Mental Health - Exam 2
A 16-year-old client diagnosed with Schizophrenia experiences command hallucinations to harm others. The client's parents ask the nurse, "Where do the voices come from?" Which is the appropriate nursing reply? A. "Your child has a chemical imbalance of the brain, which leads to altered thoughts." B. "Your child's hallucinations are caused by medication interactions." C. "Your child has too little serotonin in the brain, causing delusions and hallucinations." D. "Your child's abnormal hormonal changes have precipitated auditory hallucinations."
A
A 40-year-old female client has never experienced an intimate relationship. A nursing student tells an instructor that this client remains in Erikson's developmental stage of intimacy versus isolation. What is the instructor's most appropriate reply? A. "Erikson's stages of development are assessed by chronological age, not task achievement. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age." B. "Erikson's stages of development are assessed by task achievement, not chronological age. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age." C. "Erikson's stages of development are assessed by task achievement, not chronological age. This client is in the generativity versus stagnation stage, which occurs from 30 to 65 years of age." D. "Erikson's stages of development are assessed by chronological age, not task achievement. This client is in the intimacy versus isolation stage, which occurs from 20 to 30 years of age."
A
A client begins to smash furniture, cannot be "talked down," and refuses medications. Which is the priority nursing intervention? A. Call a violence code. B. Ask the ward clerk to put in a call for the physician. C. Place the client in seclusion. D. Place the client in four-point restraints.
A
A client diagnosed with Bipolar Disorder states, "I hate oatmeal. Let's get everybody together to do exercises. I'm thirsty and I'm burning up. Get out of my way; I have to see that guy." Which is the priority nursing action? A. Assess the client's vital signs. B. Offer to have the dietitian discuss food preferences. C. Encourage the client to lead the exercise program in the community meeting. D. Acknowledge the client briefly and then walk away.
A
A client diagnosed with Bipolar Disorder: Depressive Episode intentionally overdoses on sertraline (Zoloft). Family reports that the client has experienced anorexia, insomnia, and recent job loss. Which should be the priority nursing diagnosis for this client? A. Risk for suicide R/T hopelessness B. Anxiety: severe R/T hyperactivity C. Imbalanced nutrition: less than body requirements R/T refusal to eat D. Dysfunctional grieving R/T loss of employment
A
A client diagnosed with MDD was raised in a strongly religious family where bad behavior was equated with sins against God. Which nursing intervention is most appropriate to help the client address spirituality as it relates to his illness? A. Encourage the client to bring into awareness underlying sources of guilt. B. Teach the client that religious beliefs should be put into perspective throughout the life span. C. Confront the client with the irrational nature of the belief system. D. Assist the client to modify his or her belief system to improve coping skills.
A
A client diagnosed with Panic Disorder states, "When an attack happens, I feel like I am going to die." Which is the nurse's most appropriate reply? A. "I know it's frightening, but try to remind yourself that this will only last a short time." B. "Death from a panic attack happens so infrequently that there is no need to worry." C. "Most people who experience panic attacks have feelings of impending doom." D. "Tell me why you think you are going to die every time you have a panic attack."
A
A client diagnosed with Schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt the nurse to intervene immediately? A. Sore throat, fever, and malaise B. Akathisia and hypersalivation C. Akinesia and insomnia D. Dry mouth and urinary retention
A
A client has a history of excessive fear of water. Which term should the nurse use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia
A
A client has continual problematic relationships and rejects others before possibly being rejected. The client states, "I am afraid of failing in my job responsibilities." Which correctly written nursing diagnosis should be prioritized for this client? A. Poor self-esteem R/T negative self-image AEB fear of failure B. Altered thought processes R/T anxiety AEB delusions C. Role confusion R/T rejection and poor job productivity D. High risk for violence: self-directed R/T rejection of others
A
A client is admitted in a manic episode of bipolar I disorder. Which nursing intervention is most therapeutic for this client? A. Use a calm, unemotional approach during client interactions. B. Focus primarily on enforcing limits. C. Limit interactions to decrease external stimuli. D. Encourage the client to establish social relationships with peers.
A
A client is admitted to the psychiatric unit with a diagnosis of MDD. The client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be included in this client's plan of care? A. A simple, structured daily schedule with limited choices of activities B. A daily schedule filled with activities to promote socialization C. A flexible schedule that allows the client opportunities for decision-making D. A schedule that includes mandatory activities to decrease social isolation
A
A client is admitted with a diagnosis of PDD. Which client statement describes a symptom consistent with this diagnosis? A. "I am sad most of the time and I've felt this way for the last several years." B. "I find myself preoccupied with death." C. "Sometimes I hear voices telling me to kill myself." D. "I'm afraid to leave the house."
A
A client is diagnosed with Bipolar I Disorder: Manic Episode. Which nursing intervention should be implemented to achieve the outcome of "Client will gain 2 pounds by the end of the week?" A. Provide client with high-calorie finger foods throughout the day. B. Accompany client to cafeteria to encourage adequate dietary consumption. C. Initiate total parenteral nutrition to meet dietary needs. D. Teach the importance of a varied diet to meet nutritional needs.
A
A client is prescribed alprazolam (Xanax) for acute anxiety. Which client history should cause the nurse to question this order? A. History of alcohol dependence B. History of personality disorder C. History of schizophrenia D. History of hypertension
A
A client who has been diagnosed with Bipolar I Disorder states, "God has taught me how to decode the Bible." The nurse should anticipate which combination of medications would be ordered to address this client's symptoms? A. Lithium carbonate (Lithobid) and risperidone (Risperdal) B. Lithium carbonate (Lithobid) and carbamazepine (Tegretol) C. Valproic acid (Depakote) and sertraline (Zoloft) D. Valproic acid (Depakote) and lamotrigine (Lamictal)
A
A female client arrives at her primary care physician with complaints of increased symptoms of colitis. During the intake interview, the patient mentions having two migraines in the past 3 weeks and asks for a new medication, stating, "It doesn't seem like the current medication is working as well as I expected." In reviewing her medical record, it is noted that the client was prescribed medication for depression and a referral to a marriage counselor at her last visit 2 months ago. Which of the following might the nurse suspect given the aforementioned information? A. Maladaptive expression of anger B. Hypersensitivity to migraine medication C. Exhibiting signs of domestic abuse D. Operant conditioning
A
A highly agitated client paces the unit and states, "I could buy and sell this place." The client's mood fluctuates from fits of laughter to outbursts of anger. Which is the most accurate documentation of this client's behavior? A. "Rates mood 8/10. Exhibiting looseness of association. Euphoric." B. "Mood euthymic. Exhibiting magical thinking. Restless." C. "Mood labile. Exhibiting delusions of reference. Hyperactive." D. "Agitated and pacing. Exhibiting grandiosity. Mood labile."
A
A military veteran who recently returned from active duty in a Middle Eastern country and suffers from PTSD states he will not allow the laboratory technician, who is Iranian, to draw his blood. The patient states, "He'll probably use a contaminated needle on me." Which of these is the most appropriate nursing response by the nurse? A. "Let me see if I can arrange for a different technician to draw your blood." B. "Let me help you overcome your cultural bias by letting him draw your blood." C. "There is no other technician, so you're just going to have to let him draw your blood." D. "I don't think the technician is really Middle Eastern."
A
A nurse is running a group on self-esteem. A client asks, "Where does self-esteem come from?" Which is the most appropriate nursing reply? A. "Many factors over the life span influence development and maintenance of self-esteem." B. "Self-esteem is determined by factors outside of an individual's control." C. "Self-esteem is established in childhood and remains relatively fixed throughout life." D. "Genetics are the single largest contributor to an individual's self-esteem."
A
A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." B. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." C. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." D. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."
A
A psychiatrist prescribes an MAOI for a client. Which foods should the nurse teach the client to avoid? A. Pepperoni pizza and red wine B. Bagels with cream cheese and tea C. Apple pie and coffee D. Potato chips and diet cola
A
A son who recently brought his extremely confused parent to a nursing home for admission reports feelings of guilt. Which is the appropriate nursing reply? A. "People often have mixed emotions about decisions like this. Support groups are held here on Mondays for children of residents in similar situations." B. "You did what you had to do. I wouldn't feel guilty if I were you." C. "Support groups are available to low-income families." D. "Your parent is doing just fine. We'll take very good care of him."
A
After threatening to jump off a bridge, a client is brought to an emergency department by police. Which question should the nurse ask first to assess for suicide potential? A. "Are you currently thinking about harming yourself?" B. "Why do you want to harm yourself?" C. "Have you thought about the consequences of your actions?" D. "Who is your emergency contact person?"
A
An elderly client has met the criteria for a diagnosis of Major Depressive Disorder. The client does not respond to antidepressant medications. Which treatment should a nurse anticipate that the physician would prescribe for this client? A. Electroconvulsive therapy (ECT) B. Neuroleptic therapy C. An antiparkinsonian agent D. An anxiolytic agent
A
Arthur, who is diagnosed with Obsessive-Compulsive Disorder (OCD), reports to the nurse that he can't stop thinking about all the potentially life-threatening germs in the environment. Which is the most accurate way for the nurse to document this symptom? A. Patient is expressing an obsession with germs. B. Patient is manifesting compulsive thinking. C. Patient is expressing delusional thinking about germs. D. Patient is manifesting arachnophobia of germs.
A
During an assertiveness training group, a nurse suggests using "I" statements. The group questions the usefulness of this communication technique. Which explanation by the nurse is most appropriate? A. "When 'I' statements are used, opinions are communicated without blaming others." B. "When 'I' statements are used, anger is displaced by using indirect means." C. "When 'I' statements are used, responsibility for one's behavior is attributed to another." D. "When 'I' statements are used, eye contact is promoted."
A
One nurse confronts another and says, "You are always so talkative in the meetings. I don't know why you can't stay quiet sometimes." Which reply by the other nurse reflects the technique of clouding or fogging? A. "You're right. I do speak up a lot." B. "Sounds to me like you're agitated and we need to talk. What are you truly angry about?" C. "Are you offended that I speak up, or because my thoughts are in opposition to yours?" D. "I have the right to express my opinion."
A
The mental health nurse is evaluating care of a client who is recovering from an episode of schizophrenic psychosis. Which is the most appropriate long-term goal for the client? A. Define and test reality. B. Participate in social activities. C. Maintain appropriate eye contact. D. Verbalize feelings of anxiety.
A
The nurse begins the intake assessment of a client diagnosed with Bipolar I Disorder. The client shouts, "You can't do this to me. Do you know who I am?" Which is the priority nursing action in this situation? A. To provide self and client with a safe environment B. To redirect the client to the needed assessment information C. To provide high-calorie finger foods to meet nutritional needs D. To reorient the client to person, place, time, and situation
A
The nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement indicates a need for further instructions? A. "I will need scheduled bloodwork to monitor for toxic levels of this drug." B. "I won't stop taking this medication abruptly, because there could be serious complications." C. "I will not drink alcohol while taking this medication." D. "I won't take extra doses of this drug because I can become addicted."
A
The nurse reviews the laboratory data of a 29-year-old client suspected of having MDD. Which laboratory value would potentially rule out this diagnosis? A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL B. Potassium (K+) level of 4.2 mEq/L C. Sodium (Na+) level of 140 mEq/L D. Calcium (Ca2+) level of 9.5 mg/dL
A
Two clients are roommates on an inpatient psychiatric unit. At breakfast, client A, who had been missing her gold locket, notices client B wearing it. Which does the nurse recognize as a nonassertive or passive behavioral response from client A? A. Client A ignores the situation. B. Client A discusses the situation with her nurse and develops a plan of action. C. Client A immediately approaches client B and pulls the necklace off her neck. D. Client A offers to wash client B's clothes and "accidentally" spills bleach in the water.
A
Two clients get into an intense argument regarding TV program selections. The nurse turns off the TV and asks the clients to go to their rooms to cool off, and tells them they will discuss and attempt to resolve the problem afterward. Which assertive technique is the nurse using? A. Defusing B. Clouding or fogging C. Responding as a broken record D. Shifting from content to process
A
Which client statement demonstrates improvement in anger and aggression management? A. "I realize I have a problem expressing my anger appropriately." B. "I know I can't use physical force anymore, but I can intimidate someone with my words." C. "It's bad to feel as angry as I feel. I'm working on eliminating this poisonous emotion entirely." D. "Because my wife seems to be the one to set me off, I've decided to remain separated from her."
A
Which is an appropriate initial nursing intervention for a client with chronic low self-esteem? A. Assessing the content of negative self-talk B. Administering anxiolytic medications C. Using reassurance and physical touch D. Using distraction techniques
A
Which of the following are behavioral components of assertive communication? A. Listening B. "You" statements C. Closed posture D. Continuous direct eye contact
A
Which of the following client statements would appear in a nursing assessment of a person exhibiting the appropriate expression of anger? A. "I'm sick and tired of my family asking me how I am doing. How do they think I'm doing?" B. "I wonder how he would feel if I got drunk then drove head-on into his wife's car?" C. "I hit the wall and broke a table. It's not like I hit my wife or anything." D. "I don't really hit my kids. I just tell them I'm going to beat their backside if they don't clean their room."
A
Which statement indicates to the nurse that a client is experiencing a delusion? A. "There's an alien growing in my liver." B. "I see my dead husband everywhere I go." C. "The IRS may audit my taxes." D. "I'm not going to eat my food. It smells like brimstone."
A
A patient admitted to the hospital with PTSD is ordered the following medications. Which of these medications has a direct use in treating symptoms that are common in PTSD? Select all that apply. A. Alprazolam (Xanax) B. Propanolol (Inderal) C. Docusate sodium (Colace) D. Docusate (Dulcolax)
A, B
A patient's wife reports to the nurse that she was told her husband's PTSD may be related to cognitive problems. She is asking the nurse to explain what that means. Which of the following are accurate statements about the cognitive theory as it applies to PTSD? Select all that apply. A. People are vulnerable to trauma-related disorders when their fundamental beliefs are invalidated. B. Cognitive theory addresses the importance of how people think (or cognitively appraise) events. C. Dementia is a common symptom of PTSD. D. Amnesia is the biggest cognitive problem in PTSD and is the primary cause of trauma-related disorders.
A, B
Joe, a patient being treated for PTSD, tells the nurse that his therapist is recommending cognitive therapy. He asks the nurse how that's supposed to help his nightmares. Which of these responses by the nurse provides accurate information about the benefits of this type of therapy? Select all that apply. A. "The nightmares may be related to troubling thoughts and feelings; cognitive therapy will help you explore and modify those thoughts and feelings." B. "It is designed to help you cope with anxiety, anger, and other feelings that may be related to your symptoms." C. "It is designed to repeatedly expose you to the trauma you experienced so you can regain a sense of safety." D. "Once you learn to repress these troubling feelings, the nightmares should cease."
A, B
Which of the following explanations should the nurse include when teaching parents why it is difficult to diagnose a child or adolescent exhibiting symptoms of bipolar disorder? Select all that apply. A. Symptoms of bipolar disorder are similar to those of attention deficit-hyperactivity disorder. B. Children are naturally active, energetic, and spontaneous. C. Neurotransmitter levels vary considerably in accordance with age. D. The diagnosis of Bipolar Disorder cannot be assigned prior to the age of 18. E. Genetic predisposition is not a reliable diagnostic determinant.
A, B
A military veteran is assessed for outpatient therapy after he reports having problems at home and at work. Which of the symptoms that he describes are commonly associated with PTSD? Select all that apply. A. "I've been drinking and smoking pot daily." B. "I've been having trouble sleeping and I think I've been having nightmares but I can't remember them." C. "I slapped my wife when she was trying to hug me." D. "I've been having intense pain in the leg where I sustained a combat wound."
A, B, C
Joshua recently moved into a dormitory to begin his first year in college. The dormitory supervisor reprimanded him for not disposing of food items properly, and he responded by throwing all of his belongings from a second-story window while shouting obscenities. The campus police escorted him to campus health services, where he was diagnosed with an Adjustment Disorder With Disturbance of Conduct. Which of the following items in Joshua's history predispose him to this disorder? Select all that apply. A. Joshua reports that he doesn't have any friends in the dormitory. B. Joshua's family currently lives out of the country and is often difficult to reach. C. Joshua was notified the same day that he would have to withdraw from one of his classes because he didn't have the prerequisite credits needed to register for the class. D. Joshua has a higher than average grade point average and is a member of the National Honor Society.
A, B, C
Louisa recently experienced surviving a plane crash and is assessed by the nurse. Which statements made by Louisa indicate that she may be experiencing PTSD? Select all that apply. A. "I keep having these thoughts about the crash that just pop into my mind at random times." B. "I am so afraid that I will never be able to fly again. I worry about it constantly." C. "I have nightmares every night about the crash where I picture myself dying." D. "I believe that I was meant to survive this accident so that I can focus on the important things in life."
A, B, C
The community health nurse is visiting a homebound elderly patient who lives alone. The nurse assesses the patient's environment and finds the home dark and cold. The food pantry contains two cans of soup and half a package of crackers. The contents of the refrigerator have spoiled due to the lack of electricity. The patient states that her electricity has been turned off because her nephew who looks after her has not paid the bill this month even though she gave him the money to do so. During the physical assessment, the nurse finds that the patient has lost 8 pounds since the last visit and has what appear to be cigarette burn marks in various stages of healing on the patient's arms. The nurse determines that the patient is the victim of which type of abuse? Select all that apply. A. Neglect B. Financial C. Physical D. Sexual
A, B, C
The nursing instructor is teaching a course on human growth and development to a class of nursing students. The teaching is successful when the students identify which factors as biological aspects of aging? Select all that apply. A. Fat redistribution B. Heart hypertrophy C. Increased fibrous lung tissue D. Thickening of muscle fibers E. Enlargement of the liver
A, B, C
Which of the following instructions regarding lithium therapy should be included in the nurse's discharge teaching? Select all that apply. A. Avoid excessive use of beverages containing caffeine. B. Maintain a consistent sodium intake. C. Consume at least 2500 to 3000 mL of fluid per day. D. Restrict sodium content. E. Restrict fluids to 1500 mL per day.
A, B, C
A client who has been diagnosed with a phobic disorder asks the nurse if there are any medications that would be beneficial in treating phobic disorders. Which of the following responses by the nurse are accurate? Select all that apply. A. "Some antianxiety agents have been successful in treating social phobias." B. "Some antidepressant agents have been successful in diminishing symptoms of agoraphobia and social anxiety disorder (social phobia)." C. "Specific phobias are generally not treated with medication unless accompanied by panic attacks." D. "Beta blockers have been used successfully to treat phobic responses to public performance."
A, B, C, D
A client is prescribed phenelzine (Nardil). Which of the following client statements should indicate to the nurse that discharge teaching about this medication has been successful? Select all that apply. A. "I'll have to let my surgeon know about this medication before I have my cholecystectomy." B. "Guess I will have to give up my glass of red wine with dinner." C. "I'll have to be very careful about reading food and medication labels." D. "I'm going to miss my caffeinated coffee in the morning." E. "I'll be sure not to stop this medication abruptly."
A, B, C, D, E
A client and nurse therapist are developing a treatment plan that includes strategies to manage bipolar disorder. Which should be included? Select all that apply. A. Maintain a consistent sleep schedule. B. Become an expert on mental health. C. Create a daily medication schedule. D. Set a time frame to achieve remission. E. Develop an emergency plan.
A, B, C, E
A nurse is caring for a client who has recently undergone a radical prostatectomy. Which of the following should the nurse recognize as objective symptoms of low self-esteem? Select all that apply. A. Withdrawal from activities B. Decrease in self-care behaviors C. Poor eye contact D. Reports of pain E. Poor posture
A, B, C, E
The advance practice nurse providing therapy for the family of a client diagnosed with schizophrenia is developing a treatment plan. Which interventions should the nurse include? Select all that apply. A. Demonstrate appropriate limit setting. B. Educate family about anti-Parkinsonian medications. C. Improve patterns of family communication. D. Facilitate the client's independent living skills. E. Teach the family conflict resolution skills.
A, B, C, E
The clinic nurse is reviewing the medication list of a client diagnosed with Medication-Induced Bipolar Disorder. The nurse recognizes which may have precipitated the client's mood disturbance? Select all that apply. A. Oral contraceptives B. Antihypertensives C. Dopamine agonist D. Corticosteroids E. Alpha-adrenergics
A, B, D
The mother of a 20-year-old woman recently diagnosed with Paranoid Schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia? Select all that apply. A. Prostaglandins B. Glutamate C. Thyroxine D. Dopamine E. Erythropoietin
A, B, D
The nurse understands psychotic postpartum depression is characterized by which symptoms? Select all that apply. A. Agitation B. Fear the infant will be harmed C. Loss of libido D. Guilt E. Sleep disturbances
A, B, D
Thomas is a Marine who has recently returned from a military battle in the Middle East. The nurse is assessing Thomas to develop a plan of care. The nurse evaluates the assessment data to determine the variables associated with Thomas's response to trauma. Which variables should the nurse consider to make this determination? Select all that apply. A. The resources Thomas uses to cope with trauma B. The outcomes Thomas previously experiences with trauma C. The location and duration of the traumatic event experienced by Thomas D. The temperament Thomas displays in the presence of trauma
A, B, D
Which of the following interventions should the nurse utilize when caring for an inpatient client who is expressing anger inappropriately? Select all that apply. A. Maintain a calm demeanor. B. Clearly delineate the consequences of the behavior. C. Use therapeutic touch to convey empathy. D. Set limits on the behavior. E. Teach the client to avoid "I" statements related to expression of feelings.
A, B, D
Which of the following components should the nurse recognize as an integral part of a rehabilitative program when planning care for clients diagnosed with Schizophrenia? Select all that apply. A. Group therapy B. Medication management C. Deterrent therapy D. Supportive family therapy E. Social skills training
A, B, D, E
James is an older adult who has bilateral cataracts. Which statement made by the nurse indicates implementation of appropriate nursing interventions for this patient? Select all that apply. A. "I've arranged your plate so your meat is at one o'clock, veggies are at six o'clock, and potatoes are at nine o'clock." B. "James, I need to ask you a question. Please look at my face while I'm speaking to you." C. "I'm going to turn your TV down so you can hear what your guests are saying to you." D. "I know you have felt isolated so I signed you up for the crafts activity this afternoon." E. "I've placed the TV remote, your book, and a box of tissues on your tray table."
A, B, E
Hank is an older adult widower who lives in a long-term care facility. Recently, Hank has been complaining of fatigue, sleeping excessively, and refusing to engage in unit activities, including meals. When the nurse asks Hank about these symptoms he sighs, "Don't worry about me. I'm just a tired old man who is waiting to die." Which questions are most important for the nurse to ask Hank? Select all that apply. A. "Are you thinking of hurting yourself?" B. "Should I call your family to cheer you up?" C. "How long have you been feeling this way?" D. "Would you feel better if you came to dinner?"
A, C
A 20-year-old female has a diagnosis of Premenstrual Dysphoric Disorder. Which of the following should the nurse identify as consistent with this diagnosis? Select all that apply. A. Symptoms are causing significant interference with work, school, and social relationships. B. Patient-rated mood is 2/10 for the past 6 months. C. Mood swings occur the week before onset of menses. D. Patient reports subjective difficulty concentrating. E. Patient manifests pressured speech when communicating.
A, C, D
A patient is admitted to the community mental health center for outpatient therapy with a diagnosis of Adjustment Disorder. Which of the following subjective statements by the patient support this diagnosis? Select all that apply. A. "I was divorced 3 months ago, and I can't seem to cope." B. "I was a victim of date rape 15 years ago, when I was in college." C. "My partner came home last week and told me he just didn't love me anymore." D. "I failed one of my classes last month and I can't get motivated to register for my next semester."
A, C, D
A patient who is being seen in the community mental health center for PTSD is being considered for EMDR (eye movement desensitization and reprocessing) therapy. The nurse is asked to conduct an assessment to validate the patient's appropriateness for this treatment. Which of the following data, collected by the nurse, are most important to document when determining appropriateness for treatment with EMDR? Select all that apply. A. The patient has a history of a seizure disorder. B. The patient has a history of electroconvulsive therapy (ECT). C. The patient reports suicidal ideation with a plan. D. The patient has been using alcohol in increasing quantities over the last 3 months.
A, C, D
George recently lost his wife and two small children in a house fire. George did not return to work after the trauma and thus lost his job. George also withdrew from family and friends. George's pastor reached out and encouraged George to seek psychiatric help, which he did. George is currently a patient at a psychiatric facility. The nurse assigned to George is evaluating the plan of care. Which statements made by George would require the nurse to reevaluate George's care plan? Select all that apply. A. "I keep going over in my mind what I could have done to prevent the fire." B. "I know I will see my family again someday. I can feel them watching over me." C. "I've lost everything and don't wish to be around others, especially if they are happy." D. "I would like to drink scotch all day until I pass out, so I don't have to feel anything."
A, C, D
The nurse has been caring for a client diagnosed with GAD. Which of the following nursing interventions address this client's symptoms? Select all that apply. A. Encourage the client to recognize the signs of escalating anxiety. B. Encourage the client to avoid any situation that causes stress. C. Encourage the client to employ newly learned relaxation techniques. D. Encourage the client to reframe cognitively thoughts about situations that generate anxiety. E. Encourage the client to avoid caffeinated products.
A, C, D, E
The nurse is administering risperidone (Risperdal) to a client diagnosed with Schizophrenia. The therapeutic effect of this medication would most effectively address which of the following symptoms? Select all that apply. A. Somatic delusions B. Social isolation C. Gustatory hallucinations D. Flat affect E. Clang associations
A, C, E
The nurse should frequently assess a client with a depressive disorder for lethality risk related to suicidal ideation. Which questions should the nurse include? Select all that apply. A. "Are you thinking about hurting yourself or someone else?" B. "Can you tell me your feelings about dying?" C. "Where do you keep your gun?" D. "Have you told your psychiatrist you feel like dying?" E. "Have you thought about how you would hurt yourself?"
A, C, E
Nursing care of a client with a diagnosis of substance-induced anxiety disorder must take into consideration the nature of the substance and if the symptoms are in the context of: Select all that apply. A. Intoxication. B. Psychosocial needs. C. Previous exposure. D. Withdrawal.
A, D
The nurse who works on an inpatient psychiatric unit is working on developing a treatment plan for a patient admitted with PTSD. The patient, a military veteran, reports that sometimes he thinks he sees bombs exploding and the enemy rushing toward him. He has had aggressive outbursts and was hospitalized after assaulting a coworker during one of these episodes. Which of these nursing interventions are evidence-based responses? Select all that apply. A. Collaborate with the patient about how he would like staff to respond when he has episodes of reexperiencing traumatic events. B. Tell the patient it is not appropriate to hit other patients or staff and if that occurs, he will have to be discharged from the hospital. C. Contact the doctor and recommend that the patient be ordered an antipsychotic medication. D. Refer the patient to a support group with other military veterans.
A, D
A college student has been diagnosed with GAD. Which of the following symptoms should a campus nurse expect this client to exhibit? Select all that apply. A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia E. Irritability
A, D, E
Which of the following statements about anger are true? Select all that apply. A. Anger is not a primary emotion. B. Anger is physiological arousal. C. Anger reflects a desire for dominance and control. D. Anger, in general, may range from a self-protective response to a destructive, violent act.
A,B
A 47-year-old mother of two has recently undergone a radical mastectomy. She refuses to see anyone and remains isolated and withdrawn. Which of the following may be relevant nursing diagnoses for this client? Select all that apply. A. Disturbed body image B. Situational low self-esteem C. Ineffective coping D. Altered thought processes E. Altered sensory perception
A,B,C
A nurse is caring for four clients. Which of the following clients are most likely to have difficulty being assertive? Select all that apply. A. A 20-year-old woman who is completing college homework assignments for several peers B. A 69-year-old widow who is socially isolated C. A 17-year-old boy with conduct disorder D. A 45-year-old successful executive E. A 50-year-old diagnosed with narcissistic personality disorder
A,B,C
Which of the following are most appropriate when performing a nursing assessment with an individual in crisis? Select all that apply. A. "Tell me what happened." B. "What coping methods have you used, and did they work?" C. "Describe to me what your life was like before this happened." D. "Let's focus on the current problem." E. "I'll assist you in selecting functional coping strategies."
A,B,C
A nurse notices a client clenching fists periodically and pacing the hallway. Which nursing interventions should the nurse implement? Select all that apply. A. Acknowledge the client's behavior. B. Initiate forced medication protocol. C. Assist the client to a quiet area. D. Initiate confinement measures. E. Speak with a soft and calming voice.
A,C,D
. On the basis of Erikson's theory, how should a nurse encourage a 40-year-old client to improve his or her self-esteem? A. Encourage the client to review life goals and accomplishments. B. Encourage the client to volunteer at a school, reading to underprivileged children. C. Encourage the client to form lasting intimate relationships. D. Encourage the client to seek recognition for task achievement.
B
A client continually waits more than an hour before being seen at the mental health clinic. The client approaches the nurse and states, "When I have to wait for more than an hour to be seen, I feel like my time is not important." The nurse recognizes this as what type of behavior? A. Aggressive behavior B. Assertive behavior C. Passive-aggressive behavior D. Passive behavior
B
A client diagnosed with Bipolar I Disorder is distraught over insomnia experienced over the last 3 nights and a 12-pound weight loss over the past 2 weeks. Which should be this client's priority nursing diagnosis? A. Knowledge deficit R/T bipolar disorder AEB concern about symptoms B. Altered nutrition: less than body requirements R/T hyperactivity AEB weight loss C. Risk for suicide R/T powerlessness AEB insomnia and anorexia D. Altered sleep patterns R/T mania AEB insomnia for the past 3 nights
B
A client diagnosed with Bipolar I Disorder: Manic Episode refuses to take lithium carbonate because he complains that it makes him feel sick. Which of the following medications might be alternatively prescribed for mood stabilization in bipolar disorders? A. Sertraline (Zoloft) B. Valproic acid (Depakote) C. Trazodone (Desyrel) D. Paroxetine (Paxil)
B
A client diagnosed with OCD is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which should be the initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.
B
A client diagnosed with Schizophrenia tells the nurse, "The 'Shopatouliens' took my shoes out of my room last night." Which is the correct charting entry to describe this client's statement? A. "The client is experiencing command hallucinations." B. "The client is expressing a neologism." C. "The client is experiencing a paranoia." D. "The client is verbalizing a word salad."
B
A client has been recently admitted to an inpatient psychiatric unit. Which intervention should the nurse plan to use to reduce the client's focus on delusional thinking? A. Present evidence that supports the reality of the situation. B. Focus on feelings suggested by the delusion. C. Address the delusion with logical explanations. D. Explore reasons why the client has the delusion.
B
A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms? A. 1.3 mEq/L B. 1.7 mEq/L C. 2.3 mEq/L D. 3.7 mEq/L
B
A client has the following symptoms: preoccupation with imagined defect, verbalizations that are out of proportion to actual physical abnormalities, and numerous visits to plastic surgeons to seek relief. Which nursing diagnosis best describes the problems evidenced by these symptoms? A. Ineffective coping B. Disturbed body image C. Complicated grieving D. Panic anxiety
B
A client is diagnosed with Cyclothymic Disorder. Which client behaviors should the nurse expect to assess? A. The client expresses "feeling blue most of the time." B. The client has endured periods of elation and dysphoria lasting for more than 2 years. C. The client fixates on hopelessness and thoughts of suicide continually. D. The client has labile moods with periods of acute mania.
B
A client is diagnosed with Major Depressive Disorder (MDD). Which nursing diagnosis should the nurse assign to the client to address a behavioral symptom of this disorder? A. Altered communication R/T feelings of worthlessness AEB anhedonia B. Social isolation R/T poor self-esteem AEB secluding self in room C. Altered thought processes R/T hopelessness AEB persecutory delusions D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
B
A client is diagnosed with PTSD. Which treatment modality exposes the client to repeated and prolonged mental recounting of the traumatic event? A. Cognitive therapy B. Prolonged exposure therapy C. Group therapy D. Eye movement desensitization and reprocessing
B
A client is taking chlordiazepoxide (Librium) for GAD symptoms. In which situation should the nurse recognize that this client is at greatest risk for drug overdose? A. The client has a knowledge deficit related to the effects of the drug. B. The client combines the drug with alcohol. C. The client takes the drug on an empty stomach. D. The client fails to follow dietary restrictions.
B
A client presents in the emergency department with complaints of overwhelming anxiety. Which of the following is the priority nursing assessment? A. Suicide risk B. Cardiac status C. Current stressors D. Substance use history
B
A client refuses to go on a cruise to the Bahamas with his spouse because of fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, the nurse should use which of these statements to explain the etiology of this fear? A. "Your spouse may be unable to resolve internal conflicts, which result in projected anxiety." B. "Your spouse may be experiencing a distorted and unrealistic appraisal of the situation." C. "Your spouse may have a genetic predisposition to overreacting to potential danger." D. "Your spouse may have high levels of brain chemicals that may distort thinking."
B
A client shows a nurse a piece of artwork that took 3 days to create. How will this achievement improve the client's self-esteem? A. By providing a framework for assertive behavior B. By providing an expression of feelings and a sense of competence and pride C. By providing a positive perception of body image D. By providing appropriate boundaries for relationship establishment
B
A client who has been taking fluvoxamine (Luvox) without significant improvement asks the nurse, "I heard about something called MAOI. Can't my doctor add that to my medications?" Which is the most appropriate nursing reply? A. "This combination of drugs can lead to delirium tremens." B. "A combination of an MAOI and fluvoxamine can lead to a life-threatening hypertensive crisis." C. "That's a good idea. There have been good results with the combination of these two drugs." D. "The only disadvantage would be the exorbitant cost of the MAOI."
B
A client who is diagnosed with MDD asks the nurse what causes depression. Which is the nurse's most accurate response? A. "Depression is caused by a deficiency in neurotransmitters, including serotonin and norepinephrine." B. "The exact cause of depressive disorders is unknown. A number of things, including genetic, biochemical, and environmental influences, likely play a role." C. "Depression is a learned state of helplessness caused by ineffective parenting." D. "Depression is caused by intrapersonal conflict between the id and the ego."
B
A client's spouse asks, "What evidence supports the possibility of genetic transmission of bipolar disorder?" Which is the best nursing reply? A. "Clients diagnosed with Bipolar Disorders have alterations in neurochemicals that affect behaviors." B. "Higher rates of relatives diagnosed with Bipolar Disorder are found in families of clients diagnosed with this disorder." C. "Higher rates of relatives of clients diagnosed with Bipolar Disorder respond in an exaggerated way to daily stress." D. "More individuals diagnosed with Bipolar Disorder come from higher socioeconomic and educational backgrounds."
B
A college student is not attending classes, isolates self because of hearing voices, and yells accusations at fellow students. Based on this information, which should be the nurse's priority nursing diagnosis? A. Altered thought processes R/T hearing voices AEB increased anxiety B. Risk for other-directed violence R/T yelling accusations C. Social isolation R/T paranoia AEB absence from classes D. Risk for self-directed violence R/T depressed mood
B
A despondent client who recently lost her husband of 30 years, tearfully states, "I'll feel a lot better if I sell my house and move away." Which nursing reply is most appropriate? A. "I'm confident you know what's best for you." B. "This may not be the best time for you to make such an important decision." C. "Your children will be terribly disappointed." D. "Tell me why you want to make this change."
B
A family asks why their father is attending activity groups at the long-term care facility. The son states, "My father worked hard all of his life. He just needs some rest at this point." Which is the appropriate nursing reply? A. "I'm glad we discussed this. We'll excuse him from the activity groups." B. "The groups benefit your father by providing social interaction, sensory stimulation, and reality orientation." C. "The groups are optional. Only clients at high functioning levels would benefit." D. "If your father doesn't go to these activity groups, he will be at high risk for developing dementia."
B
A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member asks, "Should I seek psychiatric help for my mother?" Which is the nurse's most appropriate reply? A. "My mother also worries unnecessarily. I think it is part of the aging process." B. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." C. "From what you have told me, you should get her to a psychiatrist as soon as possible." D. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."
B
A newly admitted client diagnosed with MDD states, "I have never considered suicide." Later, the client confides to the nurse about plans to end it all by medication overdose. Which is the most helpful nursing reply? A. "There "Bringing this up is a very positive action on your part." C. "We need to talk about the things you have to live for." D. "I think you should consider all of your options prior to taking this action."
B
A newly admitted client is diagnosed with Bipolar Disorder: Manic Episode. Which symptom related to altered thought is the nurse most likely to assess? A. Pacing B. Flight of ideas C. Lability of mood D. Irritability
B
A newly admitted client is diagnosed with MDD with suicidal ideations. Which is the priority nursing intervention for this client? A. Teach about the effect of suicide on family dynamics. B. Carefully and unobtrusively observe on the basis of assessed data at varied intervals around the clock. C. Encourage the client to spend a portion of each day interacting within the milieu. D. Set realistic achievable goals to increase self-esteem.
B
A nursing instructor is teaching about reminiscence therapy. What student statement indicates that learning has occurred? A. "Reminiscence therapy is a group in which participants create collages representing significant aspects of their lives." B. "Reminiscence therapy encourages members to share both positive and negative significant life memories to promote resolution." C. "Reminiscence therapy is a social group where members chat about past events and future plans." D. "Reminiscence therapy encourages members to share positive memories of significant life transitions."
B
A nursing instructor is teaching about specific phobias. Which student statement indicates that learning has occurred? A. "These clients do not recognize that their fear is excessive, and they rarely seek treatment." B. "These clients have overwhelming symptoms of panic when exposed to the phobic stimulus." C. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." D. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."
B
A nursing instructor is teaching about the concept of anger. Which student statement indicates the need for further instruction? A. "Anger is physiological arousal." B. "Anger and aggression are essentially the same." C. "Anger expression is a learned response." D. "Anger is not a primary emotion."
B
A nursing instructor is teaching about the prevalence of bipolar disorder. Which student statement indicates learning has occurred? A. "This disorder is more prevalent in lower socioeconomic groups." B. "This disorder is more prevalent in higher socioeconomic groups." C. "This disorder is equally prevalent in all socioeconomic groups." D. "This disorder's prevalence cannot be evaluated on the basis of socioeconomic groups."
B
A nursing instructor is teaching about violence-intervention protocols. Which student statement indicates the need for further instruction? A. "Administering psychotropic medications can be a part of violence-intervention protocols." B. "Soothing the client by stroking an arm or shoulder can be a part of violence-intervention protocols." C. "Applying leather restraints can be a part of violence-intervention protocols." D. "Calling for assistance is a part of violence-intervention protocols."
B
A nursing student questions an instructor regarding the order for fluvoxamine (Luvox), 300 mg daily, for a client diagnosed with OCD. Which instructor reply is most accurate? A. "High doses of tricyclic medications will be required for effective treatment of OCD." B. "SSRI doses, more than what is effective for treating depression, may be required for OCD." C. "The dose of fluvoxamine (Luvox) is low due to the side effect of daytime drowsiness and nighttime insomnia." D. "The dosage of fluvoxamine (Luvox) is outside the therapeutic range and needs to be questioned."
B
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which is the priority nursing action to maintain this client's safety? A. Assess for medication noncompliance. B. Note escalating behaviors and intervene immediately. C. Interpret attempts at communication. D. Assess triggers for bizarre, inappropriate behaviors.
B
A patient treated for symptoms of PTSD following a shooting incident at a local elementary school reports, "I feel like there's no reason to go on living when so many others died." Which is the most appropriate response by the nurse now? A. "You have lots of reasons to go on living." B. "Are you having thoughts of hurting or killing yourself?" C. "You're just experiencing survivor guilt." D. "There must be something that gives you hope."
B
A student nurse has just entered a psychiatric rotation. The student asks a nursing instructor, "How will we know if someone may get violent?" Which is the most appropriate reply by the nursing instructor? A. "You can't really say for sure. There are limited indicators of potential violence." B. "Certain behaviors indicate a potential for violence. They are labeled as a 'prodromal syndrome' and include rigid posture, clenched fists, and raised voice." C. "Any client can become violent, so it is best to be aware of your surroundings at all times." D. "When a client suddenly becomes quiet, is withdrawn, and maintains a flat affect, this is an indicator of potential violence."
B
A teenager gets a C in algebra. The mother angrily states, "All you ever do is listen to music and text your friends." The teenager replies, "What is it that you're really upset about, mom?" Which response pattern is the teenager expressing? A. Clouding and fogging B. Shifting from content to process C. Delaying assertively D. Assuming responsibility for one's own statements
B
A wife brings her husband to an emergency department after an attempt to hang himself. He is a full-time student and works 8 hours at night to support his family. He states, "I can't function any longer under all this stress." Which type of crisis is the client experiencing? A. Maturational/developmental crisis B. Psychiatric emergency crisis C. Anticipated life transition crisis D. Traumatic stress crisis
B
According to the U.S. Census Bureau criteria, how would a nurse classify a 70-year-old man? A. This man would be classified as "older." B. This man would be classified as "elderly." C. This man would be classified as "aged." D. This man would be classified as "very old."
B
After teaching a client about lithium carbonate (Lithane), the nurse would conclude teaching was successful based on which client statement? A. "I should expect to feel better in a couple of days." B. "I'll call my doctor immediately if I experience any diarrhea or ringing in my ears." C. "If I forget a dose, I can double the dose the next time I take this drug." D. "I need to restrict my intake of any food containing salt."
B
An adult client assaults another client and is placed in restraints. Which client statement alerts the nurse that further assessment is necessary? A. "I hate all of you!" B. "My fingers are tingly." C. "You wait until I tell my lawyer." D. "I have a sinus headache."
B
An elderly, emaciated client is brought to an emergency department by the client's caregiver. The client has bruises and abrasions on the shoulders and back in multiple stages of healing. When directly asked about these symptoms, which type of client response should a nurse anticipate? A. The client will honestly reveal the nature of the injuries. B. The client may deny or minimize the injuries. C. The client may have forgotten what caused the injuries. D. The client will ask to be placed in a nursing home.
B
An emergency department nurse, who has worked 10 straight days, is pulled to the psychiatric unit. Which of the emergency department nurse's statements represent a passive-aggressive response? A. "Get someone else to work 3 to 11! I've been working 10 days straight, and I need a break!" B. "Okay. I'll do it," then purposefully leaves paperwork undone when leaving the unit at 11 p.m. C. "I have worked 10 days straight, and I cannot work tonight. I will work for you tomorrow if you need me." D. "Yes, I'll do it. Anything to keep peace with the hospital administration is a good thing."
B
An inpatient client with a known history of violence suddenly begins to pace. Which client behavior alerts the nurse to the client's escalating anger and aggression? A. The client requests prn medications. B. The client has a tense facial expression and body language. C. The client refuses to eat lunch. D. The client sits in group therapy with back to peers.
B
An isolative client was admitted 4 days ago with a diagnosis of MDD. Which nursing statement would best motivate this client to attend a therapeutic group being held in the milieu? A. "We'll go to the day room when you are ready for group." B. "I'll walk with you to the day room. Group is about to start." C. "It must be difficult for you to attend group when you feel so bad." D. "Let me tell you about the benefits of attending this group."
B
As clients are leaving the dayroom following a group therapy session, the nurse notices a client admitted for acute mania is clenching and unclenching both fists, swearing, and glaring at a staff member. Which action should the nurse take first? A. Calmly ask the client to go to the "quiet room." B. Instruct clients to return to the dayroom. C. Prepare to administer a sedative medication. D. Ask a staff member to call hospital security.
B
Brandy is an 18-year-old being treated in the Community Mental Health Clinic for an adjustment disorder after receiving news of her parents' impending divorce. While talking about her feelings, she becomes angry and starts shouting and crying. She screams, "I wish they would both die!" Which of these is the most appropriate nursing response? A. Contact the parents and the police to report that Brandy is expressing homicidal ideation. B. Encourage Brandy to talk more about her anger. C. Instruct Brandy that it's okay to cry but that it is not acceptable to talk that way about her parents. D. Assess Brandy for suicidal ideation.
B
During a psychoeducational group on assertiveness training, a client asks, "Why do we need to learn about this stuff?" Which is the most appropriate nursing reply? A. "Because your doctor requires you to attend this group." B. "Being assertive is the ability to stand up for yourself while respecting the rights of others." C. "Assertiveness training teaches you how to ask for what you want, when you want it." D. "Assertive people place the needs and rights of others before their own."
B
During an admission assessment, the nurse asks a client diagnosed with Schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption? A. Delusions of persecution B. Delusions of influence C. Delusions of reference D. Delusions of grandeur
B
In which way can anxiety be distinguished from fear? A. Anxiety involves the intellectual appraisal of a threatening stimulus. B. Anxiety is an emotional process while fear is a cognitive one. C. Fear involves the emotional response to the appraisal of anxiety. D. Anxiety results from a specific or known threat.
B
Jane presents in the emergency department with a friend, who reports that Jane has been sitting in her apartment "staring off into space" and doesn't seem interested in doing anything. During the assessment, Jane reveals, with little emotion, that she was raped 4 months ago. Which of these is the most appropriate interpretation of Jane's lack of emotion? A. Jane is probably hearing voices telling her to be emotionless. B. Jane is experiencing a numbing of emotional response, which is a common symptom of PTSD. C. Jane is trying to be secretive, and lying is a common symptom in PTSD. D. Jane is currently reexperiencing the traumatic event and is having a dissociative episode.
B
Lucia's 8-year-old son went missing 1 year ago. The police have few leads and have lost interest in the case. Lucia visits an outpatient mental health clinic to determine the treatment options available to help her cope with her grief. As Lucia begins speaking with the nurse, she begins sobbing uncontrollably. Which statement made by the nurse demonstrates support of Lucia? A. "Please don't cry. It will make me cry to see you so upset." B. "I'll be right back with some tissues and a glass of water." C. "Kidnapping is a terrible thing, but maybe your son will be returned home." D. "I think you need a long vacation to help you forget all about this situation."
B
Major Smith, who is being treated for PTSD symptoms following a course of military duty, reports, "I think I was in denial about even having PTSD. I thought I was just having trouble sleeping." Which of these is an accurate evaluation of the patient's comments? A. The patient is still in denial and unable to recognize that he is having flashbacks rather than insomnia. B. The patient is beginning to recognize stages of grieving and reevaluating his symptoms. C. The patient is beginning to recognize that he may be at risk for suicide. D. The patient is trying to avoid discussing symptoms of PTSD.
B
On an inpatient psychiatric unit, a restrained 16-year-old client continues to lash out verbally and threatens to abuse staff and kill self when released. Per JCAHO standards, when does the nurse expect the physician or LIP to renew the client's restraint order? A. Within 1 hour of the original restraint order B. Within 2 hours of the original restraint order C. Within 3 hours of the original restraint order D. Within 4 hours of the original restraint order
B
Once the nurse initiates restraint for an out-of-control 45-year-old patient, per JCAHO standards, what must occur within 1 hour? A. The patient must be let out of restraint. B. A physician or other LIP must conduct an in-person evaluation. C. The patient must be bathed and fed. D. The patient must be included in debriefing.
B
Physical restraints are sometimes a necessary intervention for clients. This is based on which premise? A. Clients with poor boundaries do not respond to verbal redirection, and they need firm and consistent limit setting. B. Clients with limited internal control over their behavior need external controls to prevent harm to themselves and others. C. Clients with antisocial tendencies need to submit to authority. D. Clients with behavioral dysfunction need behavioral interventions.
B
Sammy is diagnosed with a trauma disorder and is being treated at an inpatient psychiatric unit. Which nursing short-term goal is most appropriate for Sammy? A. Sammy resolves all feelings of survivor's guilt within 1 week. B. Sammy demonstrates three relaxation techniques upon discharge. C. Sammy moves through all stages of grief within 1 month. D. Sammy agrees to seek community resources upon admission.
B
The mental health nurse is creating a plan of care for a child diagnosed with a depressive disorder. The parents report the child does not seem to know how to make friends and does not seem to be doing as well in school as a family member who is in the same grade. Recently, their child started picking fights while waiting for the bus. The nurse recognizes that the child's depressive symptoms occur among which age group? A. 3 to 5 years B. 6 to 8 years C. 9 to 12 years D. 11 to 14 years
B
The nurse is caring for a client who is experiencing a flat affect, paranoia, anhedonia, anergia, neologisms, and echolalia. Which statement correctly differentiates the client's positive and negative symptoms of schizophrenia? A. Paranoia, anhedonia, and anergia are positive symptoms of schizophrenia. B. Paranoia, neologisms, and echolalia are positive symptoms of schizophrenia. C. Paranoia, anergia, and echolalia are negative symptoms of schizophrenia. D. Paranoia, flat affect, and anhedonia are negative symptoms of schizophrenia.
B
The nurse is implementing a one-on-one suicide observation level with a client diagnosed MDD. The client states, "I'm feeling a lot better, so you can stop watching me. I have taken up too much of your time already." Which is the best nursing reply? A. "I really appreciate your concern but I have been ordered to continue to watch you." B. "Because we are concerned about your safety, we will continue to observe you." C. "I am glad you are feeling better. The treatment team will consider your request." D. "I will forward you request to your psychiatrist because it is his decision."
B
The nurse is obtaining the mental health history of a newly admitted client diagnosed with Schizophrenia. The client's family reports the client is hearing voices and cannot stay focused on the topic of a discussion. Which thought disturbance is the client demonstrating? A. Delusions of reference B. Tangentiality C. Neologism D. Loose associations
B
The nurse learns at report that a newly admitted client experiencing mania is demonstrating grandiose delusions. The nurse should recognize that which client statement provides supportive evidence of this symptom? A. "I can't stop my sexual urges. They have led me to numerous affairs." B. "I'm the world's most perceptive attorney." C. "My wife is distraught about my overspending." D. "The FBI is out to get me."
B
The nurse observes a client's escalating anger. The client begins to pace the hall and shouts, "You all better watch out. I'm going to hurt anyone who gets in my way." Which is the priority nursing intervention? A. Calmly tell the client, "Staff will help you to control your impulse to hurt others." B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, "You will need to be medicated and secluded."
B
What is the priority reason for the nurse to perform a full physical health assessment on a client admitted with a diagnosis of MDD? A. The attention during the assessment is beneficial in decreasing social isolation B. Depression is a symptom of several medical conditions C. Physical health complications are likely to arise from antidepressant therapy D. Depressed clients avoid addressing physical health and ignore medical problems
B
When least restrictive methods fail for an angry, aggressive client, a physician orders restraints at 3 a.m. Per JCAHO standards, at what time and by whom does the nurse expect an in-person client evaluation? A. No later than 8 a.m., by a LIP or a clinical nurse specialist B. No later than 4 a.m., by a physician or a LIP C. No later than 3:30 a.m., by a physician or the client's case manager D. No later than 6 a.m., by the psychiatrist or a clinical nurse specialist
B
Which client statement indicates to the nurse that the client understands dietary teaching related to lithium carbonate (Lithobid) treatment? A. "I will limit my intake of fluids daily." B. "I will maintain normal salt intake." C. "I will take Lithobid on an empty stomach." D. "I will increase my caloric intake to prevent weight loss."
B
Which nursing approach is likely to be most therapeutic when dealing with a newly admitted, hostile, suspicious client? A. Place a hand on the client's shoulder and state, "I will help you to your room." B. Slowly and matter-of-factly state, "I am your nurse and I will show you to your room." C. Firmly set limits by stating, "If your behavior does not improve you will be secluded." D. Smile and state, "I am your nurse. When do you want to go to your room?"
B
Which nursing behavior will enhance the establishment of a trusting relationship with a client diagnosed with Schizophrenia? A. Establishing personal contact with family members B. Being reliable, honest, and consistent during interactions C. Sharing limited personal information D. Sitting close to the client to establish rapport
B
Which psychiatric disorder would a nurse expect to see diagnosed in a client's later life? A. Schizophrenia B. Major depressive disorder C. Phobic disorder D. Dependent personality disorder
B
Which risk factor should a nurse recognize as the most reliable indicator of potential client violence? A. A diagnosis of schizotypal personality disorder B. History of assaultive behavior C. Family history of violence D. Recent eviction from a homeless shelter
B
Which tool should the nurse use to differentiate occasional spontaneous behaviors of children from behaviors associated with bipolar disorder? A. Risky Activity tool B. FIND tool C. Consensus Committee tool D. Monotherapy tool
B
Prior to anxiety being clearly defined as a separate entity, which of the following diagnostic terms were used to identify symptoms? Select all that apply. A. Cardiac necrosis B. Vasomotor neurosis C. Vasoregulatory asthenia D. Soldier's tachycardia
B, C
The nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? Select all that apply. A. Benzodiazepine therapy B. Systematic desensitization C. Imploding (flooding) D. Assertiveness training E. Aversion therapy
B, C
Which adults are most likely to maintain a positive self-concept during the aging process? Select all that apply. A. A single, successful mid-level manager at a computer company who works 60 hours a week B. A middle-aged college professor who hosts dinner parties at her home once a semester for her students C. A busy mother of four children who volunteers at a retirement home during her children's school day D. A thirty-something housewife who struggles with addiction
B, C
A mother brings her son to the emergency department and tells the nurse that her son must have posttraumatic stress disorder (PTSD), because 2 days ago, he witnessed a car accident in which there were fatalities. She is convinced that her son has PTSD because he has been crying when he talks about the incident. She believes that boys are at greater risk for PTSD because they don't typically cry. She read on the Internet that PTSD can have dangerous consequences, so she wants her son to get some medication "to cure the PTSD before it gets too bad." Which of these statements by the nurse would accurately correct this mother's misunderstanding about PTSD? Select all that apply. A. "There are no long-term or dangerous consequences from PTSD." B. "Women appear to be at greater risk of this disorder than are men." C. "Medications have been found to be effective in treating symptoms of depression or anxiety but do not represent a cure for the disorder." D. "Fewer than 10 percent of trauma victims develop PTSD."
B, C, D
An individual experiences sadness and melancholia in September continuing through November. Which of the following factors should the nurse identify as most likely to contribute to the etiology of these symptoms? Select all that apply. A. Gender differences in social opportunities that occur with age B. Drastic temperature and barometric pressure changes C. Increased levels of melatonin D. Variations in serotonergic functioning E. Inaccessibility of resources for dealing with life stressors
B, C, D
After Margie's husband of 52 years passed away, Margie's children moved her to an assisted-living community so she would have more social interaction. She has lived in the community for 3 years, and she has been the president of the social committee. Lately, Margie has had difficulty remembering the dates and times of social events she has planned and the names of some of her closest friends in the community. When the nurse addresses this issue, Margie responds with "I've always been so sharp and now I feel like my brain is hardly working at all. I've turned into a dotty old woman who can't keep things straight. I'm so embarrassed and humiliated. I'm so glad my husband isn't here to see this." Which nursing actions are likely to improve Margie's self-esteem? Select all that apply. A. Referring Margie to a psychiatrist to treat her depression B. Hanging a large calendar on Margie's wall with important dates delineated C. Asking the social worker to assign a roommate to Margie to keep an eye on her D. Supplying Margie with a daily itinerary that lists the time and location of social events
B, D
The nurse is teaching the son of an older adult about the psychological changes associated with aging. Which statement made by the nurse is correct? Select all that apply. A. "All older adults experience decreased blood flow to the brain that can cause loss of long-term memory." B. "Short-term memory deteriorates with age, which is most likely due to poor sorting strategies in the older adult." C. "Older people have trouble learning new things just like the old saying 'you can't teach an old dog new tricks."' D. "Older people who are well-educated and mentally active do not lose their memory like their peers who aren't as mentally active." E. "Your dad can still learn new tasks; it just may take a little longer than it used to."
B, D, E
A 30-year-old client diagnosed with Depression has been exclusively cared for and financially subsidized by his mother since age 17. According to Erikson's theory, the nurse recognizes that the client has been unsuccessful in meeting which developmental task? A. Trust B. Initiative C. Intimacy D. Ego integrity
C
A 75-year-old client with a long history of depression is currently taking doxepin (Sinequan), 100 mg daily. The client also takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority? A. Risk for ineffective thermoregulation R/T anhidrosis B. Risk for constipation R/T excessive fluid loss C. Risk for injury R/T orthostatic hypotension D. Risk for infection R/T suppressed white blood cell count ANS: C
C
A client began taking lithium for the treatment of bipolar disorder approximately 1 month ago. The client asks if it is normal to have gained 12 pounds in this time frame. Which is the appropriate nursing reply? A. "That's strange. Weight loss is the typical pattern." B. "What have you been eating? Weight gain is not usually associated with lithium." C. "Weight gain is a common but troubling side effect." D. "Weight gain occurs only during the first month of treatment with this drug."
C
A client diagnosed with Generalized Anxiety states, "I know the best thing for me to do now is to just forget my worries." How should the nurse evaluate this statement? A. The client is developing insight. B. The client's coping skills are improving. C. The client has a distorted perception of problem resolution. D. The client is meeting outcomes and moving toward discharge.
C
A client diagnosed with Neurocognitive Disorder Due to Alzheimer's Disease has difficulty communicating because of cognitive deterioration. Which nursing intervention is appropriate to improve communication? A. Discourage attempts at verbal communication because of increased client frustration. B. Increase the volume of the nurse's communication responses. C. Verbalize the nurse's perception of the implied communication. D. Encourage the client to communicate by writing.
C
A client diagnosed with Paranoid Schizophrenia has a history of aggravated assault. The nurse assigns "Risk for other-directed violence" as the client's priority nursing diagnosis. Which is an appropriate, correctly written outcome for the client? A. The client will not verbalize anger or hit anyone. B. The client will verbalize anger rather than hit others. C. The client will not inflict harm on others during this shift. D. The client will be restrained if verbal or physical abuse is observed during this shift.
C
A client diagnosed with Schizoaffective Disorder is admitted for social skills training. Which information should be taught by the nurse? A. The side effects of medications B. Deep breathing techniques to decrease stress C. How to make eye contact when communicating D. How to be a leader
C
A client diagnosed with Schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should the nurse expect a physician to order to address this type of symptom? A. Haloperidol (Haldol) to address the negative symptom B. Clonazepam (Klonopin) to address the positive symptom C. Risperidone (Risperdal) to address the positive symptom D. Clozapine (Clozaril) to address the negative symptom
C
A client diagnosed with Schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply? A. "Did you take your medicine this morning?" B. "You are not going to hell. You are a good person." C. "I'm sure the voices sound scary. I don't hear any voices speaking." D. "The devil only talks to people who are receptive to his influence."
C
A client diagnosed with Schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." Which symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom? A. Magical thinking; administer an antipsychotic medication. B. Persecutory delusions; orient the client to reality. C. Command hallucinations; warn the psychiatrist. D. Altered thought processes; call an emergency treatment team meeting.
C
A client diagnosed with brief psychotic disorder tells the nurse about voices telling him to kill the president. Which nursing diagnosis should the nurse prioritize for this client? A. Disturbed sensory perception B. Altered thought processes C. Risk for violence: other-directed D. Risk for injury
C
A client diagnosed with psychosis asks the nurse to make the voices stop talking so he can go to sleep. Which is the most appropriate nursing intervention? A. Ask the client whether the voices seem familiar. B. Guide the client to bed and gently rub his back. C. Ask the client what the voices are saying. D. Suggest the client turn up the volume on the television.
C
A client has recently been placed in a long-term care facility because of marked confusion and inability to perform most activities of daily living (ADLs). Which nursing intervention is most appropriate to maintain the client's self-esteem? A. Leave the client alone in the bathroom to test ability to perform self-care. B. Assign a variety of caregivers to increase potential for socialization. C. Allow the client to choose between two different outfits when dressing for the day. D. Modify the daily schedule often to maintain variety and decrease boredom.
C
A client is diagnosed with Bipolar Disorder and admitted to an inpatient psychiatric unit. Which is the priority outcome for this client? A. The client will accomplish activities of daily living independently by discharge. B. The client will verbalize feelings during group sessions by discharge. C. The client will remain safe throughout hospitalization. D. The client will use problem-solving to cope adequately after discharge.
C
A client is diagnosed with Schizophrenia. A physician orders haloperidol (Haldol), 50 mg bid; benztropine (Cogentin), 1 mg prn; and zolpidem (Ambien), 10 mg HS. Which client behavior would warrant the nurse to administer benztropine? A. Tactile hallucinations B. Tardive dyskinesia C. Restlessness and muscle rigidity D. Reports of hearing disturbing voices
C
A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep-breathing relaxation exercises. B. Place the client in a Trendelenburg position. C. Stay with the client and offer reassurance of safety. D. Administer the ordered prn buspirone (BuSpar).
C
A client living on the beachfront seeks help with an extreme fear of crossing bridges, which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. "Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge." B. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."
C
A client on an inpatient unit is diagnosed with Bipolar Disorder: Manic Episode. During a discussion in the dayroom about weekend activities, the client raises his voice, becomes irritable, and insists that plans change. Which should be the nurse's initial intervention? A. Ask the group to take a vote on alternative weekend events. B. Remind the client to quiet down or leave the dayroom. C. Assist the client to move to a calmer location. D. Discuss with the client impulse control problems.
C
A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge? A. The client will verbalize the reason the voices make derogatory statements. B. The client will not hear auditory hallucinations. C. The client will identify events that increase anxiety and illicit hallucinations. D. The client will positively integrate the voices into the client's personality structure.
C
A college student is unable to take a final examination because of severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which is the priority nursing diagnosis that the campus nurse should assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear
C
A depressed client reports to the nurse a history of divorce, job loss, family estrangement, and cocaine abuse. According to learning theory, which is the cause of this client's symptoms? A. Depression is a result of anger turned inward. B. Depression is a result of abandonment. C. Depression is a result of repeated failures. D. Depression is a result of negative thinking.
C
A father tells his 5-year-old, "Son, today instead of picking flowers in the outfield, let's try to catch a ball." The child subsequently pays attention and catches a ball. Which principle of building self-esteem has the father implemented? A. A sense of competence B. Unconditional love C. Realistic goals D. Reality orientation
C
A high-school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she also planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol. Which is the correctly written priority nursing diagnosis for this client? A. Ineffective coping R/T situational crisis AEB powerlessness B. Anxiety R/T fear of failure C. Risk for self-directed violence R/T hopelessness D. Risk for low self-esteem R/T loss events AEB suicidal ideations
C
A home health nurse visits an 18-year-old client who lives with his mother. The client has been assessed as having low self-esteem. The nurse refers the client for individual counseling. During the next home visit, which assessed client behavior clearly indicates treatment success? A. The client wants to buy a dog but has not yet asked his mother's permission. B. The client asks his mother for permission to buy a dog. C. The client tells his mother he plans to buy a dog. D. The client buys a dog and hides it in the garage.
C
A newly admitted client has taken thioridazine (Mellaril) for 2 years, with good symptom control. Symptoms exhibited on admission included paranoia and hallucinations. The nurse recognizes which potential cause for the return of these symptoms? A. The client has developed tolerance to the medication. B. The client has not taken the medication with food. C. The client has not taken the medication as prescribed. D. The client has combined alcohol with the medication.
C
A newly admitted client is experiencing a manic episode of bipolar I disorder and presents as very agitated. The nurse should assign which priority nursing diagnosis to this client? A. Ineffective individual coping R/T hospitalization AEB alcohol abuse B. Altered nutrition: less than body requirements R/T mania AEB 10-pound weight loss C. Risk for violence: directed toward others R/T agitation and hyperactivity D. Sleep pattern disturbance R/T flight of ideas AEB sleeps 1 to 2 hours per night
C
A nurse has identified the following nursing diagnosis: "ineffective communication R/T lack of assertiveness skills AEB inability to state needs." Which statement encourages the client to acknowledge the priority of this problem? A. "Are you having thoughts of harming yourself or others?" B. "With whom are you least assertive?" C. "On a scale of 1 to 10, rank the importance of being assertive." D. "When are you available to attend the assertiveness training class?"
C
A nurse is working in a nursing home. How best can this nurse foster self-esteem in the residents of this facility? A. Allowing them to remain in their rooms as much as they desire to maintain privacy B. Administering antianxiety medications as ordered C. Providing a sense of mastery over their environment by giving choices when appropriate D. Teaching assertiveness skills and self-esteem principles
C
A nurse should assign which nursing diagnosis to a client needing assistance with assertiveness? A. Disturbed personal identity B. Disturbed thought processes C. Defensive coping D. Impaired verbal communication
C
A nursing instructor is teaching about self-concept. Which student statement indicates a need for further instruction? A. "Self-concept is the thinking component of the self." B. "Self-concept is a system of learned beliefs about self." C. "Self-concept is the degree of regard that individuals have for themselves." D. "Self-concept is the attitudes and opinions held true about personal existence."
C
A nursing supervisor is scheduling holiday hours. When the supervisor tells the staff nurse that she needs to work Christmas day, the staff nurse calmly states, "I worked last Christmas and will not work this Christmas." When the supervisor says "But I need you to work," the nurse repeats "I worked last Christmas and will not work this Christmas." This is an example of which assertive behavior technique? A. Shifting from content to process B. Standing up for one's basic rights C. Responding as a "broken record" D. Defusing
C
An adult client diagnosed with Bipolar I Disorder is prescribed lamotrigine (Lamictal), 400 mg three times a day, for mood stabilization. Which statement about this medication order is true? A. "This dosage is within the recommended dosage range." B. "This dosage is lower than the recommended dosage range." C. "This dosage is more than twice the recommended dosage range." D. "This dosage is four times higher than the recommended dosage range."
C
An elderly client diagnosed with Schizophrenia takes an antipsychotic and a beta-adrenergic blocking agent (propranolol) for hypertension. Understanding the combined side effects of these drugs, which statement by the nurse is most appropriate? A. "Make sure you concentrate on taking slow, deep, cleansing breaths." B. "Watch your diet and try to engage in some regular physical activity." C. "Rise slowly when you change position from lying to sitting or sitting to standing." D. "Wear sunscreen and try to avoid midday sun exposure."
C
An elderly client is exhibiting symptoms of major depressive disorder. A physician is considering prescribing an antidepressant. Which physiological problem should make a nurse question this medication regimen? A. Altered cortical and intellectual functioning B. Altered respiratory and gastrointestinal functioning C. Altered liver and kidney functioning D. Altered endocrine and immune system functioning
C
An elderly client who lives with a caregiver is admitted to an emergency department for a fractured arm. The client is soaked in urine and has dried fecal matter on the lower extremities. The client is 6 feet tall and weighs 120 pounds. Which condition should the nurse suspect? A. Inability for the client to meet self-care needs B. Alzheimer's dementia C. Abuse, neglect, or both D. Caregiver role strain
C
How would the nurse best describe the major maladaptive client response to panic disorder? A. Clients overuse medical care because of physical symptoms. B. Clients use illegal drugs to ease symptoms. C. Clients perceive having no control over life situations. D. Clients develop compulsions to deal with anxiety.
C
How would the nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.
C
Neuroimaging studies of individuals with a hoarding disorder have indicated less activity in the: A. Frontal cortex. B. Amygdala-hippocampal formation. C. Cingulate cortex. D. Putamen.
C
Parents ask the nurse how they should reply when their child, diagnosed with Schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply? A. "Tell him to stop discussing the voices." B. "Ignore what he is saying, while attempting to discover the underlying cause." C. "Focus on the feelings generated by the hallucinations and present reality." D. "Present objective evidence that the voices are not real."
C
Sandy, a rape survivor, is being treated for PTSD. Which of these statements are good indications that Sally is beginning to recover from PTSD? A. "I still have nightmares every night, but I don't always remember them anymore." B. "I'm not drinking as much alcohol as I had been over the last several months." C. "This traumatic event immobilized me for a while, but I have found imagery helpful in reducing my anxiety." D. All of the above
C
Studies have suggested that reexperiencing a traumatic event can become an addiction of sorts. The evidence suggests that the reason for this is which? A. People with PTSD often have addictive personalities. B. Perpetuating the traumatic experience yields secondary gains. C. The reexperiencing of trauma enhances production of endogenous opioid peptides. D. People with PTSD often have concurrent substance abuse issues.
C
The client states, "I get into trouble because I respond violently without thinking. That usually gets me into a mess." Which nursing reply is most therapeutic? A. "Everybody loses their temper. It's good that you know that about yourself." B. "I'll bet you have some interesting stories to share about overreacting." C. "Let's explore methods to help you stop and think before taking action." D. "It's good that you are showing readiness for behavioral change."
C
The dean of nursing criticizes a faculty member about views on academic freedom. The faculty member states, "Are you upset because I believe in academic freedom or because you don't?" Which technique is the faculty member using to promote assertive behavior? A. Standing up for one's basic human rights B. Delaying assertively C. Inquiring assertively D. Responding assertively with irony
C
The nurse admits an older client who is experiencing memory loss, confused thinking, and apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental status examination? A. To rule out bipolar disorder B. To rule out schizophrenia C. To rule out neurocognitive disorder (NCD) D. To rule out a personality disorder
C
The nurse is planning care for a client diagnosed with Bipolar Disorder: Manic Episode. Which should be the first priority of the listed client outcomes? A. Maintains nutritional status B. Interacts appropriately with peers C. Remains free from injury D. Sleeps 6 to 8 hours a night
C
The nurse is providing counseling to clients diagnosed with MDD. The nurse chooses to help the clients alter their mood by learning how to change the way they think. The nurse is functioning under which theoretical framework? A. Psychoanalytic theory B. Interpersonal theory C. Cognitive theory D. Behavioral theory
C
The nurse is working with a 15-year-old client suffering from low self-esteem. According to Erikson's psychosocial developmental theory, which factor has most likely influenced this client's self-esteem? A. Regret over life choices B. Lack of personal concern for others C. Inconsistent, overly harsh, or absent parental discipline D. Parental labeling of the child as "good" regardless of his or her behavior
C
Warren's college roommate actively resists going out with friends whenever they invite him. He says he can't stand to be around other people and confides to Warren "They wouldn't like me anyway." Which disorder is Warren's roommate likely suffering from? A. Agoraphobia B. Mysophobia C. Social anxiety disorder (social phobia) D. Panic disorder
C
Which client information does the nurse need to assess prior to initiating medication therapy with phenelzine (Nardil)? A. The client's understanding of the need for regular bloodwork B. The client's mood and affect score, according to the facility's mood scale C. The client's cognitive ability to understand information about the medication D. The client's access to a support network willing to participate in treatment
C
Which initial nursing approach assists clients who are aggressively acting out to accept limit setting better? A. Confronting clients with their needs for secondary gains B. Teaching relaxation techniques C. Empathizing with the client about the client's distress D. Presenting appropriate values that need to be modified
C
Which is associated with premenstrual dysphoric disorder? A. Norepinephrine B. Serotonin C. Progesterone D. Acetylcholine
C
Which is the best nursing rationale for holding a debriefing session with clients and staff after clients have witnessed a peer being "taken down" after a violent outburst? A. To reinforce unit rules with the client population B. To create protocols for the future release of tensions associated with anger C. To process feelings and concerns related to the witnessed intervention D. To discuss the client problems that led to inappropriate expressions of anger
C
Which treatment should the nurse identify as most appropriate for clients diagnosed with GAD? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)
C
While trying to control aggressive behavior, a client asks an assertiveness training nurse to give an example of an "I" statement. Which of the following statements is the best example of this assertive communication technique? A. "I would like to know why you came home late without calling me." B. "I hate it when you think you can just come home late without calling anyone to let them know where you are." C. "I feel angry when you come home late without calling." D. "I think you don't care about me, because if you did, you'd call me if you were planning on coming home late."
C
Yelling, name calling, hitting others, and temper tantrums as expressions of anger are all evidence supporting which nursing diagnosis? A. Risk for self-directed or other-directed violence related to socioeconomic factors B. Anger related to dysfunctional relationships and ineffective coping skills C. Ineffective coping related to negative role modeling and dysfunctional family systems D. Complicated grieving related to a loss
C
A 40-year-old client lives with her parents. She has a high-school diploma and works at a low-paying job. Her parents give her a weekly allowance to supplement her income. How should the nurse classify their client-parent boundaries? A. Loose B. Rigid C. Flexible D. Enmeshed
D
A cab driver stuck in traffic is suddenly lightheaded, tremulous, and diaphoretic and experiences tachycardia and dyspnea. An extensive work-up in an emergency department reveals no pathology. Which medical diagnosis is suspected, and which nursing diagnosis is the priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of panic anxiety
D
A client admitted to the psychiatric unit following a suicide attempt is diagnosed with MDD. Which behavioral symptoms should the nurse expect to assess? A. Anxiety and unconscious anger B. Lack of attention to grooming and hygiene C. Guilt and indecisiveness D. Low self-esteem
D
A client comes to a psychiatric clinic, experiencing sudden extreme fatigue and decreased sleep and appetite. The client works 12 hours a day and rates anxiety as 8/10 on a numeric scale. Which long-term outcome is realistic to address the client's crisis? A. The client will change his or her type A personality traits to more adaptive ones by week 1. B. The client will list five positive self-attributes. C. The client will examine how childhood events led to an overachieving orientation. D. The client will return to previous adaptive levels of functioning by week 6.
D
A client diagnosed with Bipolar Disorder, who has taken lithium carbonate (Lithane) for 1 year, presents in an emergency department with severe diarrhea, blurred vision, and tinnitus. The nurse should interpret these symptoms to be indicative of which of the following? A. Consumption of foods high in tyramine B. Lithium carbonate discontinuation syndrome C. Development of lithium carbonate tolerance D. Lithium carbonate toxicity
D
A client diagnosed with Bipolar I Disorder is exhibiting severe manic behaviors. A physician prescribes lithium carbonate (Eskalith) and olanzapine (Zyprexa). The client's spouse questions the Zyprexa order. Which is the appropriate nursing reply? A. "Zyprexa in combination with Eskalith cures manic symptoms." B. "Zyprexa prevents extrapyramidal side effects." C. "Zyprexa ensures a good night's sleep." D. "Zyprexa calms hyperactivity until the Eskalith takes effect."
D
A client diagnosed with Brief Psychotic Disorder is pacing the milieu and occasionally punches the wall. Which is the initial nursing action? A. Assertively instruct the client to stop punching the wall. B. Encourage the client to write down feelings in a journal. C. With the help of staff, initiate seclusion protocol. D. Ensure adequate physical space between the nurse and the client.
D
A client diagnosed with Glaucoma is being discharged to an assisted-living facility. In what way should the discharge nurse modify teaching to most effectively present information to this client? A. Repeat information at least four times. B. Present discharge teaching to the client's spouse. C. Use a taped message that can be repeated as needed. D. Reinforce critical content by providing large-print handouts.
D
A client diagnosed with MDD states, "I've been feeling 'down' for 3 months. Will I ever feel like myself again?" Which statement by the nurse best assesses this client's affective symptoms? A. "Have you been diagnosed with any physical disorder within the last 3 months?" B. "Have you ever felt this way before? C. "People who have mood changes often feel better when spring comes." D. "Help me understand what you mean when you say, 'feeling down'?"
D
A client diagnosed with OCD spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail, but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization
D
A client is diagnosed with Persistent Depressive Disorder (PDD) (dysthymia). Which should the nurse classify as an affective symptom of this disorder? A. Social isolation with a focus on self B. Low energy level C. Difficulty concentrating D. Gloomy and pessimistic outlook on life
D
A client is experiencing high stress. The client states, "My boss treats me like a doormat and thinks nothing of demanding frequent overtime." Which nursing intervention is most appropriate? A. To incorporate the family support system into the client's plan of care B. To teach thought-reframing techniques C. To encourage the client to seek other employment D. To teach the client how to use "I" statements
D
A client is newly diagnosed with OCD and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
D
A client is served divorce papers while on the inpatient psychiatric unit. When the nurse tells the client that the unit telephone cannot be used after hours, the client raises his fists, swears, and spits at the nurse. Which negative coping mechanism is the client exhibiting? A. The defense mechanism of projection B. The defense mechanism of reaction formation C. The defense mechanism of sublimation D. The defense mechanism of displacement
D
A client on an inpatient unit is angry with a peer. During lunch, when the peer is not looking, the client spits into his soup. How would the nurse document this interaction? A. "Client is displaying assertive behaviors." B. "Client is displaying aggressive behaviors." C. "Client is displaying passive behaviors." D. "Client is displaying passive-aggressive behaviors."
D
A college student who was nearly raped while jogging completes a series of appointments with a rape crisis nurse. Which client statement, made at the final session, most clearly suggests the goals of crisis intervention have been met? A. "You've really been helpful. Can I count on you for continued support?" B. "I don't work out anymore." C. "I'm really glad I didn't go home. It would have been hard to come back." D. "I carry mace when I jog. It makes me feel safe and secure."
D
A confused client has recently been prescribed sertraline (Zoloft). The client's spouse is taking paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors. Which complication does the nurse suspect, and what could be its possible cause? A. Neuroleptic malignant syndrome caused by ingestion of two different SSRIs B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase inhibitor (MAOI) C. Disturbances in serotonin caused by ingestion of an SSRI and an MAOI D. Disturbances in serotonin caused by ingestion of two different SSRIs
D
A couple resides in a long-term care facility. The husband is admitted to the psychiatric unit after physically abusing his wife. He states, "My wife is having an affair with a young man, and I want it investigated." Which is the appropriate nursing reply? A. "Your wife is not having an affair. What makes you think that?" B. "Why do you think that your wife is having an affair?" C. "Your wife has told us that these thoughts have no basis in fact." D. "I understand that you are upset. Let's talk about it."
D
A mother is concerned about her ability to perform in her new role. She is quite anxious and refuses to leave the postpartum unit. To offer effective client care, a nurse should recognize which information about this type of crisis? A. This type of crisis is precipitated by unexpected external stressors. B. This type of crisis is precipitated by preexisting psychopathology. C. This type of crisis is precipitated by an acute response to an external situational stressor. D. This type of crisis is precipitated by normal life-cycle transitions that overwhelm the client.
D
A nurse is caring for four clients. Which client does the nurse identify is least prone to developing problems with anger and aggression? A. A child raised by a physically abusive parent B. An adult with a history of epilepsy C. A young adult living in the ghetto of an inner city D. An adolescent raised by Scandinavian immigrant parents
D
A nurse is conducting a class on fall prevention at a local senior center. In relationship to the slowed cognitive processing of advanced age, which teaching modification would be most appropriate for the nurse to implement? A. Encouraging the clients to use hearing aids if needed B. Avoiding overarticulation C. Minimizing distractive stimuli D. Providing more time for client feedback
D
A nursing instructor is discussing various challenges in the treatment of clients diagnosed with Bipolar Disorder. Which student statement demonstrates an understanding of the most critical challenge in the care of these clients? A. "Treatment is compromised when clients can't sleep." B. "Treatment is compromised when irritability interferes with social interactions." C. "Treatment is compromised when clients have no insight into their problems." D. "Treatment is compromised when clients choose not to take their medications."
D
A nursing instructor is teaching about assertive rights. Which student statement indicates a need for further instruction? A. "The right to be treated with respect is an assertive right." B. "The right to say 'no' without feeling guilty is an assertive right." C. "The right to change your mind is an assertive right." D. "The right to always put oneself first is an assertive right."
D
After less restrictive means have been attempted, an order for client restraints has been obtained for a hostile, aggressive 30-year-old client. If client aggression continues, how long will the nurse expect the client to remain in restraints without a physician order renewal? A. 1 hour B. 2 hours C. 3 hours D. 4 hours
D
After the client's restraints are removed, the staff discusses the incident and establishes guidelines for the client's return to the therapeutic milieu. Which unit procedure is the staff implementing? A. Milieu reenactment B. Treatment planning C. Crisis intervention D. Debriefing
D
After vying for a nurse management position, nurse A is chosen over nurse B. When nurse manager A calls for staff meetings, nurse B is chronically late or absent. Nurse B is exhibiting which type of behavior? A. Passive B. Assertive C. Aggressive D. Passive-aggressive
D
An aggressive nurse manager tells a staff nurse that she has no business rallying staff to change the schedule. What would be an example of a technique that the staff nurse could use to stand up for her basic human rights? A. "What is the real reason that you don't want the schedule changed?" B. "Sounds to me like you're threatened by this change." C. "Are you upset because you don't want to redo the schedule?" D. "I have the right to express my opinion about the schedule."
D
An involuntarily committed client, when offered a dinner tray, pushes it off the bedside table onto the floor. Which is the nurse's priority intervention? A. Initiate forced medication protocol. B. Help the client to explore the source of anger. C. Ignore the act to avoid reinforcing the behavior. D. Set firm limits on the behavior.
D
During an admission assessment, the nurse notes that a client diagnosed with Schizophrenia has allergies to penicillin, prochlorperazine (Compazine), and bee stings. Based on this assessment data, which antipsychotic medication is contraindicated? A. Haloperidol (Haldol), because it is used only in elderly patients B. Clozapine (Clozaril), because of a cross-sensitivity to penicillin C. Risperidone (Risperdal), because it exacerbates symptoms of depression D. Thioridazine (Mellaril), because of cross-sensitivity among phenothiazines
D
During an assertiveness training group, a client admits to aggressive behaviors. The client asks for suggestions for how to become more assertive and less aggressive. Which is the most appropriate nursing reply? A. "Several techniques, including meditation and progressive muscle relaxation, appear helpful." B. "There's not much that can be done about aggressive behavior because of biological responses." C. "Certain types of medications have been proven effective in promoting assertive communication." D. "There are several techniques, including 'I' statements, role-playing, and thought stopping, that can help promote assertive behaviors and decrease aggressive behaviors."
D
Electroconvulsive therapy (ECT) is considered the treatment of choice for which client? A. 39-year-old man experiencing recurrent suicidal ideation B. 23-year-old woman experiencing postpartum depression C. 41-year-old woman describing a suicide plan D. 67-year-old man explaining a recent suicide attempt
D
How would the nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.
D
In what way should a nurse expect a school-aged child to gain positive self-esteem, according to Erikson's psychosocial developmental stages? A. Through basic need fulfillment and environmental predictability B. Through exploration and experimentation, resulting in self-confidence in ability to perform C. Through positive reinforcement of creativity and recognition of performance D. Through receiving recognition when learning, competing, and performing successfully
D
The inpatient psychiatric unit is being redecorated. At a unit meeting, staff discusses bedroom décor for clients experiencing mania. The nurse manager evaluates which suggestion as most appropriate? A. Rooms should contain extra-large windows with views of the street. B. Rooms should contain brightly colored walls with printed drapes. C. Rooms should be painted deep colors and located close to the nurse's station. D. Rooms should be painted with neutral colors and contain pale-colored accessories.
D
The mental health nurse is providing discharge teaching for a client diagnosed with Bipolar Disorder. Which statement indicates that the nurse's teaching is effective? A. "I shouldn't take my lithium when I have the flu." B. "I am looking forward to having real coffee in the morning." C. "I can get off medication in 5 years if I am stable." D. "I'll be the designated driver since I shouldn't have alcohol with lamotrigine."
D
The nurse assesses a client suspected of having MDD. Which client symptom would eliminate this diagnosis? A. The client is disheveled and malodorous. B. The client refuses to interact with others. C. The client is unable to feel any pleasure. D. The client has maxed-out charge cards and exhibits promiscuous behaviors.
D
The nurse is assessing a client diagnosed with Schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom is the nurse assessing? A. Thought insertion B. Paranoia C. Magical thinking D. Delusions of reference
D
The nurse is caring for four clients taking various medications, including imipramine (Tofranil), doxepine (Sinequan), ziprasidone (Geodon), and tranylcypromine (Parnate). The nurse orders a special diet for the client receiving which medication? A. Imipramine (Tofranil) B. Doxepine (Sinequan) C. Ziprasidone (Geodon) D. Tranylcypromine (Parnate)
D
The nurse is planning care for a child who is experiencing depression. Which medication is approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Citalopram (Celexa) D. Fluoxetine (Prozac)
D
What is likely to happen if anger is communicated passive-aggressively or aggressively? A. The individual uses the power to intimidate others. B. It is discharged against an object or person unrelated to the true target of the anger. C. Impulsive behavior can result, disregarding possible negative consequences. D. Conflict escalates, and the problem that created the conflict goes unresolved.
D
Which best describes the nurse's use of assertive behavior? A. The nurse attempts to please others and apologizes for awkwardness in a new role. B. The nurse becomes defensive and angry when peers offer suggestions for improvement. C. The nurse has problems making decisions and tends to procrastinate. D. The nurse is open and direct when asked by the nurse manager to complete assignments.
D
Which carries a warning label stating that the use of the medication increases risk for suicidal thoughts and behaviors? A. Antipsychotics B. Antiepileptics C. Mood stabilizers D. Anxiolytics
D
Which client statement expresses typical underlying feelings of clients diagnosed with MDD? A. "It's just a matter of time and I will be well." B. "If I ignore these feelings, they will go away." C. "I can fight these feelings and overcome this disorder." D. "Nothing will help me feel better."
D
Which is the best nursing reply when a client asks what the goal and benefit are of assertive skills training? A. "It protects the client from others who express aggressive feelings." B. "It gives reliable, expert information so that clients may correct faulty behaviors." C. "It clarifies misperceptions that have caused clients to distort reality." D. "It improves communication skills to improve interpersonal relationships."
D
Which nursing intervention is most appropriate when caring for an acutely agitated client with paranoia? A. Provide neon lights and soft music. B. Maintain continual eye contact throughout the interview. C. Use therapeutic touch to increase trust and rapport. D. Provide personal space to respect the client's boundaries.
D
Which of these statements by the patient are indications of complicated grieving? A. "I feel like I should have been the one to die in that hurricane." B. "Last year, several of my coworkers died in a hurricane and I still can't go back to work." C. "I've been having incapacitating migraines ever since the memorial services." D. All of the above
D
Laboratory results reveal elevated levels of prolactin in a client diagnosed with Schizophrenia. When assessing the client, which symptoms should the nurse expect to observe? Select all that apply. A. Apathy B. Social withdrawal C. Anhedonia D. Galactorrhea E. Gynecomastia
D, E
