client has been discharged from the hospital with a prescription for lorazepam. Which instruction should the nurse provide to this client?

"Make sure that you don't drink any alcohol when you're taking this medication."

A client asks the nurse to go to lunch with the client one day next week after the client is discharged. Which statement is the most therapeutic response? "My role here is to help you recover. Let's talk about what else you can be doing after discharge." "That sounds good. Call the unit when you decide which day, and we can set it up." "I'd love to do that, but I'm on vacation next week." "I'm sorry, it is not within my role to have any affiliation with you after your discharge."

"My role here is to help you recover. Let's talk about what else you can be doing after discharge." Explanation: Clients with borderline personality disorder may display negative behaviors that can interfere with therapy. The nurse will have to confront clients about their behaviors and set appropriate limits.

A mental health nurse is working with a client with antisocial personality disorder. The nurse has just reviewed the unit rule of one cigarette per break. While telling the client about the unit rules, the client asks, "Well, if I have not done anything bad all day, can I have two cigarettes instead of one?" Which would be the most therapeutic nursing response? "Well, that's a good question. I need to check with the team." "No, only one cigarette is allowed per break time." "This is a good example of trying to push your limits." "It depends on whether or not we can make that exception that day."

"No, only one cigarette is allowed per break time." Explanation: The client is trying to manipulate the nurse in order to gratify the immediate need for a cigarette. In responding to manipulative behavior, the most therapeutic intervention is to maintain the limits that have been set and not to change the rules or make concessions for the client. The correct answer is the only option that is clear and assertive and maintains the rules.

Which statement by the nurse demonstrates acceptance to the client who has made a sexually inappropriate comment?

"Our relationship is one of a professional nature."

The nurse is working with a client who has been experiencing nightmares, hyperarousal and negative thoughts following a bomb threat at the client's workplace. The nurse's colleague states, "It turned out to be just a threat, not a bombing, so technically she can't have posttraumatic stress disorder (PTSD)." What is the nurse's best response?

"PTSD is a real possibility, even though the bombing never actually took place."

A nurse is giving a presentation on mental health promotion to college students. One student asks the nurse to explain the difference between normal anxiety and an anxiety disorder. Which response is best?

"People with anxiety disorders generally find that the anxiety interferes with daily activities."

A client is to receive three treatments of electroconvulsive therapy (ECT) per week for 3 weeks. After the third treatment, the client is forgetful and confused. When the client's spouse arrives to take the client home, the nurse discusses the client's condition with the spouse. Which statement is best?

"Some people experience mild confusion after ECT. Generally it clears in a few days, though it may take longer."

Which statement by a client would the nurse recognize as evidence of an absence of insight?

"Sometimes I feel like the world would be better off if I were dead, but who doesn't feel like that from time to time?"

A client with borderline personality disorder has been admitted to the inpatient unit because the client has been engaging in wrist cutting. The client's sibling is visiting, and the sibling asks the nurse to explain why the client sometimes does this. Which response by the nurse would be most appropriate? "Sometimes the self-injurious behavior is undertaken to relieve stress." "Self-injurious behavior often calms and sedates people with this diagnosis." "Sometimes they do it to avoid the onslaught of delusional thinking." "The self-mutilation often slows the mood swings your sibling experiences."

"Sometimes the self-injurious behavior is undertaken to relieve stress." Explanation: Clients with borderline personality disorder are impulsive and may respond to stress by harming themselves. Self-harm is an effort to self-soothe by activating endogenous endorphins to provide comfort. The behavior is not sedating or calming, and it is not used to prevent delusional thinking or mood swings.

A client with a diagnosis of depression tells the nurse that the client's mood was especially bad this morning but that the client pushed through it to attend a support group. How can the nurse best validate the client?

"That shows an admirable level of perseverance on your part. Well done!"

Which statement would indicate that the nurse has a non-judgmental attitude?

"The client has struggled with her life circumstance of living with a man who beats her, and she is trying very hard to make the changes necessary to help herself."

During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this?

"The news of the terrorist attack is directed to me. The terrorists are trying to warn me."

The nurse working on a mental health unit is teaching a nursing student. The student asks the nurse about what constitutes a diagnosis for major depressive disorder. What is the nurse's best response?

"The primary diagnostic criterion is one or more major depressive episodes for at least 2 weeks with other symptoms present."

A new client with a long-standing history of obsessive-compulsive disorder (OCD) is describing to the nurse the complex ritual of locking and unlocking a door after entering a room alone. What is the nurse's most therapeutic response?

"The process you're describing sounds like it must require quite a bit of time and energy."

Which client statement indicates the most insight into his or her issue with auditory hallucinations?

"The voices aren't real but it's hard to ignore them."

A nurse has approached a new client on the psychiatric care unit in order to establish a therapeutic relationship and conduct a focused assessment. As the nurse approaches the client, the client says, "Oh good. Here comes one more person to tell me that I'm crazy." Which of the nurse's following responses would constitute countertransference?

"There's no need to get rude with me. I'm just trying to do my job and to help you out."

Which of the following statements by the nurse is an example of deception?

"This injection of Novocain will feel like a little pinch."

A nurse works in a psychiatric clinic. During a counseling session, the nurse finds that the client who has posttraumatic stress disorder (PTSD) is unable to identify the intensity of the client's emotions. The client states that extreme emotions appear out of nowhere and with no warning. What suggestion should the nurse provide to help the client get in touch with the client's emotions?

"Use a journal or a log to write down your feelings."

Which question would be best for the nurse to ask in order to assess recent memory?

"What did you eat for breakfast today?"

A client comes to the emergency department because the client thinks the client is having a heart attack. Further assessment determines that the client is not having a heart attack but is having a panic attack. When beginning to interview the client, which question would be most appropriate for the nurse to ask?

"What did you experience just before and during the attack?"

A client comes to the emergency department because the client thinks the client is having a heart attack. Further assessment determines that the client is not having a heart attack but is having a panic attack. When beginning to interview the client, which question would be most appropriate for the nurse to use?

"What did you experience just before and during the attack?"

The client presents with signs and symptoms of anxiety. What conversation initiated by the nurse demonstrates an ineffective therapeutic use of self?

"What types of dresses do you like wearing?"

A client tells the nurse, "I had to slap my child, I couldn't help that." Which response of the nurse indicates that the nurse is in the state of unknowing?

"What was going on for you when this happened?"

Which question asked by the nurse indicates that the nurse is assessing the judgment of the client?

"What would you do if you found $10 on the side of the road?"

Which statement, made by a client diagnosed with an anxiety disorder, should trigger the nurse's concern about the client's understanding of the use of defense mechanisms?

"When I have a problem, I just deny it until it goes away."

A client has just been diagnosed with bipolar disorder and is upset with the diagnosis. The client tells the nurse, "It is probably my mother's fault, she has bipolar too." Which is the best response by the nurse?

"While bipolar disorders are genetic, there are other causes as well."

When a 23-year-old client is admitted to the psychiatric unit after a suicide attempt, the client states the client is willing to speak to the nurse but only if the conversation remains confidential. Which is the nurse's best response?

"Will this conversation involve your desire to harm yourself?"

The nurse is caring for a hospitalized client who is suspicious and guarded. The client tells the nurse that the client does not want anyone to tell the family about the client's condition. What is the nurse's best response when the family calls the hospital unit to inquire about the client's condition?

"You are welcome to share any information that you think would be helpful."

An older adult reports anxiety and is prescribed diazepam by a family physician. The physician asks the office nurse to explain to the client the problematic side effects of this medication. Which instruction about this drug would be most important for the nurse to emphasize?

"You may feel dizzy and be prone to falls after taking this medication."

A 38-year-old client has been diagnosed with major depressive disorder. The client is being placed on an antidepressant and the nurse is providing medication teaching. Which would be appropriate information to provide to the client?

"You may not notice an improvement in your symptoms for 2 to 6 weeks."

A nurse is speaking to a client who attempted suicide. The client says, "It is my dream to become a doctor, and I failed the entrance exam. I am so mad at myself." Which statement indicates genuine interest by the nurse?

"You must have been really upset."

A client is prescribed medication for a psychiatric disorder. After 3 days, the client reports being constipated. Which instruction would the nurse give the client?

"You need to eat more fruits and vegetables and drink more water."

A client has experienced a first episode of major depression and has received medication and treatment, which has led to a complete remission of the symptoms. The client asks the nurse, "How much longer will I need to take the medication?" Which response by the nurse would be most appropriate?

"You'll need to continue the medication for about 6 to 12 months to see how things go."

Which client statement is suggestive of a sexual delusion?

"You've been watching me and my partner while we are together, haven't you?"

A nurse is speaking to a client with a soft smile and eye contact. Which statement said by the nurse would indicate a congruent message?

"Your hard work and determination has helped you recover."

A nurse is conducting a review class on borderline personality disorder. When describing the characteristics associated with this disorder, which would the nurse most likely include? Select all that apply. Difficulty regulating moods Overinflated self-identity Problems with interpersonal relationships Thinking that is based on delusions Impulsive behavior

- Difficulty regulating moods - Problems with interpersonal relationships - Impulsive behavior Explanation: People with BPD have problems regulating their moods, developing a self-identity, maintaining interpersonal relationships, maintaining reality-based thinking, and avoiding impulsive or destructive behavior.

When reviewing the history of a client with antisocial personality disorder, which would the nurse expect to find? Select all that apply. Repeated incidents involving assaults Consistent regular work history Lack of remorse for actions Episodes involving scams for personal gain Detailed plans for future actions

- Repeated incidents involving assaults - Lack of remorse for actions - Episodes involving scams for personal gain Explanation: A client with antisocial personality disorder shows a pervasive pattern of disregard for and violation of the rights of others. History may reveal repeated incidents of physical fights or assaults demonstrating irritability and aggressiveness, repeated failure to sustain consistent work behavior or honor financial obligations, lack of remorse for actions, conning others for personal profit or pleasure, and impulsivity or failing to plan ahead.

A nurse is assessing a client diagnosed with avoidant personality disorder. Which would the nurse expect to find? Select all that apply. Shyness Feelings of inadequacy Feelings of superiority Perfectionism Detail oriented

- Shyness - Feelings of inadequacy Explanation: Individuals with avoidant personality disorder appear timid, shy, and hesitant; fear criticism; and feel inadequate and inferior. These individuals are extremely sensitive to negative comments and disapproval and appraise situations more negatively than others do. Individuals with obsessive-compulsive personality disorder exhibit perfectionism and an intense involvement in details such that they have difficulty making decisions and completing tasks.

When developing the plan of care for a client with borderline personality disorder (BPD), which areas would the nurse identify as likely problematic? Select all that apply. Hydration Self-care Pain Sleep Nutrition Self-harm

- Sleep - Nutrition - Self-harm Explanation: Usually, clients with BPD are managing hydration, self-care, and pain well. Problem areas include sleep, nutrition, and self-harm.

Which individual is exhibiting signs or symptoms that are characteristic of posttraumatic stress disorder (PTSD)? Select all that apply.

1. A client who has quit the client's job so that the client no longer has to go to the client's old office where the client was attacked and robbed 2. A police officer who experiences panic attacks when thinking about the time the police officer was forced to shoot a violent suspect 3. A client who has frequent nightmares about the time a fellow soldier died from an improvised explosive device 4. A client who is unable to relax without first barricading the client's home after a violent home invasion and assault

When presenting a discussion of posttraumatic stress disorder (PTSD) to a group of emergency department nurses, the psychiatric-mental health nurse provides examples of traumatic events that may precede PTSD. Which example would the nurse most likely include? Select all that apply.

1. Personal assault by a family member 2. Military combat mission where there were casualties 3. Surviving an EF 4 tornado

A client is diagnosed with posttraumatic stress disorder (PTSD). The client is a survivor of a bomb blast. Which symptoms of PTSD is the nurse likely to find in the client? Select all that apply.

1. Reexperiencing the trauma through dreams 2. Feeling detached from others 3. Showing irritability and outbursts of anger 4. Losing a sense of control over one's life

The nurse is planning to give health-related education to adolescents with posttraumatic stress disorder (PTSD). What topics should the nurse discuss specifically for these clients? Select all that apply.

1. Set small, specific, achievable goals 2. Have a healthy, balanced diet 3. Abuse of alcohol and drugs can cause ill effects

A psychiatric-mental health nurse is assessing a client who has been referred for care following a violent assault. Which finding would the nurse most likely document as reflecting the diagnostic criteria for posttraumatic stress disorder (PTSD)? Select all that apply.

1. The client describes oneself as being constantly "on edge." 2. The client states, "All I can think about these days is the attack." 3. The client states "completely avoiding the neighborhood where the attack occurred."

The nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) several months ago. During a comprehensive follow-up assessment, what areas should the nurse assess? Select all that apply.

1. The client's use of alcohol or other drugs 2. Characteristics of the client's sleep 3. The effect of the client's PTSD on the family

A nurse is teaching a client about how traumatic events affect a person. Which examples are included in the teaching plan? Select all that apply.

1. Witnessing a fatal shooting 2. Being trapped inside a capsized boat 3. Receiving word of a terrorist attack in a nearby community

Research has shown that risk of suicide increases within which time frame for initiation of antidepressant therapy?

14 days

A nurse is preparing a presentation for a group of staff nurses on personality disorders. When describing antisocial personality disorders (ASPD), the nurse would explain that for a person to be diagnosed with the disorder, the person must be at least which age? 15 years 18 years 21 years 25 years

18 years Explanation: To be diagnosed with ASPD, the individual must be at least 18 years old and must have exhibited one or more childhood behavioral characteristics of conduct disorder before the age of 15 years, such as aggression to people or animals, destruction of property, deceitfulness or theft, or serious violation of rules.

Nearly what percentage of adults are affected by anxiety disorders?

25%

The nurse recognizes that who is the client most likely experiencing generalized anxiety disorder (GAD)?

40-year-old who has reported numerous absences from work, muscle aches, and difficulty falling asleep for the last 8 months

The prescription of clozapine requires weekly blood samples for at least:

6 months.

When completing discharge medication education for the client, the client asks how long it will take before the selective serotonin reuptake inhibitor (SSRI) medication will help the client's mood improve. Which is the correct response by the nurse?

7 to 10 days

A nurse administers a prescribed dose of lithium at 8 p.m. The nurse would schedule a specimen to be obtained for a blood concentration at which time?

8 a.m.

Which client is most likely to be diagnosed with body dysmorphic disorder (BDD)?

A client who firmly believes that everyone who sees the client fixates on the size of the client's ears

Which client is most likely to benefit from treatment with an antiparkinsonism agent?

A client who has a medication-induced movement disorder

Which client is most likely to benefit from electroconvulsive therapy (ECT)?

A client whose major depression has not responded appreciably to antidepressants

Which client would not be able to undergo a magnetic resonance imaging scan (MRI)?

A client with a pacemaker

Treatment approaches for clients with personality disorders generally rely on which modality? Pharmacotherapy Cognitive-behavioral therapy Individual therapy A combination of approaches

A combination of approaches Explanation: Clients with personality disorders are likely to benefit from individual psychotherapy. Group therapy provides psychoeducational experiences and teaches assertiveness skills, positive coping skills, relaxation techniques, and nonchemical coping. Clients with borderline, dependent, histrionic, and avoidant personality disorders may benefit from family treatment approaches. Pharmacologic agents such as antidepressants, lithium carbonate, or atypical antipsychotic medications are sometimes used for certain clients.

A 46-year-old client has been diagnosed with major depressive disorder. The client is seeing a nurse practitioner who is deciding on an appropriate treatment regimen. The nurse practitioner knows that which will be the most effective treatment for this client's depressive disorder?

A combination of psychotherapy and medication

The client has begun to wash the hands every hour due to the fear of germs becoming embedded in the client's skin leading the client to develop cancer. The nurse interprets this behavior as indicating which condition?

A compulsion

A 35-year-old was discharged from care after recovery from depression. The nurse therapist and the client spent many hours working through issues related to the depression. Six months later, the client is admitted again for depression associated with issues similar to those that were previously addressed in the client's therapy. The nurse therapist says to a coworker, "This is unbelievable; we're back at square one again. The client should know better at this point." The nurse's comments reflect what?

A judgmental attitude

Which individual is most likely to be diagnosed with posttraumatic stress disorder (PTSD)?

A middle-aged woman with a history of anxiety who suffered a random physical assault

Which scenario conveys the application of cultural competence in the provision of nursing care?

A new nurse has a client who speaks Spanish; the nurse has asked a Hispanic colleague to tell the new nurse about the culture, ideas for care, and how cultural beliefs might influence the client's response to health care interventions.

A nurse administrator is observing the behavior of nurses in the hospital. Which behaviors would the nurse administrator consider inappropriate? Select all that apply.

A nurse hugging a client who had come in for an initial visit A nurse speaking to a depressed client in a very strict, disciplinarian tone

The nurse is preparing to perform a psychosocial assessment of a client with schizophrenia. The client has a history of extreme aggression. What is the optimal setting for conducting an interview with the client?

A physician's intake room with other medical personnel nearby.

A client was abandoned by the parents at age 3, resulting in the client's perception of the world as a hostile place and the subsequent development of rage against men. This statement is an example of what?

A psychodynamic interpretation of the client's major depressive disorder.

A client has a diagnosis of obsessive-compulsive disorder. The symptoms of the disorder have seriously interfered with the client's ability to work. In order to effectively work with the client, the nurse must understand that a compulsion is what?

A repetitive, intrusive, and unwanted urge to perform or performance of an act contrary to one's usual standards

What does desensitization refer to?

A systematic way to replace a panic response with a relaxation response

The nurse assesses a 6-year-old child for posttraumatic stress disorder (PTSD). The caregiver explains that the child witnessed the mother being stabbed by a neighbor. Which is a behavior consistent with the child's diagnosis?

A two-month history of angry outbursts with minor provocation

Which client is most likely to be at risk for drug dependence and difficulties with withdrawal?

A woman who has been taking lorazepam for several months after witnessing a traumatic motor vehicle accident

The community mental health nurse is providing care for a large number of clients. What client should the nurse monitor most closely for the warning signs of suicide?

A young male with schizophrenia who is in danger of becoming homeless

Which question is best to ask when assessing the client's judgment? A. "If you found yourself downtown without money or a car, how would you get home?" B. "Can you describe your usual daily activities for me?" C. "On a scale of 1 to 10, how stressed would you rate yourself?" D. "What problem would you like to work on while you're hospitalized?"

A. "If you found yourself downtown without money or a car, how would you get home?"

A 22-year-old client who has been diagnosed with paranoid personality disorder has been receiving treatment. The final stage of the nursing process in the care of this client should focus on what? A. Evaluating the effectiveness of the treatment B. Encouraging the client to develop coping skills and life skills C. Engaging the client's friends and family D. Selecting specific interventions

A. Evaluating the effectiveness of the treatment

When assessing a client's mental health status, which describes the purpose of the psychosocial assessment? Select all that apply. A. To assess the client's behavioral function B. To assess the client's current emotional state C. To assess the client's plan of care D. To assess the client's mental capacity E. To assess the client's physical health status

A. To assess the client's behavioral function B. To assess the client's current emotional state D. To assess the client's mental capacity

During an admission assessment, the nurse asks a client the meaning of the proverb, "People in glass houses should not throw stones." Which clinical feature is the nurse assessing?

Abstract reasoning

If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking?

Abstract thinking

A nurse is reviewing the medical record of a female client diagnosed with borderline personality disorder (BPD). Which would the nurse identify as one of the strongest risk factors for this disorder? Abuse as a child Parental alcohol abuse Poverty History of depression

Abuse as a child Explanation: Childhood sexual abuse, which more commonly affects girls, is one of the strongest risk factors for BPD. Various studies show that physical and sexual abuse seem to be significant risk factors for BPD. Other studies cite parental loss and separation. Parental alcohol abuse, poverty, and a history of depression have not been linked to BPD.

A client who recently immigrated from Eastern Europe comes to the clinic for an evaluation. During the assessment, the nurse notes that the client has adopted the local area's mannerisms and dress. The nurse interprets this as what?

Acculturation

During the orientation phase of a nurse-client relationship, the nurse notes a change in the client's behavior. The client has forgotten a scheduled session and then accuses the nurse of breaking confidentiality. The nurse interprets this as suggesting what?

Acting out

The most important factor in the person's stress response is what?

Adaptive coping strategies

A client approaches the nurse on an inpatient psychiatric hospital unit crying, trembling, and feeling nauseous. The client states, "I've tried everything, I still feel so anxious." Which action by the nurse would be most appropriate?

Administer the prescribed PRN anxiolytic medication.

The nurse is told by a client that the client is having suicidal thoughts. Which intervention has lowest priority?

Administering a mental status exam to assess for psychosis

After teaching a group of nurses about borderline personality disorder, the leader determines that the education was successful when the group identifies that symptoms typically begin in which age group? Adolescence Young adulthood Middle-age individuals Late adulthood

Adolescence Explanation: Many children and adolescents show symptoms similar to those of BPD, such as moodiness, self-destruction, impulsiveness, lack of temper control, and rejection sensitivity. Because symptoms of BPD begin in adolescence, it makes sense that some of the children and adolescents would meet the criteria for BPD even though it is not diagnosed before young adulthood.

For a client who belongs to an ethnic group that is known to have poor metabolism of psychotropic medications, the nurse should anticipate that the client may be at risk for which problem?

Adverse drug effects

Which word is best described by the following: the protection and support of another's rights?

Advocacy

Which role of the nurse-client relationship is being exhibited when the nurse informs the client and then supports the client in whatever decision the client makes?

Advocate

A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement?

Affect

While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as?

Affect

While shopping in a grocery store, a client with borderline personality disorder (BPD) greets the sibling of a neighbor with a great big hug. Then about 5 minutes later, the client walks past the sibling and ignores the sibling. The client is demonstrating what? Dichotomous thinking Affective instability Dissociation Identity diffusion

Affective instability Explanation: Affective instability (rapid and extreme shift in mood) is a core characteristic of BPD and is evidenced by erratic emotional responses to situations and intense sensitivity to criticism or perceived slights. For example, a person may greet a casual acquaintance with intense affection, yet later be aloof with the same acquaintance. Dichotomous thinking involves evaluating experiences, people, and objects in terms of mutually exclusive categories (e.g., good or bad, success or failure, trustworthy or deceitful), which informs extreme interpretations of events that would normally be viewed as including both positive and negative aspects. Dissociation refers to times when thinking, feelings, or behaviors occur outside a person's awareness. Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed.

A client comes to the clinic for a follow-up visit. Despite being warm and friendly with the nurse on a previous visit, today the client presents with anger and sarcastic undertones with the same nurse. The client is presenting which behavior commonly seen in borderline personality disorder? Depression Identity diffusion Affective instability Dichotomous thinking

Affective instability Explanation: Affective instability is a rapid and extreme shift in mood and a core characteristic of borderline personality disorder. It is evidenced by erratic emotional responses to situations and intense sensitivity to criticism, perceived slights, or both.

A nurse working in an urban clinic is gathering data about the use of preventive mental health services by the clinic's clientele. The nurse is surprised that the data reveal more than 80% of the clients using this service are white, while the residential population in the surrounding area is predominantly African American and Asian American. Which statement most likely explains these data?

African Americans and Asian Americans perceive the system as culturally insensitive

The nurse working in the psychiatric unit observes that the African American clients experience more side effects from psychotropic drugs compared to the White clients. This is most likely for which reason?

African Americans metabolize psychotropic drugs more slowly.

A client diagnosed with schizophrenia has been prescribed clozapine. Which is a potentially fatal side effect of this medication?

Agranulocytosis

A nurse has completed four hours of his eight-hour shift on a medical-surgical unit when he receives a phone call from the nursing supervisor. The nursing supervisor informs him that he needs to give a report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that he has been busy with his client assignment and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

Allocation of scarce nursing resources

A client is currently experiencing panic. Which action would be most appropriate for the nurse to do?

Allow the client to pace

The nurse is assessing a client who has come in for a routine check-up. What factors should the nurse assess that could directly impair the client's ability to cope with illness? Select all that apply.

Amount of sleep Nutritional status Existence of chronic illness Involvement in social activities

The nurse should anticipate that an individual's culture will have the most significant influence on which situation?

An Arab American has begun grieving because her husband of several decades has just died.

Which of the following best describes feminist ethics?

An approach critiquing existing patterns of oppression and domination in society

The nurse is seeing a 26-year-old client and the client's family. The client's family describes the client as being "very, very different." The family describes a history of periods of unpredictable behavior and disregard for consequences occurring a few times each year. The client has recently been diagnosed with bipolar I disorder, a condition that is characterized by what?

An elevated mood that lasts for at least 1 week

What does the nurse recognize as the most likely explanation for the self-mutilating behaviors that occur with borderline personality disorder? The result of an inherited disorder that manifests itself as an incapacity to tolerate stress An expression of intense anger or helplessness in order to block emotional pain Use of projective identification to reduce anxiety A constitutional inability to regulate affect that predisposes clients to psychic disorganization

An expression of intense anger or helplessness in order to block emotional pain Explanation: The client does not have an inherited disorder manifesting as an inability to manage stress and does not exhibit projective identification. Borderline personality pathology is not a constitutional inability to regulate affect; rather, it consists of maladaptive behavior patterns that usually present at times of stress or perceived threat (e.g., regarding fears of rejection, abandonment, and failure). Clients who engage in self-mutilation secondary to borderline personality disorder typically use self mutilation as a cry for help, an expression of intense anger or helplessness, or a form of self punishment with the aim to block emotional pain.

The nurse is seeing a 43-year-old client whose spouse just died by suicide. Which is a common emotional response that the nurse should anticipate from this client?

Anger toward the loved one who committed suicide

A loss of pleasure or interest in a client diagnosed with depression would be documented as what?

Anhedonia

During assessment of a client with depression, the client states, "I just feel so sad and hopeless. I just don't care anymore. I don't even enjoy doing the crossword puzzles like I used to." The nurse documents this finding as indicative of what?

Anhedonia

A client has sought treatment because of the overwhelming anxiety the client experiences regarding the safety of the client's young children. The client admits that the client will not normally let the client's children leave the client's sight for fear that they will be abducted, abused, or injured. The client is unable to function at work as a result of this anxiety. The nurse would recognize that this client experiences which condition?

Anticipatory anxiety

Panic disorder is treated with cognitive-behavioral techniques, deep breathing, and relaxation, in addition to what?

Antidepressants

Which medication classification has been found to be effective in reducing or eliminating panic attacks?

Antidepressants

The nurse is interviewing a client with a history of violence. The client boasts that the client "put a kid in a wheelchair" once when the client was younger and has maimed others. The client states, "Who cares? Life's tough." Violence and insensitivity are associated with which personality disorder? Schizoid personality disorder Antisocial personality disorder Histrionic personality disorder Borderline personality disorder

Antisocial personality disorder Explanation: Those with antisocial personality disorder display aggressive, irresponsible behavior that often leads to conflicts with society and subsequent involvement in the criminal justice system. People with this disorder commonly display behaviors such as fighting, lying, stealing, abusing children and spouses, abusing substances, and participating in confidence schemes. These people, while often superficially charming, lack genuine warmth.

Avoidant, dependent, and obsessive-compulsive personality disorders are characterized by what? Odd or eccentric behaviors Dramatic or erratic behaviors Anxious or fearful behaviors Manic or withdrawn behaviors

Anxious or fearful behaviors Explanation: Clients with Cluster C personality disorders—which include avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder—are often anxious, tense, and fearful.

Which culture has a belief that mental illness is a planned attempt to manipulate others?

Arab American

A client is admitted to the psychiatric unit after taking various medications and illegal substances to get "high." In addition to the underlying diagnosis of bipolar disorder, the client is diagnosed with delirium. Currently the client is experiencing mild hallucinations and confusion. Which intervention should the nurse do first?

Arrange for an unlicensed assistant to sit with the client.

The nurse who is preparing a Native American client for surgery notes that the client is wearing a medicine bag. What intervention should the nurse implement to best address the client's spiritual needs with respect to presurgical care needs?

Ask the client how the medicine bag can be respected while preparing for surgery.

A client with schizophrenia walks up to the nurse with the client's arm outstretched and says, "My arm went away. Dog, dog, dog." How should the nurse respond?

Ask the client if the client is trying to say that something is wrong with the client's arm.

A client has a diagnosis of borderline personality disorder and lives at home with the client's parents. The client has been in the psychiatric unit for 2 weeks and is scheduled to be discharged tomorrow. Which would be most therapeutic when the client's parents come in to discuss discharge plans? Attempt to discuss placing the client into an assisted living environment Ask the parents how they have coped with the client's behaviors over the years Ask the parents to keep a written schedule of activities for each day for the client Encourage the parents to discuss the possibility of the client going into a day-care program when the client goes home

Ask the parents to keep a written schedule of activities for each day for the client Explanation: When providing family and client education upon discharge, it is important for the nurse to ask the parents to keep a written schedule of daily activities for the client in order to keep a fixed routine with the aim of preventing chronic boredom and emptiness that is often associated with borderline personality disorder.

The client is a 40-year-old man admitted s/p repair of a femoral fracture. He discloses that he has a history of an addiction to painkillers and asks that the nurse assist him in adhering to his recovery from this addiction by not administering any narcotics. As the nurse reviews postoperative orders for the client, the nurse notes that his physician has ordered Codeine 30 mg p.o. q6 hours for pain. How does the nurse best approach this situation?

Asks the physician to remove this order from the client's chart.

The family members of a military veteran are distraught that he has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action?

Assess the client for signs and symptoms associated with post-traumatic stress disorder

A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action?

Assess the client's blood pressure

Which approach to care best reflects cultural competence?

Assess the culturally mediated beliefs of each client on an individual basis.

Which is not considered a step in the values clarification process?

Assessing

The policies and procedures at a community psychiatric-mental health center include an emphasis on case finding. How can a nurse at the center best perform case finding?

Assessing all clients carefully to identify those at risk for suicide

During the stabilization phase of drug therapy for a client who is hospitalized with a psychiatric disorder, which action would be most appropriate?

Assessing the client for target symptoms and side effects

A 20-year-old client was admitted to the inpatient unit following a suicide attempt. The client is disheveled, disorganized, and dehydrated. The priority for the client's care during the first 24 hours of admission will be what?

Assessing the client's current suicidal ideation and putting the client on suicide precautions.

A client with a diagnosis of posttraumatic stress disorder (PTSD) has been brought to the emergency department (ED) by concerned family members, who state that the client is experiencing a "nervous breakdown." The ED nurse should prioritize what aspect of care during the initial care of the client?

Assessing the client's risk for self-harm and ensuring safety

The psychiatric mental health nurse is working with a client who has been diagnosed with posttraumatic stress disorder (PTSD). Assessment reveals that the client is experiencing frequent episodes of intrusion. The nurse should consequently prioritize what assessment?

Assessing the quantity and quality of the client's sleep

A client is being admitted to an inpatient setting. It is important for the nurse to first obtain which information about the client?

Assessment of history

A nurse volunteers to serve on the hospital ethics committee. Which of the following indicates that the nurse knows what the purpose of an ethics committee is?

Assist in decision making based on the client's best interests

A hospitalized client states that the client is having difficulty resting. Which intervention would help promote rest?

Assisting the client with deep-breathing exercises

A nurse is providing care to a client with borderline personality disorder. When providing for the client's biopsychosocial needs, the nurse would address which in the biologic domain? Establishing a therapeutic relationship Assisting with problem solving Establishing boundaries Assisting with sleep measures

Assisting with sleep measures Explanation: Assisting with sleep measures reflects a biopsychosocial intervention in the biologic domain. Establishing a therapeutic relationship, assisting with problem solving, and establishing boundaries would be interventions in the psychological domain.

When assuming the management of the care of a delusional client, which should be the nurse's priority intervention?

Assure the client that he or she is safe in this milieu

A nurse is describing histrionic personality disorder to a group of new nurses. Which term would the nurse most likely use? Attention seeking Psychopath Sociopath Lacking empathy

Attention seeking Explanation: A person with a histrionic personality disorder is often described as "attention seeking," "excitable," and "emotional." Psychopath and sociopath are terms used to describe the behavior of a person with antisocial personality disorder. Lacking empathy describes a person with a narcissistic personality disorder.

A client with a diagnosis of bipolar I disorder has been presented with a coping strategy by the therapist that may help the client manage behavior during manic episodes. The client has responded to the therapist's suggestion by saying, "What's the use? I don't ever see this changing." The client's statement is suggestive of a potential problem with what factor that influences communication?

Attitude

Which term is used to describe general feelings or a frame of reference around which a person organizes knowledge about the world?

Attitudes

Which type of hallucination is the most common?

Auditory

A client age 46 years has been diagnosed with cancer. He has met with the oncologist and is now weighing his options to undergo chemotherapy or radiation as his treatment. This client is utilizing which ethical principle in making his decision?

Autonomy

A nurse who provides the information and support that clients and their families need to make the decision that is right for them is practicing what principle of bioethics?

Autonomy

A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what? A. Labile B. Incongruent C. Blunted D. Flat

B. Incongruent

When initiating an assessment, the nurse should use which type of questioning? A."Why" questioning B. Open-ended questions C. Closed-ended questions D. Focus on several symptoms

B. Open-ended questions

Which intervention uses the reading of written materials to express feelings or gain insight? A. reminiscence B. bibliotherapy C. behavior modification D. token economy

B. bibliotherapy

When observing a client diagnosed with mania, the nurse observes his mood to be elated. What is another term for this type of mood? A. euthymic B. euphoric C. labile D. dysphoric

B. euphoric

A biologic theory explains anxiety disorders in which way?

Based in genetics with clinical symptoms being a result of chromosomal influence

Which medication classifications used in the treatment of panic disorder can cause physical dependence?

Benzodiazepines

A nurse administers haloperidol to a client to promote deescalation. The nurse finds that after administering the drug, the client has started having jerky and involuntary movements of the head and arms. Which medication would be useful in treating this problem?

Benztropine

Which statement regarding posttraumatic stress disorder (PTSD) and children is accurate?

Best practices demonstrate that adolescents who have PTSD are at increased risk of drug

Which personality disorder is most often treated within the inpatient psychiatric setting? Antisocial Schizotypal Borderline Dependent

Borderline Explanation: People with borderline personality disorder are believed to be the most frequent recipients of psychiatric care in both inpatient and outpatient settings due to the frequency of engaging in self-destructive behaviors.

A client is admitted to the mental health unit after the client's spouse brings the client to the emergency department. Upon arrival, the spouse explained that the client had been crying all weekend and stating that the client wanted to die. Upon further assessment, the spouse reports that the client always has difficulty controlling anger and frequently worries that the spouse will leave the client. Recently, the client has been getting drunk every night, which the client never used to do. What diagnosis should the nurse suspect applies to this client? Bipolar disorder Borderline personality disorder Depression Mania

Borderline personality disorder Explanation: Borderline personality disorder is characterized by a disruptive pattern of instability related to self-identity, interpersonal relationships, and affect combined with marked impulsivity and destructive behavior.

A 30-year-old client who has not paid rent in 4 months is being evicted from an apartment. The client is brought to the hospital after the client uses a kitchen knife to cut the client's wrist in response to the stress of the eviction. The client's behavior is consistent with what? Paranoid personality disorder Borderline personality disorder Schizotypal personality disorder Antisocial personality disorder

Borderline personality disorder Explanation: A person with borderline personality disorder almost always appears to be in a state of crisis and tends to have an exaggerated response to stressors. This exaggeration of emotional response is not typical of paranoid, schizotypal, or antisocial personality disorders.

Impulsivity and difficulty controlling anger are characteristic of which mental health diagnosis? Depression Schizophrenia Posttraumatic stress disorder Borderline personality disorder

Borderline personality disorder Explanation: Impulsivity and difficulty controlling anger are characteristic of borderline personality disorder

The nurse is in the process of planning the care of a psychiatric-mental health client and has specified the following outcome: The client will be free from self-inflicted harm. What is this client's most likely diagnosis? Dependent personality disorder Borderline personality disorder Antisocial personality disorder Schizoid personality disorder

Borderline personality disorder Explanation: Self-mutilation is frequently performed by individuals who have borderline personality disorder. Persons with dependent personality disorder, antisocial personality disorder, or schizoid personality disorder are not prone to self-mutilation and the accompanying attention that it provides.

A nurse fails to communicate a change in the client's condition to the physician. Which element related to proving malpractice has been met?

Breach of duty

Which is the primary religion of Cambodians?

Buddhism

When discussing various types of anxiolytic medications with a client, the nurse recognizes that which medication has the lowest potential for abuse?

Buspirone

The client's medical record should contain which of the following? Select all that apply. A. Opinions B. Biases C. History of presenting illness D. Chief complaint E. Diagnoses

C. History of presenting illness D. Chief complaint E. Diagnoses

A delusion represents a problem in which area? A. Motivation B. Memory C. Thinking D. Orientation

C. Thinking

A client with bipolar disorder has been ordered a medication that is classified as an anticonvulsant. Which drug does the nurse know falls within this class of medications?

Carbamazepine

Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?

Care-based ethics

A personality disorder is defined as a collection of traits that do what? Cause behavioral dysfunction and inner distress Are malleable and poorly defined Lead to aggression and violence Lead to withdrawn and antisocial behavior

Cause behavioral dysfunction and inner distress Explanation: A personality disorder can be defined as a collection of personality traits that have become fixed and rigid to the point that the person experiences inner distress and behavioral dysfunction. A personality disorder also can be considered a lifelong pattern of behavior that affects many areas of the person's life, causes problems, and is not produced by another disorder or illness.

A personality disorder is defined as a collection of traits that do what? Cause behavioral dysfunction and inner distress Are malleable and poorly defined Lead to aggression and violence Lead to withdrawn and antisocial behavior

Cause behavioral dysfunction and inner distress Explanation: A personality disorder can be defined as a collection of personality traits that have become fixed and rigid to the point that the person experiences inner distress and behavioral dysfunction. A personality disorder also can be considered a lifelong pattern of behavior that affects many areas of the person's life, causes problems, and is not produced by another disorder or illness.

The nurse educates a class on factors that enhance the risk of suicide. The instructor determines the need for additional education when the class identifies which as one of these factors?

Cautiousness

A client exhibiting an uncoordinated gait has presented at the clinic. The nurse knows that what brain structure has the function of balance and coordination?

Cerebellum

The nurse is caring for a mental health client who has developed difficulty with balance and muscle tone after a car accident that involved a head injury. Based on this information, what area of the brain was most likely injured in the accident?

Cerebellum

What part of the brain would be responsible for activities such as walking and dancing?

Cerebellum

On meeting a client for the first time, the nurse pats the client on the shoulder. The client expresses discomfort with the nurse's behavior. To which culture does the client most likely belong?

Chinese

A client with obsessive-compulsive disorder (OCD) is preparing for exposure and response prevention behavioral therapy. What does the nurse recommend as the first step?

Chronicle situations that trigger obsessions.

A nurse is preparing an educational program identifying the major barriers experienced by culturally diverse populations when accessing mental health services. Which information should the nurse include? (Select all that apply.)

Client and health care provider do not share a common language Health care beliefs are not shared by both client and health care provider Group value systems are not mutually accepted

A client tells the mental health nurse that the client is taking a sewing class to cope with the client's son's move to another state. The use of this adaptive coping skill is an example of which aspect in the therapeutic relationship?

Client self-exploration

The nurse walks into the client's room and finds the client sobbing uncontrollably. When the nurse asks what the problem is, the client responds, "I am so scared. I have never known anyone who goes into a hospital and comes out alive." On this client's care plan the nurse notes a nursing diagnosis of ineffective coping related to stress. What is the best outcome to be expected for this client?

Client will adapt relaxation techniques to reduce stress.

Which must be addressed to establish a trusting working relationship before proceeding with the assessment?

Client's feelings and perceptions

The nurse is preparing a psychosocial assessment for use with clients with various mental health conditions. For which group of clients should the nurse include mostly closed-ended questions?

Clients with adult attention deficit hyperactivity disorder

The major difference between bipolar I and bipolar II disorder is what?

Clients with bipolar II disorder do not have symptoms of mania that interfere enough to cause marked functional disturbances.

Into which personality disorder category are individuals placed whose behavior appears odd or eccentric? Cluster A Cluster B Cluster C Cluster D

Cluster A Explanation: Cluster A includes individuals whose behavior appears odd or eccentric, such as paranoid or schizoid personality disorder.

Which cluster of disorders corresponds to symptoms of being dramatic and emotional? Cluster A Cluster B Cluster C Cluster D

Cluster B Explanation: Cluster B includes individuals who appear dramatic, emotional, or erratic. Cluster C includes clients who appear anxious or fearful, such as avoidant, dependent, and obsessive-compulsive. Cluster A includes individuals whose behavior appears odd or eccentric. There is currently no Cluster D in the DSM-5.

An adult client was admitted to the psychiatric mental health unit following a suicide attempt. The client has responded well to treatment, so discharge is being considered. In anticipation of the client's discharge, the nurse should:

Collaborate with the family to make sure the client's home environment is safe.

The nurse performs an assessment of a client who presents with symptoms of mental illness for the first time. Which is the nurse's priority?

Collect comprehensive data

When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the client's actions and allows the nurse to do what?

Communicate concern and empathy to the client

A 68-year-old parent is the sole care provider for a 39-year-old child who has a diagnosis of bipolar disorder. The 39-year-old has been experiencing worsening of the illness over several years. The nurse should recognize that the parent is at risk for what?

Compassion fatigue

A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the most effective way for the nurse to proceed?

Complete the assessment in several short interactions.

A client spends hours stacking and unstacking towels. The client is repeatedly checking to make sure that the towels are in order of color. What term is used to identify this behavior?

Compulsion

The mental health nurse explains that the difference between an obsession and a compulsion can correctly be identified as what?

Compulsion involves repeating a purposeful action

Asking the client to complete serial sevens assesses what?

Concentration

Clients taking benzodiazepines need education about what?

Concomitant use of alcohol

When assessing a client immediately following electroconvulsive therapy (ECT), the nurse expects what in a client?

Confusion

A client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor?

Coping mechanism

A young parent tells the nurse, "I can't stop smoking. That is what I do to make myself feel better." What is the term used to describe this behavior?

Coping mechanism

Humans are able to adapt to physiological and psychological threats. Which is key to a person's adaptation to these situations?

Coping mechanisms

The nurse has a client who seems like the nurse's sister, with whom the nurse has a close and positive relationship. This phenomenon is best characterized by which term?

Countertransference

Which occurs when the nurse responds to the client based on personal unconscious needs and conflicts?

Countertransference

The nurse makes certain that her client, who is Hispanic, is able to attend Mass each Sunday morning in the hospital chapel. The client had asked the nurse to help the client get to Mass. The nurse is engaging in what type of behavior?

Culturally competent nursing care

Which represents the best brief definition of culture?

Culture is a shared structure for living.

A nursing instructor is reviewing the various biologic theories related to the etiology of depression. Which would the instructor most likely include as being involved when describing psychoimmunology (psychoneuroimmunology)?

Cytokines

Which would best assess a client's judgment? A. Interpreting proverbs B. Counting by serial sevens C. Spelling words backward D. Discussing hypothetical situations

D. Discussing hypothetical situations

A client is showing no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which term when documenting the client's affect? A. Restricted affect B. Broad affect C. Absent affect D. Flat affect

D. Flat affect

In the space of five minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as ... A. Tangential thinking B. Flight of ideas C. Lack of insight D. Labile mood

D. Labile mood

When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination? A. Abstract reasoning B. Judgment C. Insight D. Orientation

D. Orientation

During an assessment, which would be the most important question topic? A. Motor behavior B. History C. Roles and relationships D. Suicidal ideation

D. Suicidal ideation

In planning the care of a client who has been admitted to the hospital after a suicide attempt, an expected outcome should relate directly to what? A. The client's compliance with therapy B. The client's coping skills C. The client's mood and affect D. The client's refraining from suicide attempts

D. The client's refraining from suicide attempts

A client's frequent night awakenings, early morning rising, and daytime drowsiness have prompted the nurse to add a diagnosis of "disturbed sleep pattern" to the client's plan of care. What information should immediately follow this diagnosis? A. Previous attempts at alleviating the diagnosis B. The client's preferred intervention for the diagnosis C. The DSM-IV-TR diagnosis that corresponds to the nursing diagnosis D. The evidence supporting the diagnosis

D. The evidence supporting the diagnosis

The psychiatric nurse shows an understanding of the primary role a nursing diagnosis plays in nursing care when A. Using it to communicate client needs to other members of the nursing team B. Including references to it in client-focused documentation C. Including it to explain client needs to families and caregivers D. Using it to select client-specific nursing interventions

D. Using it to select client-specific nursing interventions

A professional boxer has suffered several concussions while boxing. Since retirement, the client has experienced periods of depression and suffers from short-term memory loss. Which provides the best explanation for the neurological basis of the client's symptoms?

Damage to the hippocampus

A client comes in for a therapy session and begins to have a panic attack. The therapist asks the client to relax in the chair and then gently asks the client to imagine the client in a very safe and calm place. This technique, often useful in anxiety disorders, is called what?

Deep breathing

An elderly client is admitted to the hospital with fatigue and weight loss of 20 pounds in 1 month. Upon further assessment, the client is diagnosed with depression. What other thing should the nurse assess this client for based on the weight loss?

Dehydration

A client with schizophrenia states that the client is God's messenger and the client's mission is to become president. The nurse documents these comments as evidence of what?

Delusional thinking

A nurse is assessing a client diagnosed with schizophrenia. When documenting the findings, which would the nurse identify as a positive symptom? Select all that apply.

Delusions Hallucinations

A psychiatric-mental health nurse is working on developing cultural competence. Which would be most appropriate for the nurse to do?

Demonstrate an appreciation of, and a genuine interest in, the individual and his or her cultural beliefs.

A 70-year-old client comes to the clinic with the client's daughter for group therapy. The client wants the daughter to do everything with the client, is afraid to be left alone, and is having difficulty making any individual decisions. Interventions for this client would center around the diagnosis of which personality disorder? Narcissistic Dependent Antisocial Schizoid

Dependent Explanation: Dependent personalities lack self-confidence and are unable to function in an independent role. Clients go to great lengths to seek nurturance and support from others. They experience difficulty in making everyday decisions and are preoccupied with fears of being left alone to care for themselves.

The client is a 29-year-old who is having a great deal of difficulty with a new job. The client has been unable to make decisions individually and feels overwhelmed when the client needs to begin a new project. The client often relies on one of her coworkers to help with decisions and projects. Which would describe the client correctly? Narcissistic personality Dependent personality Schizotypal personality Histrionic personality

Dependent personality Explanation: Clients with dependent personality have a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation. In addition, they need so much approval from others that they have tremendous difficulty making independent decisions or starting projects. In effect, they do not trust their own judgment and often believe that others have better ideas.

The nurse is conducting an admission assessment of a 41-year-old client. Each time that the nurse asks the client a question, the client defers to the client's spouse to answer the question. Such behavior is consistent with which personality disorder? Borderline personality disorder Histrionic personality disorder Dependent personality disorder Antisocial personality disorder

Dependent personality disorder Explanation: Persons with dependent personality disorder are polite and compliant but unable to function in an independent role or an assertive manner. Persons with borderline, histrionic, or antisocial personality disorders are more apt to overemphasize their own needs, priorities, and opinions.

Which term describes feelings of being disconnected from oneself as seen in a panic attack?

Depersonalization

Which mental health disorder has the most significant risk factor for suicide?

Depression

A nurse is caring for a client with posttraumatic stress disorder (PTSD). On reassessing the client, the nurse finds that the client shows signs of another psychiatric disorder as well. Signs of which psychiatric disorders would the nurse likely see in this client? Select all that apply.

Depression Anxiety disorder

When assessing an elderly client who has newly been diagnosed with an anxiety disorder, the mental health nurse's priority is to carry out which task?

Determine the client's risk for self-harm or harm to others

After teaching a class about the phases of the therapeutic relationship, the instructor determines a need for additional education when the class identifies which as a goal of the working phase?

Develop a sense of trust within the relationship.

A client was admitted to the psychiatric unit 3 days ago because of suicidal ideation. The client's suicidal risk has lessened considerably, and the client currently denies having any desire to kill himself or herself. In addition, the client is able to identify reasons why the client wants to be alive. Which nursing intervention would be most appropriate at this time?

Developing a personal plan for managing suicidal thoughts when they occur

A nurse pulls the curtains before changing the dressing of the surgical wound on the abdomen of a post-surgical client. What value is served?

Dignity

A client with a personality disorder is upset and calls the nurse a "stupid cow." Which is an effective initial response to this client's behavior? Demonstrate empathy by reaching out to touch the client. Discuss displacement of anger and set limits. Report the behavior to the health care provider so that consistency and consequences can be followed. Walk away from the client.

Discuss displacement of anger and set limits. Explanation: It is important to maintain open and clear lines of communication. The nurse should calmly set limits for the client's inappropriate expressions of anger. The client may view touch as a threat. Reporting the behavior to the health care provider would not be an initial response to the client's anger. Walking away and leaving the client does not help the client to learn to recognize anger without losing control.

The nurse in charge of an inpatient psychiatric unit is irritated with a client who has borderline personality disorder. Which step should the nurse take? Confront the client firmly about how the client's behavior makes the nurse feel. Direct the client to another staff member when the client tries to interact. Discuss the feelings with a colleague to promote coping. Arrange for the client to be transferred to another unit.

Discuss the feelings with a colleague to promote coping. Explanation: Clients often test the nurse for a response, and nurses must decide how to respond to particular behaviors. This can be tricky because even negative responses can be viewed as positive reinforcement for the client. Discussing feelings with a colleague can promote the nurse's adaptive coping with the stress of working with a client diagnosed with a personality disorder. Grossly inappropriate and disrespectful behaviors require confrontation. There is no need to direct the client to another staff member or arrange for a transfer.

A client diagnosed with body dysmorphic disorder (BDD) will primarily focus on what?

Discussing real or imagined defects in appearance, such as having a "long" nose

A nurse taking an admission history from a client suspects that the physician will diagnose major depression. For the physician to make this diagnosis, the client will have to demonstrate specific symptoms. The nurse knows that some of these symptoms include what? Select all that apply.

Disruption in sleep Disruption in appetite Disruption in concentration Excessive guilt

A culturally competent nurse can identify that some cultural and ethnic groups feel that mental illness is caused by what?

Disruption of harmony

Which occurs when thinking, feeling, or behaviors occur outside a person's awareness? Affective instability Impulsivity Dissociation Dichotomous thinking

Dissociation Explanation: A cognitive dysfunction seen in BPD is dissociation, or times when thinking, feeling, or behaviors occur outside a person's awareness. Affective instability is evidenced by erratic emotional responses to situations and intense sensitivity to criticism or perceived slights. Impulsivity occurs when there is difficulty delaying gratification or thinking through the consequences before acting on feelings, leading to unpredictable actions. Cognitively, people with BPD have dichotomous thinking. They evaluate experiences, people, and objects in terms of mutually exclusive categories, which informs extreme interpretations of events that would normally be viewed as including both positive and negative aspects.

A client in a psychiatric clinic has a history of two distinct personality states. The client is also unable to remember important personal information. What is the client likely to be suffering from?

Dissociative identity disorder

A nurse is caring for a client with posttraumatic stress disorder (PTSD). During the assessment interview, the nurse finds that the normally calm client at times becomes very aggressive and uses abusive language. When in the aggressive state, the client fails to recognize personal information. What is this behavior indicative of?

Dissociative identity disorder

A nurse is assessing a client and determines that the client is experiencing severe anxiety based on which finding?

Distorted sensory awareness

A client is brought to the emergency department by her son, who states, "I am unable to care for my mother anymore." The nurses identifies this son's ethical problem as being which of the following?

Distress

An elderly client falls out of bed after a nurse inadvertently left the side rails down. The nurse feels guilty and is upset about the incident. This is an example of which of the following types of ethical situations?

Distress

Before a client became depressed, the client was an active, involved parent with three children, often attending school functions and serving as a volunteer. The client is hospitalized for a major depressive episode and now reveals feeling like an unnecessary burden on the family. Which nursing diagnosis is most appropriate?

Disturbance of self-concept related to feelings of worthlessness

An elderly client in the hospital has not had a bowel movement for 3 days and the nurse planned to give the client a stool softener this morning. The client declined the medication, however, stating that the client's spouse will be bringing the client a herbal medication later in the day that is often used by members of their ethnic group. Which reaction demonstrates cultural care accommodation/negotiation?

Documenting the client's wishes and informing the client's care team what the client will be taking

A client has been diagnosed with Parkinson's disease. His symptoms of spasticity are related to a decrease in which neurotransmitter?

Dopamine

A client with Parkinson's disease is hospitalized on a medical unit. The nurse would be correct in identifying which neurotransmitter decreased in this disease?

Dopamine

A client with schizophrenia is exhibiting hallucinations and delusions. The mental health nurse knows that these symptoms are associated with hyperactivity of which neurotransmitter?

Dopamine

A nurse is aware that which of these represents a biochemical variation that may exist between clients of different cultures?

Drug metabolism

A client diagnosed with anxiety disorder has been prescribed benzodiazepine drugs. The nurse is explaining the possible side effects of the medications. Which side effects of the drug explained by the nurse is correct? Select all that apply.

Dry mouth Blurred vision Constipation

In what phase of the therapeutic relationship does the assessment process begin?

During the initiating or orienting phase

In order to help preserve and maintain a client's cultural belief regarding the need for "hot foods," which action should the culturally competent nurse take?

Educate the staff to help them assist the client in selecting food choices from the client's menu that supports this belief

While providing care to a client with psychosis, the psychiatric nurse uses communication initially for which reason?

Eliciting the client's cooperation through the establishment of trust

While interviewing a client, the nurse puts herself into the client's situation and tries to imagine what it would be like and how it would feel. The nurse is demonstrating what?

Empathy

A nurse is caring for a client with anxiety disorder. The nurse knows that the client will have dyspnea and tachycardia if she has an anxiety attack. According to the Carper's patterns of nursing knowledge, which pattern of knowing is this indicative of?

Empirical knowing

When comparing social interactions with therapeutic interactions, the nurse understands that therapeutic interactions do what?

Encourage personal goal setting

A client with obsessive-compulsive disorder (OCD) is being discharged from the health care facility. What does the nurse teach the client and the family?

Encourage the client to participate in follow-up therapy.

A nurse is preparing a teaching plan for a client with antisocial disorder. Which would the nurse most likely employ to promote successful education? Using a lecture approach to provide information. Engaging the client in a discussion to direct the topic to the client. Establishing general goals for teaching. Allowing the client to guide the teaching to other topics.

Engaging the client in a discussion to direct the topic to the client. Explanation: Client education efforts have to be creative and thought provoking. In teaching a person with antisocial disorder, a direct approach is best, but the nurse must avoid "lecturing," which the client will resent. In teaching the client about positive health care practices, impulse control, and anger management, the best approach is to engage the client in a discussion about the issue and then direct the topic to the major educational points. These clients often take great delight in arguing or showing how the rules of life do not apply to them. A sense of humor is important, as are clear teaching goals and avoiding being sidetracked.

A group of at-risk teenagers have successfully completed an outdoor training program in which they had to collaborate and conquer a number of challenges. The nurse should identify what likely outcome of this program?

Enhanced resilience for the participants

A client has been successfully treated on the psychiatric mental health unit following a suicide attempt. In preparation for discharge, the nurse should prioritize what action?

Ensuring a plan is in place for the client's community-based care

A client diagnosed with bipolar disorder is admitted to an inpatient psychiatric facility with acute mania and threats of attacking others in the household. Which would be the priority?

Ensuring safety

Which is considered a part of the social domain of the biopsychosocial interventions for the client diagnosed with borderline personality disorder (BPD)? Medication administration Establishing boundaries Self-harm prevention Nutritional management

Establishing boundaries Explanation: The social domain includes establishing boundaries as clients with BPD have difficulty maintaining satisfying interpersonal relationships. Medications, prevention of harm to self and others, and encouraging adequate nutrition are part of the biologic domain.

Nursing interventions for physical stress related illness should include what?

Establishing daily routines of meals and sleeping

The nurse is preparing to perform the initial interview of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What action should the nurse prioritize during this interaction?

Establishing therapeutic rapport with the client

Which assessment question is most likely to allow the nurse to differentiate between anxiety disorder due to a general medical condition and psychological factors affecting a medical condition?

Establishing whether the client's anxiety preceded the medical problem or whether the medical problem appeared first

A nursing student learns to model behavior exemplified by the instructor. This is an example of?

Ethical conduct

A nurse working on a critical care unit was informed by a client with multiple sclerosis that she did not wish to be resuscitated in the event of cardiac arrest. The client is no longer able to express her wishes, and the family has informed the physician that they want the client to be resuscitated. Aware of the client's wishes, the nurse is involved in a situation that may involve what?

Ethical distress

A nurse has been working for 15 hours continuously without a break. The nurse administrator insists that the nurse should go home and sleep. According to the Carper's patterns of nursing knowledge, which pattern of knowing is this indicative of?

Ethical knowing

Using the nursing process to make ethical decisions involves following several steps. Which step is the nurse implementing when she reflects on the decision-making process and the role it will play in making future decisions?

Evaluating

Which is the most effective way in which the nurse can assess the progress of a client's mental status based on the expected outcome of the therapeutic plan?

Evaluation

A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment?

Evaluation of insight and judgment

What occurs during the working phase of the nurse-client relationship?

Evaluation of mutually identified goals

A client is diagnosed with schizoaffective disorder. Which would the nurse identify as supporting this diagnosis?

Evidence of hallucinations and delusions accompanied by major depression

The nurse in charge of an inpatient psychiatric unit is frustrated and angry with a client who has borderline personality disorder. Which steps should the nurse take? Confront the client firmly but compassionately about how the client's behavior makes the nurse feel. Direct the client to another staff member when the client tries to interact. Examine the nurse's own feelings to discover the source of the nurse's anger. Ignore the feelings and move on from the client.

Examine the nurse's own feelings to discover the source of the nurse's anger. Explanation: Working with clients who have personality disorders is difficult. For this reason, nurses may find it helpful to discuss their emotional reactions to clients who have personality disorders with knowledgeable and trusted nurse colleagues. Doing so can facilitate nurses working through negative countertransferences, resulting in their tolerating and accepting feelings of irritation and anger as natural reactions to clients with personality disorders. This realization can increase the nurse's own self-awareness and sense of emotional control.

A teenager and the teenager's parents visit the clinic to discuss the teen's skin picking. There are many bleeding wounds and various stages of scabs located up and down both arms. The parents are very upset about this behavior and want it to stop. Which would the health care provider document?

Excoriation disorder

A client has been diagnosed with depression and states that the client is reluctant to receive treatment, stating that the client "would prefer to just wait this out." What is the nurse's most appropriate action?

Explain to the client that untreated depression often becomes increasingly severe and frequent over time

A nurse and client are in the orientation phase of the nurse-client relationship. Which behavior would occur during this phase? Select all that apply.

Explanation of the purpose of the relationship Discussion of client's expectations Reviewing the client history

Which is the most commonly seen adverse side effect of typical antipsychotics?

Extrapyramidal symptoms and tardive dyskinesia

A client is scheduled to have an elective surgical procedure performed and cannot decide if he wants to do it or not. He asks the nurse to help him make the decision because he does not feel that he knows enough about the procedure. Which of the following is the best way for this nurse to advocate for this client?

Facilitate the client's decision by allowing him to verbalize his feelings and by providing information to help him assess his options.

The nurse is providing care for a client whose history of intimate partner violence has resulted in posttraumatic stress disorder (PTSD). The client has few friends and states that the client is estranged from the client's family. How can the nurse best enhance the client's social support?

Facilitate the client's participation in a support group

When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what?

Failure to integrate identity, memory, and consciousness

Children learn cultural characteristics as they associate with others. Which entity has the most profound influence on the development of traditional values and practices?

Family

A nurse on the oncology unit is caring for a client on hospice care. The client is weak and is resting. The client's daughter comes storming onto the unit and demands that the nurse do everything she can to treat her mother. This is an example of what type of values conflict?

Family conflict

A nursing instructor is teaching a class on empathy. The instructor determines that the class needs additional education when the students identify that empathy involves what?

Feeling the same emotions that the client is feeling at a given time

Which is not involved in empathy?

Feeling the same emotions that the client is feeling at a given time

A female client is brought to the emergency room with matted hair, bruising, and malnutrition. The nurse suspects physical abuse and neglect. The nurse states, "this happens to many women." Which type of ethical approach is the nurse exhibiting?

Feminist

A client rings the call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics

Fidelity

A client informs the nurse that while on vacation at a theme park, the sound of fireworks triggered an intense reminder of a house fire experienced as a child. The client describes experiencing the smells from the fire, choking sensations, burning eyes and images of the flames destroying the insides of his home. Which symptom is experienced by the client?

Flashback

Following a change in job position, a minister asks a client how the client likes the new job. The client states, "Oh everything is great. I can really see myself going far in this new position." However, the client's voice is monotone and the client's face is nearly absent of affective expression. The minister is worried about this client and describes this facial expression as what?

Flat

Which type of affect is represented by showing no facial expression?

Flat

While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and moves facial muscles very little, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what?

Flat

A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process?

Flight of ideas

During a conversation, the client states, "It's raining outside and raining in my heart. Did you know that St. Valentine used to visit jails? I've never been to jail." The nurse can correctly identify this thought process as what?

Flight of ideas

Which antidepressant medication is classified as a selective serotonin reuptake inhibitor (SSRI)?

Fluoxetine

A 20-year-old client who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment?

Focused

A client has been on lithium for 3 weeks now. The client approaches the nurse, saying, "I feel like I'm going to throw up, and I can't even hold this cup of coffee straight. Why can't I do the crossword puzzle? I usually can do them in about 5 minutes." What is the appropriate nursing intervention at this time?

Further assess the client's symptoms, call the physician, hold the client's next dose of lithium, and have a blood level drawn because the client is showing symptoms of toxicity.

When teaching prevention to the parents of a 15-year-old client who recently attempted suicide by taking an overdose of alprazolam, the nurse describes which behavioral clue?

Giving away valued personal items

The mental health nurse is responsible for maintaining professional boundaries. Which would be an example of a professional boundary violation?

Giving personalized gifts to a client

A client with schizophrenia believes that the client has discovered how to jump to the moon. The nurse would document this belief as what?

Grandiose delusion

A client in the clinic appears to have elevated self-esteem, is more talkative than usual, and is easily distracted. This client is exhibiting symptoms of what?

Grandiosity

The nurse is meeting an African American client for the first time. Which nonverbal behavior is appropriate in this situation? Select all that apply.

Greet the client with a handshake Maintain eye contact with the client

A young adult client is brought to the outpatient mental health clinic by the client's father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father reports the client continues to hear voices despite adhering to the medication. Which term best describes the client's abnormality of perception?

Hallucination

A nurse is assessing a client with anxiety. Which signs and symptoms would the nurse attribute to sympathetic nervous stimulation? Select all that apply.

Heart racing Hypertension

How does the nurse help to decrease anxiety and build confidence in a client with obsessive-compulsive disorder?

Help the client find alternative methods to deal with anxiety.

Which theorist was most widely known for the belief that the cornerstone of all nursing care is the therapeutic relationship?

Hildegard Peplau

Under which component of the psychosocial assessment should the nurse document observations concerning the client's cultural considerations?

History

Which personality disorder is diagnosed more often in women? Histrionic Schizoid Antisocial Narcissistic

Histrionic Explanation: Borderline and histrionic personality disorders are diagnosed more often in women.

A nurse is caring for a client with major depression. The client tells the nurse that the client "just isn't sure that life is worth living." The nurse documents which nursing diagnosis as the priority?

Hopelessness related to symptoms of depression

The nurse is providing care for a recent immigrant from India. When the client identifies as a member of the culture's lowest caste, what concern should the nurse address first with the client?

How the client feels about seeking medical and psychiatric care

A client has posttraumatic stress disorder (PTSD) following a disaster that resulted in mass casualties. What question should the nurse prioritize when exploring the physical dimensions of this client's PTSD?

How would you describe the quality and quantity of your sleep since the incident?

Excess tyramine caused by monoamine oxidase inhibitors (MAOIs) can result in what?

Hypertensive crisis

While caring for a client in the hospital, the nurse becomes concerned that the client may be having thoughts of suicide. Which statement would be most therapeutic?

I've noticed something is bothering you. Please share you thoughts with me."

A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what?

Ideas of reference

During an initial assessment, a client exhibits pressured speech and points to patterns on the wallpaper stating, "This is the writing about the tsunami. Thousands of people died because I read the writing." Which term should the nurse use to document this observation?

Ideas of reference

The client tells the nurse, "I am regularly doing my sitting breathing exercises. Why do I still feel breathless while walking?" The nurse replies, "Sitting breathing exercises alone may not achieve the desired effects. You also should perform daily deep breathing exercises while walking. This should help you to reduce breathlessness while walking." According to the Peplau model, in which phase of the nurse-client relationship would this conversation occur?

Identification phase

The nurse assesses a client who experienced a traumatic brain injury (TBI) for deficits. Which question should the nurse ask to best monitor the client for parietal lobe involvement?

Identify a square object by reaching into a bag.

Which action by the nurse or client represents the working phase of the therapeutic relationship?

Identifying past ineffective behaviors

Which is considered a tricyclic antidepressant (TCA) used in the treatment of clients with panic disorder?

Imipramine

Emotional regulation skills are taught to those diagnosed with borderline personality disorder to manage what? Problem solving Impulsive behaviors Physical disability Psychotic behaviors

Impulsive behaviors Explanation: Emotional regulation skills are taught to manage intense, labile moods which can lead to engaging in impulsive behaviors. These skills involve helping the client label and analyze the content of the emotion and develop strategies to reduce emotional vulnerability and the desire to act impulsively.

Emotional regulation skills are taught to those diagnosed with borderline personality disorder to manage what? Problem solving Impulsive behaviors Physical disability Psychotic behaviors

Impulsive behaviors Explanation: Emotional regulation skills are taught to manage intense, labile moods which can lead to engaging in impulsive behaviors. These skills involve helping the client label and analyze the content of the emotion and develop strategies to reduce emotional vulnerability and the desire to act impulsively.

When documenting observations of the behaviors exhibited by a client diagnosed with borderline personality disorder, the nurse can correctly use which terms? Impulsive, self-destructive, unstable Impulsive, aggressive, and manipulative Perfectionistic, rigid, and controlling Emotional, dramatic, and theatrical

Impulsive, self-destructive, unstable Explanation: Borderline personality behavior is characteristically impulsive, self-destructive, and unstable. It is antisocial, not borderline personality, behavior that is characteristically impulsive, aggressive, and manipulative. Obsessive-compulsive, not borderline personality, behavior is characteristically perfectionistic, rigid, and controlling, whereas histrionic personality, not borderline behavior, is characteristically emotional, dramatic, and theatrical.

Gambling, binge eating, and engaging in unsafe sex are examples of what? Identity diffusion Dissociation Affective instability Impulsivity

Impulsivity Explanation: Impulsivity occurs in people who have difficulty delaying gratification or thinking through the consequences before acting on their feelings. Examples of impulsivity are gambling, spending money irresponsibly, binge eating, engaging in unsafe sex, and abusing substances. Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed. Dissociation occurs when thinking, feeling, or behaviors occur outside a person's awareness.

Which is one characteristic that differentiates generalized anxiety disorder (GAD) and panic disorder?

In GAD, the person usually does not experience eruptions of acute anxiety.

A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what?

Incongruent

The nurse is assessing a client and finds two enlarged supraclavicular lymph nodes. The nurse asks the client how long these enlarged nodes have been there. The client states, "I can't remember. A long time I think. Do I have cancer?" The nurse is aware that that body responds to stress. Which is an immediate physiologic response to stress the nurse would expect to see in this client?

Increased blood pressure

The nurse is planning a presentation to a group of nursing students on the topic of anxiety disorders. Which would the nurse include when describing panic disorder?

Individuals may believe they are having a heart attack when a panic attack occurs.

Which stage of Erikson's psychosocial development includes building confidence in one's own abilities?

Industry versus inferiority

The nurse is assessing a client and finds that the client has very low self-esteem. According to Erikson's stage of psychosocial development, this behavior may be an indication of failure in which stage?

Industry vs. inferiority (school age)

During the admission assessment of a 27-year-old client who has been diagnosed with an anxiety disorder, the nurse observes that the client is becoming increasingly restless and agitated. How should the nurse respond to this development?

Inform the client that the assessment can be postponed if the client is finding it overwhelming.

To care for an acutely suicidal client, which is the most effective initial mode of treatment?

Inpatient care

When providing care to a client who consistently attempts to manipulate the staff, the nurse can best maintain the therapeutic milieu by doing what? Instructing the staff to enforce all unit rules consistently Encouraging questions and discussing the client's concerns Promoting social ostracism of the client's exhibiting manipulation Scheduling staff one-on-one time with the client

Instructing the staff to enforce all unit rules consistently Explanation: Being consistent in expectations regarding rules and regulations for all clients will minimize the threat of manipulation. The other options provided are appropriate but do not represent the best way to minimize manipulation.

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which professional value?

Integrity

A group of students is reviewing information about the etiology of generalized anxiety disorder (GAD). The students demonstrate understanding of this information when they identify which as representing the bases for this disorder?

Intense worry and stress about work or simple family life

A client with a diagnosis of schizophrenia lacks insight into the illness. The client presents with significantly declined function and is consistently nonadherent with medications. Which medication administration route is best suited for optimal treatment of this client's condition?

Intramuscularly

A nursing role in providing client education regarding panic disorder includes which of the following? (Select all that apply.)

Introduction of appropriate coping skills Identification of alternate treatment modalities Involving family and support persons when appropriate Providing feedback to support the client

An adolescent client reveals that she is about to take a math test from her tutor. Nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety does what?

Is conducive to concentration and problem solving

Which is an inaccurate statement regarding a preconception?

It enables the nurse to get an accurate picture of the client's problems.

Why is understanding a client's cultural context important to a psychiatric mental health nurse?

It influences perceptions of health and illness.

The nurse is providing teaching to a client diagnosed with schizoaffective disorder. The nurse should explain to the client that which is true about this disorder?

It is a mix of psychotic and mood symptoms.

What is the most significant benefit of using Beck's Depression Inventory to the practice of evidence-based nursing practice?

It is a standardized, reliable depression tool.

The partner of a client with obsessive-compulsive disorder (OCD) reports that the client regularly exhibits "strange behaviors." What does the nurse tell the partner about these behaviors? Select all that apply.

It is an attempt by the client to overcome anxiety. It is associated with an irrational persistent thought. The client will repeat the act several times during the day.

A psychiatric-mental health nurse is feeling highly anxious before conducting an interview with a client. The nurse's experience of anxiety will impact the client assessment in which way?

It will be detrimental to the interaction by decreasing the nurse's focus and attention.

Which correctly describes the primary effect of a selective serotonin reuptake inhibitor (SSRI) antidepressant drug?

Its ability to block the reuptake of serotonin

When the nurse asks the client, "If you found a stamped addressed envelope on the ground, what would you do?" the nurse is assessing which component of the assessment?

Judgment

A nurse is interviewing a client who is suffering from posttraumatic stress disorder (PTSD). Which intervention would help the nurse ensure the client's comfort during the interview?

Keep environmental noises to a minimum.

The nurse is caring for a client who immigrated from Cambodia. What might the client perceive as the cause of the client's mental illness?

Khmer Rouge brutalities

At the end of a 12-hour shift, the nurse overhears that a client that the nurse has cared for before is being readmitted to the mental health facility. The nurse says to the charge nurse, "I better stay around for a couple of hours. I am the only one the client will talk to." This is a warning sign that the nurse is experiencing which obstacle to establishing a therapeutic relationship?

Lack of self-awareness

As a culture, what do African Americans believe is the cause of mental illness?

Lack of spiritual balance

A nurse interviews a new client in the day room of the psychiatric unit. The nurse is wearing a jacket and a bag and frequently asks the client to repeat the last statement. The nurse's demeanor with the client is reflective of what?

Lacking genuine interest

A parent of a high school student age 17 years is allowing the child to make the decision on the college he will attend. When the child requests direction from the parent in making this decision, the parent responds by informing him that he will need to make this decision on his own. This is an example of which type of value transmission?

Laissez-faire

The nurse is managing the care for a post operative client. How does the nurse demonstrate advocacy?

Limiting visitors due to client complaining of pain

Which is considered the first-line treatment for bipolar disorder?

Lithium

A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy?

Liver function

A client with psychosis who was recently admitted to a psychiatric unit says to the nurse, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech?

Loose associations

As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process?

Loose associations

The nurse is assessing a client who recently immigrated to the United States. The client is experiencing a high level of stress and reports that nobody in the workplace is willing to work with or talk to the client. What is the most likely cause of stress in the client?

Low sense of belonging

A client with a history of intimate partner violence has been diagnosed with posttraumatic stress disorder. The client is wholly unwilling to discuss any aspects of personal history or current mental status with the nurse. What is the nurse's best initial action?

Make efforts to demonstrate empathy to the client

A nurse caring for a client with borderline personality disorder (BPD) consistently informs the client of the length of the relationship and routinely prepares the client for termination and the end of hospitalization. Which is the nurse trying to prevent? Poor social skills Depression Mania Maladaptive expression of emotions

Maladaptive expression of emotions Explanation: Informing the client of the length of the relationship as much as possible allows the client to engage in and prepare for termination with a safe and adaptive expression of the emotions attached to the ending of the relationship.

A nurse is caring for a group of hospitalized clients with various psychiatric diagnoses. The nurse identifies which client as having the highest risk for a suicide attempt?

Man with major depressive disorder

A 30-year-old woman has been brought to the emergency department after causing a disturbance. She is wearing a pair of tight, pink yoga pants, high heels, a sports bra, and a bright-colored hat. The woman's care providers would recognize that the woman's dress may suggest what?

Mania

A 46-year-old client sustained a closed-head injury 4 hours ago. The client now presents to the emergency department because the client is having difficulty breathing. This is a result of swelling surrounding which brain structure?

Medulla oblongata

The brain stem consists of which structure?

Midbrain

Which stage of psychosocial development involves establishing the next generation?

Middle adult

A client has been diagnosed with major depression. The client reports that the client often wakes up during the night and has trouble returning to sleep. The nurse interprets this finding as suggesting what?

Middle insomnia

During which type of anxiety does a person's perceptual field actually increase?

Mild

Which level of anxiety helps the client focus the client's attention to learn, problem solve, think, act, feel, and protect himself or herself?

Mild

Antisocial personality disorders are assessed with which tool?

Milton Clinical Multiaxial Inventory (MCMI)

The mental health nurse is gathering a health history on a new client. The client is constantly pacing the floor and is concerned only with stating that the client is about to die. The nurse would classify this level of anxiety as what?

Moderate

A client who has been taking lithium for bipolar disorder is admitted to the hospital with the following symptoms: dry mouth, nausea and vomiting, blurred vision, dizziness, and muscle twitching. What should the nurse suspect?

Moderate lithium toxicity

A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention?

Monitoring blood levels of the medication.

A combat veteran with posttraumatic stress disorder has been admitted to the psychiatric unit after consuming a large number of antidepressants and drinking half a quart of whiskey 2 days earlier. What aspect of care should the nurse prioritize?

Monitoring the client for suicidal ideation

A nursing instructor is developing an education plan for a group of students about schizophrenia and schizoaffective disorders. The instructor identifies that in addition to psychosis, what other condition must be present at the same time for a diagnosis of schizoaffective disorder?

Mood disturbance

When a client is experiencing panic, which is the priority intervention?

Move the client to a quiet environment.

When interacting with a client for the first time, which information would be appropriate for the nurse to disclose? Select all that apply.

Name Level of education Reason for being on the unit

Which personality disorder is categorized as a Cluster B disorder? Paranoid personality disorder Obsessive-compulsive personality disorder Schizoid personality disorder Narcissistic personality disorder

Narcissistic personality disorder Explanation: Clients with Cluster B disorders display dramatic, emotional, and attention-seeking behaviors. These include antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder.

A client receives the first dose of fluphenazine. The next day, during the follow-up appointment, the nurse finds the client is confused and mute, and the client's temperature is 103°F. The client also presents with rigidity and diaphoresis. The nurse should investigate further for which condition?

Neuroleptic malignant syndrome

A client with a diagnosis of schizophrenia has been brought to the emergency department by a worker from the group home where the client resides. The worker states that the client has stopped taking medications and drank 2 to 3 gallons of water over the past several hours. What assessments should the nurse who is caring for this client prioritize?

Neurological assessment and monitoring of electrolyte levels

A nurse is preparing an inservice program for a group of mental health nurses on the topic of borderline personality disorder. When discussing the need for hospitalization, which would the nurse include as the most likely reason for inpatient hospitalization? Dichotomous thinking Identity diffusion Affective instability Nonsuicidal self-injury

Nonsuicidal self-injury Explanation: Hospitalization is necessary during acute episodes involving nonsuicidal self-injury, but once this is controlled, the client is discharged. Dichotomous thinking, identity diffusion and affective instability characterize borderline personality disorder. Unless these are acute and lead to parasuicidal behavior, the client is treated in outpatient or day treatment settings.

Racial bias is evident in mental health care treatment, as reflected by what?

Nonwhite clients are institutionalized much more frequently than are whites.

What is one way in which nurses can develop cultural self-awareness?

Objectively examine personal beliefs, values, and practices.

A client attends an outpatient mental health clinic accompanied by the client's spouse for an assessment. The client's spouse reports the client is easily irritated if the home is not maintained in a specific order and when the client is unable to complete a "to do" list on time. The client has a serious and formal demeanor. Which personality disorder best describes this client? Obsessive-compulsive personality disorder Avoidant personality disorder Narcissistic personality disorder Paranoid personality disorder

Obsessive-compulsive personality disorder Explanation: Perfectionism, rigidity, controlling behavior, and extreme orderliness characterize people with obsessive-compulsive personality disorder. Their rigid perfectionism often results in indecisiveness, preoccupation with detail, and an insistence that others do things their way. Resisting authority and insisting that they and they alone are right are common behavioral patterns. Hoarding worthless objects, displaying stinginess, working excessively, showing stubbornness, and moralizing also occur to a high degree in people with this disorder.

According to Purnell's model of cultural competence, which would not be included as a primary cultural characteristic?

Occupation

For which reason is depression in older adults often undiagnosed and untreated?

Older adult depression is often seen as "normal aging."

A group of nursing students is reviewing material about assessing mental status. The students demonstrate a competent understanding of this assessment when they identify which as a component of cognitive functioning?

Orientation

It is the nurse's responsibility to define the boundaries of the relationship during which phase of the nurse-client relationship?

Orientation

The nurse is reviewing the client's documented history and considers how the nurse can be most therapeutic to a client who was recently admitted to a psychiatric unit. The nurse is functioning in which phase of the therapeutic relationship?

Orientation

When the mental health nurse asks the client, "Do you recall what month and year this is?" the nurse is assessing which part of the mental status examination?

Orientation

A nurse is caring for a client on an inpatient mental health unit of a hospital. The nurse tells the client, "You are scheduled to attend therapy sessions every morning at 9:00 a.m. Please make sure that you complete your morning routine, such as using the restroom, bathing, and eating breakfast, before you come for the sessions." Which phase of the nurse-client relationship does this communication indicate, according to the Peplau's model?

Orientation phase

A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline?

Orthostatic hypotension

The nurse can document correctly that a client diagnosed with an anxiety disorder is experiencing moderate anxiety when the nurse observes the client doing what?

Pacing and repeatedly asking staff what time the "doctor will be here."

The nurse has read in a client's admission record that the client has been taking propranolol for psychiatric, rather than medical, reasons. The nurse should recognize that the client likely has a history of which mental health condition?

Panic disorder

A client is diagnosed with a personality disorder manifested by odd, eccentric behavior. Which personality disorder would be associated with this manifestation? Avoidant Dependent Obsessive-compulsive Paranoid

Paranoid Explanation: Paranoid, schizoid, and schizotypal personality disorders are characterized by behavior that is odd or eccentric. Avoidant, dependent, and obsessive-compulsive personality disorders are characterized by anxiety and fearfulness.

A client admitted on the inpatient mental health unit has been suspicious of other clients on the unit. This client is often angry at others' comments, and carries a grudge against a roommate for accidentally using the client's bath towel. Which personality disorder is most likely the client's diagnosis? Antisocial Borderline Paranoid Histrionic

Paranoid Explanation: People with paranoid personality disorder are suspicious and quick to take offense, project negative feelings onto others, have few friends, project hidden meaning into innocent remarks, are guarded, and are quick to react with anger and counterattack in response to imagined character or reputation attacks.

When the nurse helps the cognitively impaired client bathe and dress, what role is the nurse assuming?

Parent surrogate

A nursing faculty is discussing laissez-faire values with students. Which of the following is an example of those values?

Parents allowing a child to decide not to have an intravenous line inserted

A nurse obtains an order for a bed alarm for a confused client. This is an example of which of the following ethical principles?

Paternalism

A nurse is in the orientation phase of the nurse-client relationship with a client diagnosed with a mental disorder. When interviewing the client during this first encounter, which information would be most important about the client for the nurse to obtain?

Perception of the problem

A newly admitted client's history includes multiple suicide attempts. How can the nurse on the psychiatric-mental health unit best protect the client's safety?

Performing vigilant assessment and close observation

While being assessed, a client with schizophrenia states, "Everywhere I turn, the government is watching me because I know too much. They are afraid that I might go public with the information about all those conspiracies." The nurse interprets this statement as indicating which type of delusion?

Persecutory

A client is admitted to a mental health unit with reports of fatigue, poor appetite, and difficulty making decisions. The client also states feeling unhappy most of the time for "as long as the client can remember." Which diagnosis should the nurse anticipate for this client?

Persistent depressive disorder

Which characteristics should the nurse implement when conducting a psychosocial assessment?

Personal

A nurse who has worked with a client with post-traumatic stress disorder (PTSD) regularly for several months stares blankly at the nurse for a long time. The nurse understands that the client is dissociating. According to the Carper's patterns of nursing knowledge, which pattern of knowing is this indicative of?

Personal knowing

The nurse is working in a mental health facility. The nurse ensures that all able-bodied clients in the facility participate in the group exercise program every morning. For which reasons would this intervention be beneficial for the clients with mental illness? Select all that apply.

Physical activity improves mood and lowers anxiety. Physical activity prevents medical conditions. Physical activity can foster a sense of well-being.

A South Asian client is being discharged from the hospital after knee surgery. The nurse is informing the client about the necessary follow-up appointment. Which should the nurse anticipate regarding the client's follow-up appointment?

Plan to see the client at the scheduled time, sharp.

The delivery of culturally competent nursing care requires the incorporation of which concept into the planning?

Planning and implementing care in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations.

A female nurse enters the room of a male Cambodian client who is about to undergo a procedure. When the nurse tries to apply cardiac monitoring leads to the client's chest, the client recoils and makes a disapproving facial expression. Which explains the client's reaction to the nurse's actions?

Politeness is highly valued in the Cambodian culture

Police officers bring a client to the mental health unit for admission. The client had been directing traffic on a busy city street, shouting rhymes such as "to work, you jerk, for perks" and making obscene gestures at cars that came close to the client. When the client's spouse is contacted at work, the spouse reports that the client stopped taking lithium 3 weeks ago and has not slept or eaten for 3 days. With which two features characteristic of the manic phase of bipolar disorder can the nurse identify?

Poor judgment and hyperactivity

What relaxation technique does the nurse teach the client with obsessive-compulsive disorder (OCD)?

Practicing deep breathing

The nurse in an psychiatric inpatient facility encourages clients to attend daily prayer sessions. What is the most likely reason for the nurse's action? Choose the best answer.

Prayer helps in coping with stress.

The client, age 2, is with his mother in clinic today. He continues to grab for the otoscope, then looks sheepishly toward his mother as she tells him "no". According to Kohlberg (1964), the client is in which stage of learning?

Preconventional

The Rorschach test is designed to provide what type of information about the client?

Preferred coping styles

A drug that is an antagonist functions to do what?

Prevent natural or other substances from activating cell function

`The primary nursing goal for a client who is admitted for suicidal ideation or attempt would be what?

Prevent self-destructive behavior.

The nurse is caring for a client recently diagnosed with a psychiatric illness. Which key areas should the nurse focus on while caring for this client? Select all that apply.

Preventing deterioration of mental status Promoting mental health Promoting physical health

Which is the greatest predictor of a future suicide attempt?

Previous attempt

Which would not be included as a purpose of the psychosocial assessment?

Previous compliance with treatment regimen

A family member of an adolescent who has expressed a desire to commit suicide asks the nurse, "What might predict the possibility of future suicide attempts?" Which would the nurse include in the response?

Previous suicide attempt

When interviewing a Native American client, the nurse avoids which behavior because it is deemed unacceptable by the client's culture?

Prolonged eye contact

A client has admitted to the nurse that the client is "tempted to end it all." How can the nurse prevent a future malpractice lawsuit if the client makes a suicide attempt?

Promptly act on, and document, the client's statement.

A client with borderline personality disorder has been admitted to the inpatient unit after being found in the client's parents' bedroom, burning the client's arm with an iron. This injury required a brief stay in the hospital's burn unit prior to transfer to your psychiatric unit. Which is the nursing care priority for this client during the first 24 hours of admission? Suicidal assessment Working on self-esteem Impulse control Protection from self-mutilation

Protection from self-mutilation Explanation: Clients with borderline personality disorder become intensely and inappropriately angry if they believe others are ignoring them and consequently may impulsively try to harm or mutilate themselves.

The nurse has been asked to assess a 54-year-old client's memory. Which technique would allow the nurse to evaluate recent memory?

Provide the client with three words and ask the client to recall the words several minutes later.

The psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what?

Provides long, irrelevant explanations when asked why the client abuses alcohol.

A nursing instructor is describing the care of a client with acute anxiety to a class of nursing students. The instructor determines that more education is necessary when the students identify which intervention as appropriate?

Providing the client with a comforting touch

A client has been started on an antipsychotic medication and is exhibiting muscle stiffness of the arms, slowness of gait, and tremors. Which extrapyramidal syndrome (EPS) is the client displaying?

Pseudoparkinsonism

A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring?

Pseudoparkinsonism

Which extrapyramidal side effect is noted by a client who has bradykinesia and a shuffling gait?

Pseudoparkinsonism

Which would be considered a "usual or expected" response during the first few sessions?

Rambling due to nervousness

Pharmacotherapy is essential to the management of the client with bipolar disorder. The nurse understands that the goals for such therapy are what? Select all that apply.

Rapid control of symptoms Decreased frequency of manic episodes Prevention of future episodes Decreased severity of manic episodes

During the termination phase, a client begins to raise old problems that have already been resolved. Which would be appropriate nursing responses? Select all that apply.

Reassure the client that they already covered these issues. Review with the client the learned methods to control the problems.

A client with posttraumatic stress disorder (PTSD) has been prescribed lorazepam 1 mg SL q6h PRN. What assessment finding indicates that treatment is having the desired effect?

Reduced anxiety

A client with bipolar disorder is currently experiencing mania. The nurse identifies a nursing diagnosis of sleep deprivation related to the effects of the mania. Which would be most appropriate for the nurse to include in the client's plan of care?

Reducing environmental stimuli

Relaxation techniques help clients with anxiety disorders because they can promote what?

Reduction of autonomic arousal

The nurse is scheduled to begin a clinical rotation at an outpatient mental health clinic that is in a neighborhood with a large number of Asian residents. Since the nurse does not share this cultural background with the potential clients, which is the best way for the nurse to ensure cultural sensitivity in this setting?

Reflect on, analyze, and foster awareness of the nurse's own culture

When asking a client to "tell me how having schizophrenia has affected your life," the nurse is assessing the client's capacity for what?

Reflective insight

A client begins to exhibit hallucinations and delusions along with disorganized speech after forgetting to take antipsychotic medication. The nurse suspects that the client is at which point in the clinical course of the disorder?

Relapse

Which nonverbal cue should the nurse be especially alert for when caring for a Filipino client?

Relying on facial expressions to convey various emotions

A nurse is conducting a 6-week social skills training program. A young adult with schizophrenia asks the nurse to call the client on the weekends so the client has someone to talk to who really cares. Which action should the nurse take?

Remind the client about the importance of boundaries to keep the relationship therapeutic

Children of parents who abused alcohol and substances are able to develop self-esteem and self-efficacy by developing which characteristics?

Resilience

A client experiencing stress has tachycardia and tachypnea. On the basis of the physiological model of the general adaptation syndrome, in which stage is this client?

Resistance

During which phase of the nurse-client relationship may the client express ambivalence about the relationship?

Resolution

A 24-year-old with schizophrenia and paranoid delusions is admitted to the hospital. The student nurse asks the charge nurse about what approach to take with the client, who has been exhibiting hostility and isolation. Which approach would be the most appropriate direction from the charge nurse?

Respect the client's need for personal space and avoid physical contact.

The nursing faculty is explaining value transmission. The example of a child receiving an exemplary report from school and being given money from the parents can be described as what type of behavior?

Rewarding

A client with PTSD is brought to the nurse in a primary care setting with lower back pain after falling from a ladder. The client became aggressive with their partner before agreeing to come to the setting. The nurse smells alcohol on the person's breath and the client does not make eye contact or expand openly to assessment questions. Which are priority nursing assessments? Select all that apply.

Risk for self-injury Risk for aggression Risk for substance abuse

Which would be the priority nursing diagnosis for a client diagnosed with borderline personality disorder (BPD)? Disturbed thought process Ineffective coping Personal identity disturbance Risk for self-mutilation

Risk for self-mutilation Explanation: One of the first diagnoses to consider is risk for self-mutilation because protection of the client from self-injury is always a priority. Disturbed thought process, ineffective coping, and personal identity disturbance are all potential nursing diagnoses, but they would not be the priority.

Which would be the priority nursing diagnosis for a client diagnosed with borderline personality disorder (BPD)? Risk for self-mutilation Ineffective coping Disturbed thought process Chronic low self-esteem

Risk for self-mutilation Explanation: One of the first diagnoses to consider with this client population is risk for self-mutilation, because protection of the client from self-injury is always a priority. The other diagnoses may be appropriate for the client, but risk for self-mutilation would be the priority.

A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has priority?

Risk for suicide related to highly lethal plan

Which must the nurse consider a priority in the assessment of mental status?

Safety

A client is receiving lithium carbonate for the treatment of mania. The nurse would reinforce which teaching component regarding lithium treatment?

Schedule bloodwork for lithium levels.

A nurse is caring for a client diagnosed with schizophreniform disorder. The nurse demonstrates understanding of this disorder when identifying that the client is at risk for developing what?

Schizophrenia

What are the signs and symptoms of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders?

Schizophrenia lasts at least 6 months and includes at least 1 month of 2 or more active-phase symptoms.

During the orientation phase of the nurse-client relationship, the client is involved with what?

Seeking assistance

A client who has attempted suicide has an underlying diagnosis of depression. Which would the nurse anticipate being ordered for the client?

Selective serotonin reuptake inhibitor

A nursing student is caring for an elderly client who is taking sertraline for depression. The instructor quizzes the student about the medication and its actions. To what classification of drugs should the student assign sertraline?

Selective serotonin reuptake inhibitor

A nurse is developing a plan of care for a client with panic disorder that will include pharmacologic therapy. Which would the nurse most likely expect to administer?

Selective serotonin reuptake inhibitor (SSRI)

A client is diagnosed with panic disorder. When considering the neurochemical theory of the disorder, which would the nurse expect to administer as the drug of choice initially?

Selective serotonin reuptake inhibitors

A client with major depression is prescribed paroxetine. The nurse develops an education plan for the client based on the understanding that this drug belongs to which class of drugs?

Selective serotonin reuptake inhibitors

Which medication classification has been used to treat social phobia?

Selective serotonin reuptake inhibitors (SSRIs)

Evaluating the cultural practices of others according to the nurse's own culture can be counteracted by the nurse's use of which practice?

Self-analysis

A nursing instructor is describing the nurse-client relationship to a group of nursing students. Which would the instructor emphasize as crucial for establishing and maintaining the relationship?

Self-awareness

A client with a psychiatric disorder is scheduled to undergo a personality test. Which explanations can the nurse provide when the client asks why the test must be completed? Select all that apply.

Self-concept Impulse control Defense mechanisms

A client relates that the client has panic attacks and, during the attacks, rushes to the emergency department because the client feels like the client is dying. The nurse discloses that the nurse has had panic attacks during which the nurse also felt very fearful. Which statement represents an accurate statement about this self-disclosure?

Self-disclosure can help normalize the client's experience.

Which characteristic would be most prevalent in an individual demonstrating low self-efficacy?

Self-doubt

The nurse is admitting a client with histrionic personality disorder to the inpatient unit. The nurse would anticipate that this client may exhibit which behavior? Manipulation Distrust Perfection Self-dramatization

Self-dramatization Explanation: The client with histrionic personality disorder uses self-dramatization and emotional exaggeration to draw attention to self. The antisocial personality tends to be manipulative. Paranoid personality disorder causes the client to be suspicious and distrust others. In obsessive-compulsive personality disorder, the client's perfectionism interferes with task completion.

Clients with borderline personality disorder (BPD) are usually admitted to the inpatient setting because they exhibit what? Aggression Splitting Self-harm Impulsivity

Self-harm Explanation: Clients with BPD are usually admitted to the inpatient setting because of threats of self-harm.

A nurse is caring for a client diagnosed with bipolar disorder. The client is experiencing a manic episode. The nurse would be especially alert for signs indicating what?

Self-injury

The most serious consequence of behaviors seen in borderline personality disorder includes what? Identity diffusion Impulsivity Self-injury Dissociation

Self-injury Explanation: The turmoil and unsuccessful interpersonal relationships and social experiences associated with borderline personality disorder may lead the person to undermine the self when a goal is about to be reached. The most serious consequences are suicide attempts and parasuicidal behaviors. Identity diffusion occurs when a person lacks aspects of personal identity or when personal identity is poorly developed. Impulsivity occurs in people who have difficulty delaying gratification or thinking through the consequences before acting on their feelings. Dissociation occurs when thinking, feeling, or behaviors occur outside a person's awareness.

As part of a client's treatment plan for borderline personality disorder, the client is engaged in dialectical behavior therapy. As part of the therapy, the client is learning how to control and change behavior in response to events. The nurse identifies the client as learning which type of skills? Emotion regulation skills Mindfulness skills Distress tolerance skills Self-management skills

Self-management skills Explanation: Self-management skills focus on helping clients learn how to control, manage, or change their behavior, thoughts, or emotional responses to events. Emotion regulation skills are taught to manage intense, labile moods and involve helping the client label and analyze the context of the emotion, as well as developing strategies to reduce emotional vulnerability. Teaching individuals to observe and describe emotions without judging or blocking them helps clients experience emotions without stimulating secondary feelings that may cause more distress. Mindfulness skills are the psychological and behavioral versions of meditation skills usually taught in Eastern spiritual practice; they are used to help the person improve observation, description, and participation skills by learning to focus the mind and awareness on the current moment's activity. Distress tolerance skills involve helping the individual tolerate and accept distress as a part of normal life.

A client in the emergency department has self-inflicted wounds on both arms. Assessment reveals that the client was diagnosed with borderline personality disorder 6 months ago, for which the client has been receiving outpatient treatment. The client tells the nurse that the client recently found out the client's therapist is moving and will no longer be able to work with the client. What is the priority nursing diagnosis for this client? Anxiety Self-mutilation Loneliness Stress

Self-mutilation Explanation: Although all the above are problems for this client, the highest priority nursing diagnosis is self-mutilation. If left untreated, self-mutilation can lead to suicide attempts.

A nurse is assessing the vital signs of a client in the cardiac clinic. The nurse observes the client's blood pressure and heart rate are higher than what is normally expected for this client. The client tells the nurse, "It makes me nervous to come into the clinic." What is the most likely explanation for the unexpected change in the client's vital signs.

Self-preservation

When assessing risk of suicide, which are important assessment components? Select all that apply.

Seriousness of suicidal ideation Degree of hopelessness Previous attempt Lethality of method

A client hospitalized for uncontrolled manic behavior constantly belittles other clients on the general ward and is demanding special favors from the nurses. Which is the most effective nursing intervention for this client?

Set limits with specific and consistent consequences for belittling or demanding behavior.

Which is not a primary behavior of caring, one of the core values of nursing?

Setting boundaries within the relationship

A client on an inpatient psychiatric unit has features of borderline personality disorder. The client is frequently angry, has an unstable sense of self, and is highly impulsive. The client can be verbally abusive to staff, who feel manipulated by the client's behaviors. Which intervention does the nurse determine as priority? Social skills training Setting limits Stress management techniques Increased recreational therapy

Setting limits Explanation: The nurse introduces the use of limit setting when clients engage in manipulative, acting-out, dependent, or similar inappropriate behaviors.

A nurse determines that a client who is experiencing anxiety is using relief or primitive survival behaviors. The nurse determines that the client is experiencing which degree of anxiety?

Severe

Which side effect is associated with selective serotonin reuptake inhibitors (SSRIs)?

Sexual dysfunction

Considering the nature of its content, which areas may be the most uncomfortable or difficult for the nurse to assess?

Sexuality

A nurse is caring for an older adult who has cancer and is experiencing complications requiring a revision of the plan of care. The nurse sits down with the client and the family and discusses their preferences while sharing her judgments based on her expertise. Which of the following types of health care decision making does this represent?

Shared decision making

When conducting an assessment with a client from another country, what can a nurse do to ensure the client receives culturally sensitive care?

Show genuine interest in the client's culture and personal life experiences.

A client taking lithium for bipolar disorder is having mild diarrhea. The nurse informs the client that this is an example of what?

Side effect

Eight months ago, a client was in a hotel fire and was the last person to be rescued from the roof. The client watched the client's spouse burn to death from the helicopter. The client continues to have nightmares and is fearful that the client will die in a fire. An appropriate nursing diagnosis for the client is what?

Sleep pattern disturbance related to recurrent nightmares

The nurse is caring for a client who has recently developed psychomotor retardation. Based on this information, which behavior would the nurse expect to see in this client?

Slowness of body movements

A client receiving lithium therapy has a plasma blood concentration of 2.2 mEq/L. Which would the nurse expect to assess?

Slurred speech

A 30-year-old client who has been unemployed secondary to the client's anxiety disorder states that the client would like to have a job where the client is alone and no one needs to evaluate the client's work. The nurse interprets these comments as an indicator of what?

Social anxiety disorder

Which is a primary risk factor for suicide?

Social isolation

A 30-year-old client who has been unemployed secondary to anxiety disorder states that the client would like to have a job where the client is alone and no one needs to evaluate the client's work. The nurse interprets these comments as an indicator of what?

Social phobia

A nurse is caring for a client with schizoid personality trait. When developing a plan of care for the client, which would a nurse most likely include? Social skills training Anger management training Relaxation techniques Coping skills training

Social skills training Explanation: Because individuals with schizoid personality trait often lack customary social skills, social skills training is useful in enhancing their ability to relate in interpersonal situations. The primary focus is to increase the client's ability to feel pleasure. The nurse balances interventions between encouraging enough social activity and too much activity, which prevents the individual from retreating to a fantasy world that becomes intolerable. Anger management, relaxation techniques, and coping skills are not appropriate for a client with schizoid personality trait.

A client diagnosed with delusional disorder who uses excessive health care resources most likely has which type of delusions?

Somatic

A nurse is assessing a client who is reporting the sensation of "bugs crawling under the skin" and intense itching and burning. The client states, "I know bugs have invaded my body." There is no evidence to support the client's report. The nurse interprets this as which type of delusion?

Somatic

A nurse is caring for a client who has a diagnosis of posttraumatic stress disorder (PTSD) and has been referred for care. During the client interview, what statement by the client should the nurse prioritize for follow-up?

Sometimes I feel like I can't even cope unless I've had a few drinks to calm my nerves.

A nurse receives feedback from a colleague that the nurse tends to maintain direct eye contact while speaking to clients. Which client may interpret this nonverbal communication as disrespectful?

South Asians

Which condition involves a persistent, irrational fear attached to an object or situation that objectively does not pose a significant danger?

Specific phobia

The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform?

Spell "America" backward.

For clients with borderline personality disorder, there is a tendency to see the world as either good or bad. As a result, these clients use the primitive defense of what? Regression Denial Splitting Compensation

Splitting Explanation: Because borderline personality disorder clients view the world in absolutes, nurses and other treatment team members are alternatively categorized as all good or all bad. The primitive defense is termed splitting and presents clinicians with a challenge to work openly with each other, as well as the client, until the issue can be resolved through team meetings and clinical supervision. Regression, denial, and compensation are ego defense mechanisms

When clients diagnosed with borderline personality disorder (BPD) see nurses as either all good or all bad, the client is using which primitive defense? Splitting Defending Invalidating Projective identification

Splitting Explanation: Because clients with BPD view the world in absolutes, nurses and other treatment team members are alternately categorized as all good or all bad. This primitive defense is called splitting, and it presents clinicians with a challenge to work openly with each other, as well as the client, until the issue can be resolved through team meetings and clinical supervision. This is not an example of defending, invalidating, or projective identification.

Which occurs when a client tends to adore and idealize other people even after a brief acquaintance but then quickly leaves them if these others do not meet the client's expectations in some way? Splitting Thought stopping Decatastrophizing Positive self-talk

Splitting Explanation: Splitting occurs in this situation. Thought stopping is a technique to alter the process of negative or self-critical thought patterns such as, "I'm dumb, I'm stupid." Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen. In positive self-talk, the client reframes negative thoughts into positive ones.

Which occurs when a client tends to adore and idealize other people even after a brief acquaintance but then quickly leaves them if these others do not meet the client's expectations in some way? Splitting Thought stopping Decatastrophizing Positive self-talk

Splitting Explanation: Splitting occurs in this situation. Thought stopping is a technique to alter the process of negative or self-critical thought patterns such as, "I'm dumb, I'm stupid." Decatastrophizing is a technique that involves learning to assess situations realistically rather than always assuming a catastrophe will happen. In positive self-talk, the client reframes negative thoughts into positive ones.

A client who has been diagnosed with panic disorder visits the clinic and experiences a panic attack. The client tells the nurse, "I'm so nervous. My hands are shaking, and I'm sweating. I feel as if I'm having a stroke right now." What would be the priority intervention at this time?

Stay with the client while remaining calm.

A nurse is with an adolescent who reports nothing to live for and wishing to be dead. Which nursing action would be the priority?

Staying with the client to explore more of the client's thoughts about suicide

The nurse caring for several clients on a surgical unit notes that one of the clients the nurse is caring for is Muslim. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action?

Stereotyping

While working on the unit, a nurse overhears another nurse colleague talking with several staff members about a client who is of Asian descent. During the conversation, the nurse says, "Asians are always so intelligent." The observing nurse interprets this statement as what?

Stereotyping

The mental health nurse is interviewing a client of Asian descent regarding the client's health care practices. The nurse understands that cultural competence is important in the care of this client. Cultural competence in health care can be best described as what?

Striving to achieve the ability to work within the cultural context of an individual or community from a diverse cultural or ethnic background

A nurse is providing a presentation about suicide for a group of health professionals. Which would the nurse address as a major contributing factor to the rising suicide rate among men?

Substance abuse

A parent of four small children lost a spouse in an automobile accident 3 months ago and is admitted to the hospital with severe depression. Since the spouse's death, the client's mood has been somber; until now, the client has refused treatment. What is this client at high risk for?

Suicide

A college student wakes up and notices a racing heart and dilated pupils. The student is scheduled to write an exam later that morning. Which system is responsible for this physiological response?

Sympathetic nervous system

When a parent observes the parent's young child heading toward a busy road the parent becomes stressed, feeling the parent's heart pounding, breathing heavily, and hands becoming wet with perspiration. Which physiological system is activated with the parent's "fight or flight" reaction to this danger?

Sympathetic nervous system

A client who experiences panic anxiety around dogs is sitting in a room with a dog and the client's nurse therapist. The nurse therapist is using which behavioral intervention for this type of anxiety?

Systematic desensitization

Which is a cardiovascular response of the sympathetic nervous system?

Tachycardia

The nurse is assessing a client who performs ritualistic counting of objects in the client's surroundings. What does the nurse tell the client about obsessive-compulsive disorder and its treatment? Select all that apply.

Talk openly with the nurse about obsessions, compulsions, and anxiety. Do not skip medication; it is an important part of the treatment. Learn and practice deep breathing and guided imagery.

A nurse is seeing a client prior to discharge after being admitted to hospital for suicidal ideation. As the nurse begins the discharge process, the client closes the eyes and begins rapid, shallow breathing. The client also begins to shake and perspire profusely. Which actions should the nurse take? Select all that apply.

Talk to the client in a comforting manner. Take the client to a quiet space. Reassure the client of being safe.

After educating a client who is receiving phenelzine, the nurse determines that the education was successful when the client states the need to avoid consuming which food or beverage?

Tap beers

A client with obsessive-compulsive disorder (OCD) states making a concerted effort to reduce the frequency and duration of rituals. What intervention should the nurse include to assist in these efforts?

Teach the client nonpharmacologic relaxation techniques

The psychiatric-mental health nurse is providing care for a child who has been diagnosed with disinhibited social engagement disorder. What intervention best addresses the characteristics of this disorder?

Teaching the child how to interact appropriately with strangers

A group of nursing students are reviewing signs and symptoms of anxiety. The students demonstrate a need for additional review when they identify what?

Tearfulness

All except which are considered clinical symptoms of anxiety?

Tearfulness and sadness

A nurse is engaged in a therapeutic nurse-client relationship. The relationship is in the working phase. With which would the client be involved? Select all that apply.

Testing new ways for problem solving Discussing problems related to needs Examining personal issues

The nurse is performing an assessment of a client with a psychiatric illness. The nurse has 10 cards with different inkblot shapes. Which test is the nurse about to perform?

The Rorschach Test

The nurse is performing a psychosocial assessment of a client with a mental illness. What information should the nurse gather while taking the history? Select all that apply.

The age of the client The spiritual beliefs of the client

The nurse is educating the client's family about compulsive behavior. The nurse is correct when making which statement?

The behavior neutralizes anxiety caused by obsessive thoughts.

The nurse's assessment of a child from a dysfunctional family background suggests that the child lacks resilience. What outcome should the nurse identify after performing appropriate interventions?

The child demonstrates that the child is empowered to solve life problems

What action by a 6-year-old child would most strongly suggest a diagnosis of disinhibited social engagement disorder?

The child gives adults enthusiastic hugs immediately after meeting them

The nurse is assessing a 6-year-old child who witnessed the murder of the child's parents. The nurse suspects that the child has developed posttraumatic stress disorder (PTSD). Which specific behavioral manifestation leads the nurse to interpret this?

The child is easily startled and hyper-vigilant.

The pediatric nurse is caring for a child who comes from an abusive background and who has been diagnosed with reactive attachment disorder. What behavior should the nurse anticipate when planning this child's care?

The child will be reluctant to engage with the nurse

When engaged in a therapeutic relationship, the nurse's focus is on what?

The client

A police officer was diagnosed with posttraumatic stress disorder after attending to a violent crime scene. What aspect of the client's current health status would most likely warrant inpatient treatment?

The client alluded to "ending this misery" in a conversation with a colleague

A client with posttraumatic stress disorder (PTSD) is having a flashback experience of a traumatic event. The client asks the nurse if the client can hold the nurse's hand. What should the nurse interpret from this behavior?

The client benefits from supportive touch.

Of the following actions, which indicate that the relationship between nurse and client may be moving outside professional boundaries? Select all that apply.

The client brings the nurse a baked item for their lunch. The nurse is spending more time with the client than the others in the group. The nurse tells a friend that the nurse is the only one who truly understands this client.

A client is experiencing moderate anxiety. Which manifestation would the nurse most likely observe? Select all that apply.

The client can sustain attention on a particular focus. The client verbally states, "For some reason, I am feeling anxious now."

The nurse is performing an assessment of a client with psychiatric illness. The nurse documents that the client has a restricted affect. Which behavior of the client is indicative of restricted affect? Choose the best answer.

The client displays only one type of facial expression

On assessment, the nurse finds that the client demonstrates low hardiness. Which can the nurse anticipate regarding the client based on this observation? Choose the best answer.

The client has difficulty in problem solving under stress.

The nurse is assessing a client for warning signs of suicide. Which would be a concern?

The client has engaged in risky behaviors and tends to be impulsive.

The nurse understands that a certain level of anxiety is required in a client for effective learning. Which anxiety-related symptom indicates the client may be able to learn effectively?

The client has heightened awareness.

A nurse is performing a follow-up assessment of a client who had been treated for posttraumatic stress disorder (PTSD) a year ago. The client tells the nurse that the client is not able to maintain relationships and that the relationships last for a very short time. What is the most likely reason for this problem?

The client has issues with developing trust.

A client reports the client has been experiencing increased stress at work. The client has been managing the stress by drinking 2-3 glasses of wine per evening. Despite the nurse recommending that drinking alcohol is not an effective way to manage the stress, the client reports it is unlikely that the client will be able to stop. Which statement explains why this will be difficult for the client?

The client has no adaptive coping mechanisms.

The nurse is working with an inpatient who has a history of suicide attempts. What action by the client should the nurse follow up on because it may constitute a suicide planning behavior?

The client has requested extra bedding despite the warm weather

A nurse is caring for a client with posttraumatic stress disorder. Which behavior of the client indicates the resolution phase?

The client is able to independently express feelings and emotions with the client's friends.

A nurse assesses a client and determines that the client is experiencing mild anxiety based on what?

The client is aware and alert

The nurse is assessing a client of Middle Eastern descent. The nurse finds that the client is standing at a distance of approximately 1.5 feet while speaking to the nurse. What should the nurse interpret from this behavior?

The client is behaving in a manner that is culturally acceptable.

The nurse is speaking to a female client of Cambodian origin. The client looks down while speaking to the nurse. Considering the woman's culture, how should the behavior of this nonverbal client be interpreted?

The client is being polite to the nurse.

A client suffered a gunshot injury in a robbery and subsequently developed posttraumatic stress disorder (PTSD). What aspect of the client's current condition was confirm that the client is experiencing hyperarousal?

The client is easily startled by sudden noises

A client who has been admitted for an appendectomy states, "I'm really afraid of the surgery because my mother died when she was admitted for an emergency surgery." When preparing to work with the client concerning this anxiety about the surgery, the nurse recognizes what?

The client is expressing fear about the surgery. The client's fear is the body's physiologic and emotional response to a known danger.

A nurse observes that a client who has posttraumatic stress disorder (PTSD) is startled even by small noises. What is this behavior indicative of?

The client is hypervigilant.

A client with a diagnosis of posttraumatic stress disorder (PTSD) tells the nurse, "When things get really bad, it sometimes feels like I'm not even in my body, like I'm floating around and watching myself." How should the nurse best interpret this client's statement?

The client is likely experiencing derealization as a result of PTSD

A nurse is meeting a client for the first time. The nurse observes that the client smiles appropriately but is using rambling speech while answering the nurse's questions. Which would most likely be the reason for this behavior?

The client is nervous and insecure.

A nurse is meeting an older adult client for the first time. What may hinder the nurse's ability to effectively carry out the psychiatric assessment? (Select all that apply.)

The client is not wearing a hearing aid. The nurse and the client speak different primary languages. The client has a cognitive impairment. The client is experiencing pain.

Which factor has the least influence on achieving mental health for the client who has anxiety disorder?

The client is often late to school and makes poor grades in most of the client's subjects.

The nurse is assessing a client who spends several hours arranging and rearranging items around the house. What does the nurse anticipate is the cause of this compulsive behavior?

The client is preoccupied with perfection.

A nurse recently began working with a client in the community. The client arrived 15 minutes late for the last appointment and did not show up for today's scheduled appointment, despite confirming the day before. How should the nurse best interpret this client's behavior?

The client is testing the parameters of the relationship.

Of the following clinical information, which one would be the most important in determining whether the client would be diagnosed with a mental disorder?

The client is unable to continue school work and has been sitting on the client's bed for 3 days.

During the assessment of a psychiatric client, the nurse documents "oriented x 3" on the client's assessment sheet. What does this indicate?

The client knows the correct date.

A client with posttraumatic stress disorder (PTSD) is treated with exposure therapy. What change is most likely expected in the client after receiving this therapy?

The client may be able to control thoughts and feelings about the event.

A nurse is assessing a victim of rape with a diagnosis of posttraumatic stress disorder (PTSD). The client is trying to recall and express the trauma. The nurse finds that, at times, the client is unable to remember certain facts associated with the trauma. What would the nurse interpret from this finding?

The client may have repressed memories.

The nurse is assessing a client who has presented to the emergency department in emotional distress. What client data represents the greatest risk for suicide?

The client overdosed on pills 2 years earlier

A client diagnosed with obsessive-compulsive disorder comes to the clinic with the client's spouse. During the visit, the spouse states, "The client is always checking and rechecking to make sure that all of the appliances are turned off before we go out. It's nerve-wracking. We can never get out of the house on time. Isn't checking once enough?" An understanding of what would the nurse need to incorporate into the response?

The client performs the ritual to relieve anxiety temporarily.

The nurse is working with an outpatient who has a history of depression and suicide attempts. What assessment finding should the nurse interpret as indicating a high degree of planning for a future attempt?

The client recently purchased a large bottle of over-the-counter analgesics

Which would indicate that the nurse-client relationship has passed from the orienting phase to the working phase?

The client recognizes feelings of anger and expresses them appropriately.

The psychiatric mental health nurse has taught some relaxation techniques to a client with obsessive-compulsive disorder (OCD). What outcome would most clearly suggest that this intervention has been successful?

The client reports increased quality and quantity of sleep

The psychiatric mental health nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) after the death of the client's child from a medical error. What assessment finding would most warrant interventions aimed at addressing the client's dissociation?

The client reports large gaps in memory of the traumatic event

The nurse is reviewing the health record of a client who developed posttraumatic stress disorder (PTSD) following a spouse's cardiac arrest and death. The health record states that the client experienced derealization during the traumatic event. What assessment finding would substantiate this statement?

The client states that the client cannot remember what happened during and immediately after the event

The nurse can be confident that the admitted client diagnosed with an anxiety disorder will respond well to treatment when the client which of the following conditions are present?

The client states, "I understand what I need to do, and I'm ready to do it so I'm back to normal."

The nurse is working with a 17-year-old client with a complex and dysfunctional family background. What aspect of this client's history should the nurse identify as the most significant risk factor for posttraumatic stress disorder (PTSD)?

The client was sexually abused by the mother's boyfriend at a young age

A mental health nurse has formed a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. An appropriate outcome for this nursing diagnosis would include what?

The client will demonstrate improved ability to express self.

The nurse is caring for a client diagnosed with anxiety disorder. The client is demonstrating difficulty concentrating and is preoccupied with feelings of helplessness. When creating the plan of care, which goal would be most appropriate for this client?

The client will display ability to cope with anxiety.

The nurse is counseling a 28-year-old client with avoidant personality disorder. Despite being employed, the client verbalizes having low quality of life due to anxiety and isolation. Which therapeutic goals does the nurse establish as priority? The client will be able to accept a job promotion. The client will experience increased self-esteem. The client will engage in less risk-taking behavior The client will form a romantic relationship.

The client will experience increased self-esteem. Explanation: People with avoidant personality disorder have a pattern of social discomfort, timidity, and fear of negative evaluation. They are preoccupied with what they perceive as their own shortcomings and will form relationships with others only if they believe acceptance is guaranteed. People with this disorder often view themselves as unattractive and inferior to others and are often socially inept. The priority goal should address increasing the client's self-esteem.

A mental health nurse has formed a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. An appropriate outcome for this nursing diagnosis would include what?

The client will reframe negative thoughts in a more positive way.

A nurse is caring for a client who has panic attack. The nurse takes the client in a small, isolated room. How would this intervention benefit the client? Choose the best answer.

The client would have an enhanced sense of security.

A client who is being treated for posttraumatic stress disorder tells the nurse, "Sometimes it's like I can't feel anything—not happiness, not sadness, not fear. Nothing." How should the nurse best interpret the client's statement?

The client's emotional numbing is a protective mechanism

The nurse-therapist is conducting a group therapy session in which one of the participants is an adult who has been diagnosed with narcissistic personality disorder. The nurse recognizes the significance of childhood experiences in the etiology of personality disorders, which for this client may have included what pattern? The client's parent catered to the client's every need and the client used temper tantrums to successfully get the client's way. The client's parents had excessively high performance expectations of the client and failure was met with severe sanctions. The client's parent was a rigid disciplinarian who demanded complete subservience from both the client and the client's other parent. The client's parent was in a constant state of crisis and depended heavily on the client for emotional support.

The client's parent catered to the client's every need and the client used temper tantrums to successfully get the client's way. Explanation: Narcissistic personality disorder is characterized by an exaggerated sense of self-importance. It is plausible that a client's high degree of control and entitlement early in life may have contributed to or exacerbated such tendencies. The other patterns of interaction would not tend to promote entitlement or a grandiose self-view.

The nurse-therapist is conducting a group therapy session in which one of the participants is an adult who has been diagnosed with narcissistic personality disorder. The nurse recognizes the significance of childhood experiences in the etiology of personality disorders, which for this client may have included what pattern? The client's parent catered to the client's every need and the client used temper tantrums to successfully get the client's way. The client's parents had excessively high performance expectations of the client and failure was met with severe sanctions. The client's parent was a rigid disciplinarian who demanded complete subservience from both the client and the client's other parent. The client's parent was in a constant state of crisis and depended heavily on the client for emotional support.

The client's parent catered to the client's every need and the client used temper tantrums to successfully get the client's way. Explanation: Narcissistic personality disorder is characterized by an exaggerated sense of self-importance. It is plausible that a client's high degree of control and entitlement early in life may have contributed to or exacerbated such tendencies. The other patterns of interaction would not tend to promote entitlement or a grandiose self-view.

The nurse has been asked to identify a location to conduct an interview with a psychiatric-mental health client. Which is an essential consideration when choosing a location?

The client's right to privacy

The nurse is assessing a client who was sexually assaulted several months ago and who has subsequently developed posttraumatic stress disorder (PTSD). The nurse observes that the client's nonverbals are closed and the client is reluctant to engage with the nurse. How should the nurse best interpret this client's behavior?

The client's trauma likely has an impact on the client's ability to trust

A nurse is assessing an adolescent client who has recently been self-mutilating. The nurse asks the client questions that seek to uncover the motivation underlying the behavior. The nurse's approach best reflects what?

The exploration of behaviors to uncover the client perspective

The mental health nurse instructs a client prescribed phenelzine to avoid aged foods, such as wine and cheese. For which reasons are these instructions important for client safety?

The foods contain tyramine, which may provoke hypertensive crisis.

The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding?

The general assessment and motor behavior component

A client who has just been prescribed lithium for bipolar disorder is being given education from the nurse about this medication. Which is important for the nurse to include in teaching?

The higher the sodium level, the lower the lithium level will be.

A group of nursing students is reviewing information about antisocial personality disorder. The students demonstrate understanding of this disorder when they state what? The disorder occurs more frequently in women. The individual must be at least 18 years of age. The disorder is found primarily in Asian individuals. Alcohol abuse disorder rarely accompanies this disorder.

The individual must be at least 18 years of age. Explanation: To be diagnosed with antisocial personality disorder, the individual must be at least 18 years of age and must have exhibited one or more childhood behavioral characteristics of conduct disorder before the age of 15 years. The disorder occurs more frequently in men and crosses all cultures and ethnicities. This personality disorder is strongly associated with alcohol and drug abuse.

When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore?

The length and quality of relationships

The nurse at the student health center is seeing a group of nursing students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What does guided imagery involve?

The mindful use of a word, phrase, or visual image, which allows oneself to be distracted and temporarily escape from stressful situations

Which is a true statement regarding depressive disorders?

The neurotransmitters norepinephrine, dopamine, and serotonin have been implicated.

A nurse uses the utilitarian action guiding theory when deciding how to handle the following ethical conflict: A 13-year old female patient with anorexia refuses to eat food despite the fact that she is slowly starving to death. The parents insist the nurse use a feeding tube to feed her. Which statement is an example of this theory in practice?

The nurse forces food via an eating tube because the end result is good in that it will save the patient's life

Which observation should lead the nurse manager to recognize that countertransference is affecting the therapeutic effectiveness of an individual nurse on the unit?

The nurse frequently refers to an elderly, cognitively impaired client as "my granny"

It is brought to the nurse administrator's attention that a nurse has developed an intimate relationship with a client. Which behavior indicates the nurse has engaged in an intimate relationship with a client?

The nurse is having dinner with a client outside the hospital premises.

A nurse understands that giving positive regard to the client helps in building trust for the nurse. Which actions are appropriate while conveying positive regard? Select all that apply.

The nurse should address the client by name. The nurse should actively listen to the client. The nurse should respond openly to the client.

A client has developed posttraumatic stress disorder (PTSD) after a violent sexual assault committed by a close family member. When planning this client's care, the nurse should follow what guideline?

The nurse should avoid touching the client during interactions unless necessary

The nurse is assessing an older adult client with lower back pain. In the course of assessment, the nurse learns that the client lost a spouse 10 weeks ago. The client laughs inappropriately and states, "My spouse just up and left me!" Which is the nurse's best response?

The nurse should recognize the incongruity between content and behavior and find ways of exploring further.

Which situation would most likely indicate a violation of professional boundaries? Select all that apply.

The nurse strongly defends a client's behavior during a staff meeting. A nurse tells other staff that the nurse is the only one who understands the client. A nurse begins to spend increasing amounts of time with one client on the unit.

A client is talking to a nurse about the recent death of the client's grandmother. The client is sad, and tears roll down the client's cheeks as the client talks. The nurse remembers how the nurse felt when the nurse's own grandmother died the previous summer. The nurse puts a hand on the client's shoulder and says, "This must be very difficult for you." The nurse is demonstrating empathy based on what?

The nurse's response reflects an attempt to communicate understanding of the client's feelings.

A client with schizophrenia is prescribed an antipsychotic medication. Which immediate side effects would the nurse include in the education plan for this medication?

The potential for sedation

Which is a nurse's primary tool for treating clients with mental disorders?

The therapeutic use of self

A client reveals in a therapy session that the client has thought about killing a neighbor. What is the therapist's obligation regarding this revelation?

The therapist must notify authorities and the potential victim.

A nurse is talking with a client who has experienced panic attacks. The client asks the nurse, "What causes these attacks?" Which information would the nurse most likely integrate into the response about the etiology of panic disorders?

There is evidence of a substantial familial predisposition to panic disorder

Benzodiazepines work by the following mechanism of action:

They act directly on GABA receptors and are thought to increase the amount of GABA

Which is an accurate statement regarding women and suicide?

They are less likely to complete suicide than men.

Which is one of the most common reasons clients are often concerned about confidentiality of treatment for mental health problems?

They are worried about the opinions of people who know them outside the hospital, due to shame produced by societal views of mental illness.

Nurses who value client advocacy follow what guideline?

They give priority to the good of the individual client rather than to the good of society in general.

Which aspect of the mental status exam refers to information about how the client's thoughts connect to one another?

Thought process

The nurse is teaching shoulder exercises to a client recovering from a mastectomy. The nurse might view the client's mild anxiety during the session positively, because mild anxiety helps what? Select all that apply.

To focus attention to learn To feel and think To motivate to make a change To engage in goal-directed activity

The psychiatric nurse recognizes that excessive social communication with a client is to be avoided primarily due to which reason?

To prevent the client from viewing the nurse as a friend rather than health care provider

A client is admitted to the hospital with posttraumatic stress disorder (PTSD). When approaching the client for the first time, the nurse speaks softly and gently, in a nonthreatening manner. What is the most appropriate reason for this behavior of the nurse?

To prevent the risk of triggering fears in the client

A nurse is performing an admission assessment. The client reports taking larger and larger doses of medication to get the desired effect. Based on this information, the nurse interprets this as suggesting what possible outcome?

Tolerance

A nurse working with a client with borderline personality disorder could establish which as outcome criteria? Display anger more frequently. Act out neediness. Filter concerns and insecurities through the nurse. Tolerate stress without self-mutilation.

Tolerate stress without self-mutilation. Explanation: Clients with borderline personality disorder frequently engage in impulsive acts, particularly self-mutilation. Tolerating stress without self-mutilation indicates a positive outcome for a client with such maladaptive behaviors as the typical impulsivity of self-mutilation.

After teaching a group of mental health nursing students about the care of a client experiencing a panic attack, the instructor determines that additional education is required when the students identify which as an appropriate intervention?

Touching the client in an attempt to comfort the client

Which would not be an initial intervention for the client with acute anxiety?

Touching the client in an attempt to comfort the client

All except which problem stem from attitudes in which the focus is on the nurse's beliefs and values rather than those of the client?

Treating the client as a source of cultural information

A nurse notices that a neighbor has been admitted to an inpatient psychiatric unit. The nurse understands that the nurse may not discuss this with any of the nurse's family or neighbors, because doing so would breach the client's confidentiality. Confidentiality is a component of which element of the therapeutic relationship?

Trust

A nurse tells a client that the nurse will come back in 10 minutes to reassess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing?

Trust

A nursing student is working with a client who has a history of abusing alcohol. Although the nurse has an aversive feeling toward people who abuse alcohol, the nurse feels that the client is worthy of respect and attention regardless of the nurse's own personal feelings. Which correctly describes the nurse's response to the client?

Unconditional positive regard

A nurse arrives on the medical unit wearing large dangling earrings. This is an example of which type of conduct?

Unprofessional

When caring for a client with mania, which would the nurse most likely assess?

Unusual self-confidence

What kinds of thoughts does the nurse identify in a client with obsessive-compulsive disorder (OCD)? Select all that apply.

Unwanted Intrusive Impulsive

A nurse working in a psychiatric unit is counseling a rape survivor. How can the nurse use cognitive processing therapy for the client?

Use structured sessions to focus on examining beliefs that interfere with daily life.

A nurse is preparing a plan of care for a client with anxiety. Which would the nurse likely include? Select all that apply.

Using appropriate coping skill Identifying treatment modalities Involving family for support, if appropriate Providing supportive feedback

A nurse is preparing a plan of care for a client with anxiety. Which elements would the nurse likely include? Select all that apply.

Using appropriate coping skills Identifying treatment modalities Involving family for support, if appropriate Providing supportive feedback

The nurse is managing the care of a terminally ill client whose spouse insists that all measures be continued. The nurse speaks to the spouse about obtaining a hospice consult. This is an example of "ethical

Valuing

A nurse is contributing to the interdisciplinary care plan for a client who has been diagnosed with PTSD. Which should be included in the care plan?

Vigilant monitoring for potential indications of self-harm

A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response?

Warn the client's neighbor and report to the authorities.

Which is a nonneurologic side effect of antipsychotic medications?

Weight gain

In which culture is autonomy utilized in making health care decisions?

Western

Which culture is comfortable with making direct eye contact?

Western

What does the nurse teach the client with obsessive-compulsive disorder about relaxation techniques?

What does the nurse teach the client with obsessive-compulsive disorder about relaxation techniques?

A group of students is reviewing information about anxiety disorders in preparation for a class examination. The students demonstrate understanding of the material when they state what?

Women experience anxiety disorders more often than do men.

A nurse is caring for a client with hemiplegia who has been depressed. The client tells the nurse, "I don't feel I would ever be independent again. I would be a burden to everybody in my house." The nurse responds by stating, "Your family misses you a lot and wants you home as soon as possible. The rehab team is very confident about your progress." Which phase of nurse-client relationship is occurring?

Working

During which phase of the nurse-client relationship does the client identify and explore specific problems?

Working

The client tells the nurse, "I am regularly doing my sitting breathing exercises. Why do I still feel breathless while walking?" The nurse replies, "Sitting breathing exercises alone may not achieve the desired effects. You also should perform daily deep breathing exercises while walking. This should help you to reduce breathlessness while walking." According to Peplau's model, the nurse and client are in which phase?

Working

When conducting a suicide risk assessment, the nurse understands that which method has the least lethality?

Wrist slashing

The client is a 2-month-old infant extremely ill from HSV sepsis. Her mother and father have decided to stop additional medical intervention and allow the infant to pass away naturally. The mother does not want her relatives to know that they plan to stop pursuing aggressive medical treatment because it is against their family's religious beliefs to withdraw medical support. What does the nurse tell the client's mother?

Yes, it is her decision who to inform about the family's medical decision.

The nurse asks the client to explain the meaning of the proverb "a stitch in time saves nine." Which explanation given by the client indicates concrete thinking?

You should not forget to sew up holes in your clothes.

A client is receiving clozapine. For which life-threatening disorder should the nurse be alert when assessing this client?

agranulocytosis

A psychiatric-mental health nurse is teaching the family members of a client about strategies for engaging with their family member who has recently been diagnosed with posttraumatic stress disorder (PTSD). The nurse should encourage the client's family to:

anticipate that the client is likely to be irritable and withdrawn at times.

Which nursing assessment is most appropriate for an older client presenting with reports of generalized anxiety?

assess for depression

The genetic theory, when applied to the occurrence of depression, supports that the psychiatric nurse should ...

assess for depression in the client's family history.

Which nursing intervention is focused on the primary goal of anxiety management and treatment?

assessing the client's ability to implement stress management techniques effectively

Two nursing students are giving a presentation on the limbic system. Which can they accurately include as actions of this brain structure?

behavior

A nurse is seeing a client who is having severe to panic level anxiety after a physical assault months previously. The client tells the nurse, "When the panic starts I feel like I am watching myself through a window." The nurse can most accurately describe this experience as:

depersonalization.

The nurse is caring for a client diagnosed with Parkinson's disease. How would the nurse explain which transmitter is increased by taking antiparkinson's medication?

dopamine

Which client behavior would the nurse document as being an automatism?

drumming one's fingers on the table top

Which are anticholinergic side effects that may occur with the use of antipsychotic drugs? Select all that apply.

dry mouth constipation urinary retention

In which way do neurons communicate through the use of synapses?

electrochemically

A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medications. After teaching the client and family about managing the disorder, the nurse determines that the education was effective when they state that which should be reported immediately?

elevated temperature

During an individual therapy session, a nurse is listening to a client describe the client's drug addiction. The client says, "I know I am doing the wrong thing for my kids, but I just can't stop using drugs." The nurse maintains eye contact and nods occasionally. The nurse responds by saying, "You're going through a difficult time." The nurse's actions and words are an example of:

empathy.

One of the most common ways in which neurotransmitters are deactivated within the nervous system at the neuronal level is:

enzymatic degradation, primarily by monoamine oxidase (MAO).

A client has been referred for care because the client's primary care provider suspects that the client has posttraumatic stress disorder (PTSD) following a motor vehicle accident. When working with this client, the psychiatric-mental health nurse should begin by:

establishing therapeutic rapport with the client.

A psychiatric nurse tells a client that the nurse will return in 15 minutes to talk with the client. The nurse goes to a meeting that runs overtime and returns in an hour, apologizing for being late. This behavior may have an impact between the nurse and the client in the area of ...

establishing trust in the introductory phase of the relationship.

A client with a specific phobia of spiders is seeing a therapist for the first session of treatment. The therapist hands the client a clear container with a large house spider inside. This activity is repeated continuously until the client's fear subsides. Which strategy is being used to treat the client's specific phobia?

flooding

A client with a specific phobia of spiders is seeing a therapist for the first session of treatment. The therapist hands the client a clear container with a large house spider inside. Which strategy is being used to treat the client's specific phobia?

flooding

The nurse provides care to a client who is diagnosed with a traumatic brain injury (TBI) because of a motor vehicle accident. The client is noted to have mood and affect changes, specifically impulsive behavior. Which lobe of the brain is likely affected based on the client's symptoms?

frontal

Which nursing intervention demonstrates congruence in a therapeutic nurse-client relationship?

getting an appointment with the client at the time previously agreed upon

A client is diagnosed with trichotillomania. What would the nurse expect to observe with the client?

hair loss on the scalp, eyebrows and/or eyelashes

A client who is depressed tells the nurse, "If I'm honest, I really see suicide as the only way out." In order to challenge the client's belief, the nurse should ...

help the client to identify and explore other options.

Which parts of the psychosocial assessment can be obtained by observing the client? (Select all that apply.)

hygiene and grooming posture unusual movements

A 36-year-old client has been receiving a selective serotonin reuptake inhibitor for treatment of depression. The client is exhibiting manifestations of serotonin syndrome. The nurse should be aware of which symptom of this syndrome?

hyperreflexia

The nurse provides care to a client who is diagnosed with bipolar disorder. The client reports fatigue, being sensitive to cold, constipation, and weight gain. When applying concepts associated with psychoneuroimmunology, which disorder should the nurse include in this client's plan of care?

hypothyroidism

What activity should be included in the first step of self-reflection?

identifying one's own values, attitudes, strengths and weakness

How should the nurse describe the mood and affect of a client who has a mask-like facial expression but states, "I'm really happy."

incongruent

The function of the thalamus and the hypothalamus is to coordinate:

internal and external responses.

A nurse is seeing a client who is experiencing symptoms of moderate anxiety. She tells the nurse she and her parents disagree over her sexual orientation. Which theory would best explain the course of the client's anxiety?

interpersonal

Termination takes place during the resolution phase of a nurse-client relationship. During the termination process, a client brings up resolved problems and presents them as new issues to work toward. The nurse interprets the client's action as indicating what? The client:

is attempting to prolong the nurse-client relationship.

A nursing faculty is presenting a lecture on ethics. The correct definition of ethical distress is:

knowing the correct action, but unable to perform due to constraints

During an assessment of a client with bipolar disorder, the nurse observes the client laughing loudly, then sobbing immediately after. How should the nurse most accurately describe this observation?

labile mood

Which action most clearly demonstrates a nurse's commitment to social justice?

lobbying for an expansion of Medicare eligibility and benefits

Which client is at the greatest risk for developing tardive dyskinesia due to long-term use of antipsychotic agents?

male client, 50 years of age, who is diagnosed with depression

The nurse is assessing a client who is depressed. The nurse asks the client, "What is your current address?" What is the nurse trying to assess?

memory

An adolescent who is seeing the school health nurse states, "I won't be able to hang out with my friends on Friday night because I have two essays due Monday." What level of anxiety is the adolescent experiencing?

mild

The nurse provides care to a client who presents to the emergency department (ED) with symptoms indicative of a traumatic brain injury (TBI). The client states, "I am unable to see anything. I think I am blind now!" Which area of the cerebrum should the nurse suspect the TBI affected based on the client's statement?

occipital lobe

A client diagnosed with schizophrenia is having delusions that the client is being plotted against by the government. This would be documented as which type of delusion?

persecutory

The overall goals of care for individuals experiencing a stress response are to focus on interventions to develop ...

positive coping skills.

When an Arabic client newly diagnosed with type 2 diabetes is insistent that the client's family provide all food, the nurse initially ...

provides the client and the client's family with detailed instructions with the dietary requirements of the condition.

During the assessment of a client who has a pattern of eating disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment?

self-concept

A school health nurse is seeing a 7-year-old child. The mother of the child describes the child holding on to her leg and crying loudly when she attempts to leave the child at school each morning. The nurse should explain that the child is experiencing:

separation anxiety disorder.

What should the nurse avoid when demonstrating genuine interest for a client by making a self-disclosure?

shifting the emphasis to the nurse

A nurse is driving on a back country road when a man flags the nurse down and yells that his wife is having a baby. As a registered nurse she is eager to help. The nurse recalls that she is covered under the Good Samaritan Law. This law states:

that the nurse's license is protected if she acts in a reasonable manner given the circumstances.

Which of the following is a characteristic of the care-based approach to bioethics?

the promotion of the dignity and respect of clients as people

When assessing a client who reports mild symptoms of depression, the nurse expects that the diagnostic tests ordered will include:

thyroid stimulating hormone (TSH).

The nurse is assessing a client who has recently received a diagnosis of posttraumatic stress disorder. When conducting this assessment, the nurse should:

try to identify any strengths or skills that can be applied during recovery.

When caring for an older adult taking a psychotropic medication, the psychiatric nurse must be aware that older adults:

usually require a lower dose of these medications than do younger counterparts

A nurse needs to be aware of which professional values? Select all that apply.

• Altruism • Autonomy • Human dignity • Social Justice

Which of the following nursing situations is an example of the care-based approach to ethics? Select all that apply

• Holding the hand of a dying client • Providing a back rub to a client on bed rest • Involving the parent in the bed bath of a child

Nurses have cited specific reasons for a decrease in the quality of nursing care. Select all that apply.

• Inadequate staffing • Decreased satisfaction

Students nurses need to know about the Code of Ethics for Nurses. The Code of Ethics includes a set of principles to follow. Identify the tenets of the Code of Ethics for Nurses. Select all that apply.

• The nurse maintains standards of personal conduct. • The nurse is active in developing a core of research based principles. • The nurse holds personal information as confidential.