Mental Health

In planning for the discharge of a client with a cognitive disorder, it is important to assess the client's caregiver support system. Which aspects are the most crucial to assess? Select all that apply. 1. Availability of resources for caregiver support. 2. Ability to provide the level of care and supervision needed by the client. 3. Willingness to transport the client to medical and psychiatric services. 4. Interest in engaging the cognitively disordered family member in reminiscence and games. 5. Willingness to install door alarms and make other safety changes. 6. Understanding the client's abilities and limitations.

1, 2, 3, 5, 6. It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical care to the client. The caregiver must also have realistic expectations of the client, given his abilities and limitations. Reminiscing and engaging the client in games is desirable but not crucial to care.

A co-manager of a convenience store was taking the daily receipts to the bank when she was robbed at gun point. She did not report the robbery and could not be found for 2 days. In a city 100 miles away, a hotel manager called the police because the woman gave a false name and address. After learning that the robbery was confirmed by the bank cameras, she was admitted to the hospital with a diagnosis of Dissociative Fugue. The nurse should include which of the following in the client's care plan? Select all that apply. 1. Develop trust and rapport to provide safety and support. 2. Rule out possible physical and neurological causes for the fugue. 3. Help the client discuss what she can remember about the trip to the bank. 4. Seclude the client from the other clients because of her lack of memory. 5. Question her repeatedly about the robbery and how she responded. 6. Encourage the client to talk about her feelings about what has been happening.

1, 2, 3, 6. A client experiencing a Dissociate Fugue needs to feel safe and supported as well as evaluated medically and neurologically. Then it is appropriate to discuss what she can remember about the trip to the bank and her feelings about all that has happened to her since then. It is not appropriate to seclude her from others or to apply pressure to get details about the crime at this time. The police and the bank will ask these questions during their investigations.

Transfer data for a client brought by ambulance to the hospital's psychiatric unit from a nursing home indicate that the client has become increasingly confused and disoriented. The client's behavior is found to be the result of cerebral arteriosclerosis. Which of the following behaviors of the nursing staff should positively influence the client's behavior? Select all that apply. 1. Limiting the client's choices. 2. Accepting the client as he is. 3. Allowing the client to do as he wishes. 4. Acting nonchalantly. 5. Explaining to the client what he needs to do step-by-step.

1, 2, 5. Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.

An 83-year-old woman is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She has already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." The nurse should tell the grandson which of the following? Select all that apply. 1. "I agree she needs to rest, but there is no one specific medicine for your grandmother's condition." 2. "The doctor will look at the results of those tests in the ED and decide what other tests are needed." 3. "Delirium commonly results from underlying medical causes that we need to identify and correct." 4. "Tell me about your grandmother's behaviors and maybe I could figure out what medicine she needs." 5. "I'll ask the doctor to postpone more tests until tomorrow."

1, 2, 3. The client does need rest and it is true that there is no specific medicine for delirium, but it is crucial to identify and treat the underlying causes of delirium. Other tests will be based on the results of already completed tests. Although some medications may be prescribed to help the client with her behaviors, this is not the primary basis for medication orders. Because the underlying medical causes of delirium could be fatal, treatment must be initiated as soon as possible. It is not the nurse's role to determine medications for this client. Postponing tests until the next day is inappropriate.

A client is diagnosed with Generalized Anxiety Disorder (GAD) and given a prescription for venlafaxine (Effexor). Which of the following information should the nurse include in a teaching plan for this client? Select all that apply. 1. Various strategies for reducing anxiety. 2. The benefits and mechanisms of actions of Effexor in treating GAD. 3. How Effexor will eliminate his anxiety at home and work. 4. The management of the common side effects of Effexor. 5. Substituting adaptive coping strategies for maladaptive ones. 6. The positive effects of Effexor being evident in 4 to 5 days.

1, 2, 4, 5. It is appropriate to provide education on medication mechanisms, benefits, and managing side effects. No medication will eliminate all anxiety, so teaching about anxiety reduction and adaptive coping is needed. Effexor is a serotonin-norepinephrine reuptake inhibitor antidepressant and it will take 2 to 4 weeks to feel the effects.

A client diagnosed with Post Traumatic Stress Disorder is readmitted for suicidal thoughts and continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about being awakened at night. "My dad would be on top of me trying to have sex with me. I couldn't breathe." Which of the following suggestions would be appropriate for the nurse to make for the insomnia? Select all that apply. 1. Trying relaxation techniques to help decrease her anxiety before bedtime. 2. Taking the quetiapine (Seroquel) 25 mg as needed as ordered by the physician. 3. Staying in the dayroom and trying to sleep in the recliner chair near staff. 4. Listening to calming music as she tries to fall asleep. 5. Processing the content of her flashbacks no less than hour before bedtime. 6. Leaving her door slightly open to decrease noise during the nightly checks.

1, 2, 4, 6. Relaxation techniques and listening to calming music decrease anxiety and promote sleep. Seroquel is often effective in decreasing nightmare and flashbacks and has a beneficial side effect of drowsiness. Leaving her door slightly open will decrease the noise of making 15 minute checks at night. Staying in the dayroom in a recliner with all the noise and lights is not likely to help. Processing memories an hour or two before bedtime doesn't allow enough time to calm down before sleep.

A client has been in the critical care unit for 3 days following a severe myocardial infarction. Although he is medically stable, he has begun to have fluctuating episodes of consciousness, illogical thinking, and anxiety. He is picking at the air to "catch these baby angels flying around my head." While waiting for medical and psychiatric consults, the nurse must intervene with the client's needs. Which of the following needs have the highest priority? Select all that apply. 1. Decreasing as much "foreign" stimuli as possible. 2. Avoiding challenging the client's perceptions about "baby angels." 3. Orienting the client about his medical condition. 4. Gently presenting reality as needed. 5. Calling the client's family to report his onset of dementia.

1, 2, 4. The abnormal stimuli of the critical care unit can aggravate the symptoms of delirium. Arguing with hallucinations is inappropriate. When a client has illogical thinking, gently presenting reality is appropriate. Dementia is not the likely cause of the client's symptoms. The client is experiencing delirium, not dementia.

The nurse is developing a long term care plan for an outpatient client diagnosed with Dissociative Identity Disorder. Which of the following should be included in this plan? Select all that apply. 1. Learning how to manage feelings, especially anger and rage. 2. Joining several outpatient support groups that are process-oriented. 3. Identifying resources to call when there is a risk of suicide or self-mutilation. 4. Selecting a method for alter personalities to communicate with each other, such as journaling. 5. Trying different medicines to find one that eliminates the dissociative process. 6. Helping each alter accept the goal of sharing and integrating all their memories.

1, 3, 4, 6. Managing suicidal thought, urges to self-mutilate and the intense anger are critical safety issues. Then the focus can switch to communication methods for each alter and the integration issues. Process groups can be overwhelming when too much is revealed or when child alters are unable to understand the group content. There are no known medicines to stop the process of dissociating.

A client is taking diazepam (Valium) for generalized anxiety disorder. Which instruction should the nurse give to this client? Select all that apply. 1. To consult with his health care provider before he stops taking the drug. 2. To avoid eating cheese and other tyramine-rich foods. 3. To take the medication on an empty stomach. 4. Not to use alcohol while taking the drug. 5. To stop taking the drug if he experiences swelling of the lips and face and difficulty breathing.

1, 4, 5. The nurse should instruct the client who is taking diazepam to take the medication as prescribed; stopping the medication suddenly can cause withdrawal symptoms. This medication is used for a short term only. The drug dose can be potentiated by alcohol and the client should not drink alcoholic beverages while taking this drug. Swelling of the lips and face and difficulty breathing are signs and symptoms of an allergic reaction. The client should stop taking the drug and seek medical assistance immediately. The client does not need to avoid eating foods containing tyramine; tyramine interacts with monoamine oxidase inhibitors, not Valium. The client can take the medication with food.

The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.

1. Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient.

A client with obsessive-compulsive disorder reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I can't stop until I do it just right." The nurse interprets the client's behavior as most likely representing an effort to obtain which of the following? 1. Relief from anxiety. 2. Control of his thoughts. 3. Attention from others. 4. Safe expression of hostility.

1. A client who is exhibiting compulsive behavior is attempting to control his anxiety. The compulsive behavior is performed to relieve discomfort and to bind or neutralize anxiety. The client must perform the ritual to avoid an extreme increase in tension or anxiety even though the client is aware that the actions are absurd. The repetitive behavior is not an attempt to control thoughts; the obsession or thinking component cannot be controlled. It is not an attention-seeking mechanism or an attempt to express hostility.

A client with panic disorder is taking alprazolam (Xanax) 1 mg P.O. three times daily. The nurse understands that this medication is effective in blocking the symptoms of panic because of its specific action on which of the following neurotransmitters? 1. Gamma-aminobutyrate. 2. Serotonin. 3. Dopamine. 4. Norepinephrine.

1. Alprazolam, a benzodiazepine used on a short-term or temporary basis to treat symptoms of anxiety, increases gamma-aminobutyrate, a major inhibitory neurotransmitter. Because gamma-aminobutyric acid is increased and the reticular activating system is depressed, incoming stimuli are muted and the effects of anxiety are blocked. Alprazolam does not directly target serotonin, dopamine, or norepinephrine.

The client with dementia states to the nurse, "I know you. You're Margaret, the girl who lives down the street from me." Which of the following responses by the nurse is most therapeutic? 1. "Mrs. Jones, I'm Rachel, a nurse here at the hospital." 2. "Now Mrs. Jones, you know who I am." 3. "Mrs. Jones, I told you already, I'm Rachel and I don't live down the street." 4. "I think you forgot that I'm Rachel, Mrs. Jones."

1. Because of the client's short-term memory impairment, the nurse gently corrects the client by stating her name and who she is. This approach decreases anxiety, embarrassment, and shame and maintains the client's self-esteem. Telling the client that she knows who the nurse is or that she forgot can elicit feelings of embarrassment and shame. Saying, "I told you already" sounds condescending, as if blaming the client for not remembering.

Which of the following statements by a client who has been taking buspirone (BuSpar) as prescribed for 2 days indicates the need for further teaching? 1. "This medication will help my tight, aching muscles." 2. "I may not feel better for 7 to 10 days." 3. "The drug does not cause physical dependence." 4. "I can take the medication with food."

1. Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. BuSpar is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects not occurring for 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.

The nurse should warn a client who is taking a benzodiazepine about using which of the following medications in combination with his current medication? 1. Antacids. 2. Acetaminophen (Tylenol). 3. Vitamins. 4. Aspirin.

1. Combining a benzodiazepine with an antacid impairs the absorption rate of the benzodiazepine. Acetaminophen, vitamins, and aspirin are safe to take with a benzodiazepine because no major drug interactions occur.

When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the following types of care should the nurse expect to include? 1. Prompting and guiding activities of daily living. 2. Managing a medication schedule. 3. Constant supervision and total care. 4. Supervision of risky activities such as shaving.

1. Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment— that is, when the client still has motor function but lacks judgment about safety issues.

The nurse is attempting to draw blood from a woman with a diagnosis of delirium who was admitted last evening. The client yells out, "Stop; leave me alone. What are you trying to do to me? What's happening to me?" Which response by the nurse is most appropriate? 1. "The tests of your blood will help us figure out what is happening to you." 2. "Please hold still so I don't have to stick you a second time." 3. "After I get your blood, I'll get some medicine to help you calm down." 4. "I'll tell you everything after I get your blood tests to the laboratory."

1. Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not reflect loss of self control requiring medication intervention.

In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics? 1. Disturbances in cognition and consciousness that fluctuate during the day. 2. The failure to identify objects despite intact sensory functions. 3. Significant impairment in social or occupational functioning over time. 4. Memory impairment to the degree of being called amnesia.

1. Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree

Which of the following should the nurse expect to include as a priority in the plan of care for a client with delirium based on the nurse's understanding about the disturbances in orientation associated with this disorder? 1. Identifying self and making sure that the nurse has the client's attention. 2. Eliminating the client's napping in the daytime as much as possible. 3. Engaging the client in reminiscing with relatives or visitors. 4. Avoiding arguing with a suspicious client about his perceptions of reality.

1. Identifying oneself and making sure that the nurse has the client's attention addresses the difficulties with focusing, orientation, and maintaining attention. Eliminating daytime napping is unrealistic until the cause of the delirium is determined and the client's ability to focus and maintain attention improves. Engaging the client in reminiscing and avoiding arguing are also unrealistic at this time.

A 3-year-old child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which of the following comments by the nurse would be most appropriate? 1. "It's okay to cry when something hurts." 2. "That really didn't hurt, did it?" 3. "We're mean to hurt you that way, aren't we?" 4. "You were very good not to cry with the needle."

1. It is not normal for a preschooler to be totally passive during a painful procedure. Typically a preschooler reacts to a painful procedure by crying or pulling away because of the fear of pain. However, an abused child may become "immune" to pain and may find that crying can bring on more pain. The child needs to learn that appropriate emotional expression is acceptable. Telling the child that it really didn't hurt is inappropriate because it is untrue. Telling the child that nurses are mean does not build a trusting relationship. Praising the child will reinforce the child's response not to cry, even though it is acceptable to do so.

On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend sniffs glue. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, the nurse should consider which of the following? 1. The boys probably fear punishment. 2. Sniffing glue is illegal. 3. The boys' observations could be wrong. 4. Glue-sniffing is a minor form of substance abuse.

1. Telephoning the crisis shelter indicates that the boys are alarmed but are reluctant to talk with their parents. The boys may fear that their parents will assume that they have been sniffing glue and punish them. The nurse should focus on helping the boys talk with their parents. Although sniffing glue is dangerous and potentially lethal, it is not illegal. To prove that the observations are incorrect requires an intervention beginning with the boys' parents. Sniffing glue is included in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revised, as inhalant abuse. It is not a minor form of substance abuse.

A young child who has been sexually abused has difficulty putting feelings into words. Which of the following should the nurse employ with the child? 1. Engaging in play therapy. 2. Role-playing. 3. Giving the child's drawings to the abuser. 4. Reporting the abuse to a prosecutor.

1. The dolls and toys in a play therapy room are useful props to help the child remember situations and reexperience the feelings, acting out the experience with the toys rather than putting the feelings into words. Role-playing without props commonly is more difficult for a child. Although drawing itself can be therapeutic, having the abuser see the pictures is usually threatening for the child. Reporting abuse to authorities is mandatory, but doesn't help the child express feelings.

A client is brought to the emergency department by his brother. The client is perspiring profusely, breathing rapidly, and complaining of dizziness and palpitations. Problems of a cardiovascular nature are ruled out, and the client's diagnosis is tentatively listed as a panic attack. After the symptoms pass, the client states, "I thought I was going to die." Which of the following responses by the nurse is best? 1. "It was very frightening for you." 2. "We would not have let you die." 3. "I would have felt the same way." 4. "But you're okay now."

1. The nurse responds with the statement, "It was very frightening for you," to express empathy, thus acknowledging the client's discomfort and accepting his feelings. The nurse conveys respect and validates the client's self-worth. The other statements do not focus on the client's underlying feelings, convey active listening, or promote trust.

The client, a veteran of the Vietnam war who has posttraumatic stress disorder, tells the nurse about the horror and mass destruction of war. He states, "I killed all of those people for nothing." Which of the following responses by the nurse is appropriate? 1. "You did what you had to do at that time." 2. "Maybe you didn't kill as many people as you think." 3. "How many people did you kill?" 4. "War is a terrible thing."

1. The nurse states, "You did what you had to do at that time," to help the client evaluate past behavior in the context of the trauma. Clients commonly feel guilty about past behaviors when viewing them in the context of current values. The other statements are inappropriate because they do not help the client to evaluate past behavior in the context of the trauma.

The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, "I'm tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurse should tell the son: 1. "Your dad lost his short-term memory, but he still has his long-term memory." 2. "You need to be more accepting of your dad's behavior." 3. "I want you to understand your dad's level of anxiety." 4. "Telling your dad that you are tired of hearing about the past will help him stop."

1. The son's statements regarding his father's recalling past events is typical for family members of clients in the early stage of Alzheimer's disease, when recent memory is impaired. Telling the son to be more accepting is critical and not an attempt to educate. Understanding the client's level of anxiety is unrelated to the memory loss of Alzheimer's disease. The client cannot stop reminiscing at will.

When helping the families of clients with Alzheimer's disease cope with vulgar or sexual behaviors, which of the following suggestions is most helpful? 1. Ignore the behaviors, but try to identify the underlying need for the behaviors. 2. Give feedback on the inappropriateness of the behaviors. 3. Employ anger management strategies. 4. Administer the prescribed risperidone (Risperdal).

1. The vulgar or sexual behaviors are commonly expressions of anger or more sensual needs that can be addressed directly. Therefore, the families should be encouraged to ignore the behaviors but attempt to identify their purpose. Then the purpose can be addressed, possibly leading to a decrease in the behaviors. Because of impaired cognitive function, the client is not likely to be able to process the inappropriateness of the behaviors if given feedback. Likewise, anger management strategies would be ineffective because the client would probably be unable to process the inappropriateness of the behaviors. Risperidone (Risperdal) may decrease agitation, but it does not improve social behaviors.

Nursing staff are trying to provide for the safety of an elderly female client with moderate dementia. She is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should: 1. Move the client to a room near the nurse's station and install a bed alarm. 2. Have the client sleep in a reclining chair across from the nurse's station. 3. Help the client to bed and raise all four bedrails. 4. Ask a family member to stay with the client at night.

1. Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.

The husband of a client with Alzheimer's disease that was diagnosed 6 years ago approaches the nurse and says, "I'm so excited that my wife is starting to use donepezil (Aricept) for her illness." The nurse should tell the husband: 1. The medication is effective mostly in the early stages of the illness. 2. The adverse effects of the drug are numerous. 3. The client will attain a functional level of that of 6 years ago. 4. Effectiveness in the terminal phase of the illness is scientifically proven.

1. When compared with other similar medications, donepezil (Aricept) has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.

A client diagnosed with obsessive-compulsive disorder arrives late for an appointment with the nurse at the outpatient clinic. During the interview, he fidgets restlessly, has trouble remembering what topic is being discussed, and says he thinks he is going crazy. Which of the following statements by the nurse best deals with the client's feelings of "going crazy?" 1. "What do you mean when you say you think you're going crazy?" 2. "Most people feel that way occasionally." 3. "I don't know you well enough to judge your mental state." 4. "You sound perfectly sane to me."

1. When the client says he thinks he is "going crazy," it is best for the nurse to ask him what "crazy" means to him. The nurse must have a clear idea of what the client means by his words and actions. Using an open-ended question facilitates client description to help the nurse assess his meaning. The other statements minimize and dismiss the client's concern and do not give him the opportunity to openly discuss his feelings, possibly leading to increased anxiety.

The nurse is to administer Xanax (alprazolam) to help a client of Japanese descent calm down. The order reads Xanax 0.25 to 1 mg by mouth as needed for agitation. What is the best dose for the nurse to give this client? ________________________ mg.

2 mg. Asians have a greater sensitivity to psychotropic medication and generally require much less than other cultural groups to achieve positive results. The smallest dose is safest to start; the dosage can always be increased. However, a dose that is too high for the client is likely to cause unpleasant or even serious side effects. Those side effects likely would lead to distress and noncompliance in the future.

A nurse is assessing a client who is being abused. The nurse should assess the client for which characteristic? Select all that apply. 1. Assertiveness. 2. Self-blame. 3. Alcohol abuse. 4. Suicidal thoughts. 5. Guilt.

2, 3, 4, 5. The victim of abuse is usually compliant with the spouse and feels guilt, shame, and some responsibility for the battering. Self-blame, substance abuse, and suicidal thoughts and attempts are possible dysfunctional coping methods used by abuse victims. The victim of abuse is not likely to demonstrate assertiveness.

When working with a group of adult survivors of childhood sexual abuse, dealing with anger and rage is a major focus. Which strategy should the nurse expect to be successful? Select all that apply. 1. Directly confronting the abuser. 2. Using a foam bat while symbolically confronting the abuser. 3. Keeping a journal of memories and feelings. 4. Writing letters to the abusers that are not sent. 5. Writing letters to the adults who did not protect them that are not sent.

2, 3, 4, 5. Using a foam bat while symbolically confronting the abuser, keeping a journal of memories and feelings, and writing letters about the abuse but not sending them are appropriate strategies because they allow anger to be expressed safely. Directly confronting the abuser is likely to result in further harm because the abusers commonly deny the abuse, rationalize about it, or blame the victim.

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.

2, 3, 4. A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime.

The family of a client, diagnosed with Alzheimer's disease, wants to keep the client at home. They say that they have the most difficulty in managing his wandering. The nurse should instruct the family to do which of the following? (Select all that apply). 1. Ask the physician for a sleeping medication. 2. Install motion and sound detectors. 3. Have a relative sit with the client all night. 4. Have the client wear a Medical Alert bracelet. 5. Install door alarms and high door locks.

2, 4, 5. Motion and sound detectors, a Medical Alert bracelet, and door alarms are all appropriate interventions for wandering. Sleep medications do not prevent wandering before and after the client is asleep and may have negative effects. Having a relative sit with the client is usually an unrealistic burden.

A client who is pacing and wringing his hands states, "I just need to walk" when questioned by the nurse about what he is feeling. Which of the following responses by the nurse is most therapeutic? 1. "You need to sit down and relax." 2. "Are you feeling anxious?" 3. "Is something bothering you?" 4. "You must be experiencing a problem now."

2. Asking, "Are you feeling anxious?" helps the client to specifically label the feeling as anxiety so that he can begin to understand and manage it. Some clients need assistance with identifying what they are feeling so they can recognize what is happening to them. Stating, "You need to sit down and relax," is not appropriate because the client needs to continue his pacing to feel better. Asking if something is bothering the client or saying that he must be experiencing a problem is vague and does not help the client identify his feelings as anxiety.

A potentially pregnant 16-year-old client says that she has been "hooking up" with a boy she considers to be her boyfriend. Which of the following responses should the nurse make first? 1. "You mean you have had sexual intercourse?" 2. "Describe what you mean by hooking up." 3. "I think we need to talk about what's involved in sexual intercourse." 4. "All you have been doing with your boyfriend is hooking up?"

2. Because of the client's potential pregnancy, the nurse needs to determine exactly what the client means by the term "hooking up" by asking the client to describe what she has been doing in sexual encounters with her boyfriend. Asking the client if she means sexual intercourse or telling the client that they need to talk about sexual intercourse makes an assumption that may or may not be appropriate. The nurse needs to determine exactly what the client means by the terms used. Repeating the client's statement does not elicit the necessary information to interpret the client's statement. Additionally, this type of response assumes an understanding of what the client has said.

Which of the following is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks? 1. Repeating the directions until the client follows them. 2. Asking the client to do one step of the task at a time. 3. Demonstrating for the client how to do the task. 4. Maintaining routine and structure for the client.

2. Because the client is experiencing difficulty processing and completing complex tasks, the priority is to provide the client with only one step at a time, thereby breaking the task up into simple steps, ones that the client can process. Repeating the directions until the client follows them or demonstrating how to do the task is still too overwhelming to the client because of the multiple steps involved. Although maintaining structure and routine is important, it is unrelated to task completion.

A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? 1. Speech. 2. Judgment. 3. Endurance. 4. Balance.

2. Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.

A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation.

2. Elderly clients have increased risk for falls due to balance problems, medication use, and decreased eyesight. Haldol may cause extrapyramidal side effects (EPSE) which increase the risk for falls. The client is not agitated, so restraints are not indicated. Ativan may increase fall risk and cause paradoxical excitement.

The term motor apraxia relates to a decline in motor patterns essential for complex motor tasks. However, the client with severe dementia may be able to perform which of the following actions? 1. Balance a checkbook accurately. 2. Brush the teeth when handed a toothbrush. 3. Use confabulation when telling a story. 4. Find misplaced car keys.

2. Highly conditioned motor skills, such as brushing the teeth, may be retained by the client who has dementia and motor apraxia. Balancing a checkbook involves calculations, a complex skill that is lost with severe dementia Confabulation is fabrication of details to fill a memory gap. This is more common when the client is aware of a memory problem, not when dementia is severe. Finding keys is a memory factor, not a motor function.

A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate? 1. "Please come away from the door. I'll show you your room." 2. "It's Tuesday and you are in the hospital. I'm Anne, a nurse." 3. "The door is locked to keep you from getting lost." 4. "I want you to come eat your lunch before you go the doctor."

2. Loss of orientation, especially for time and place, is common in delirium. The nurse should orient the client by telling him the time, date, place, and who the client is with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.

A client diagnosed with Obsessive-Compulsive Disorder has been taking sertraline (Zoloft) but would like to have more energy every day. At his monthly checkup, he reports that his massage therapist recommended he take St. John's Wort to help his depression. The nurse should tell the client: 1. "St. John's Wort is a harmless herb that might be helpful in this instance." 2. "Combining St. John's Wort with the Zoloft can cause a serious reaction called Serotonin Syndrome." 3. "If you take St. John's, we'll have to decrease the dose of your Zoloft." 4. "St. John's Wort isn't very effective for depression, but we can increase your Zoloft dose."

2. The effectiveness of St. John's Wort with depression is unconfirmed. The critical issue is that the combination of St. John's Wort and Zoloft (an SSRI antidepressant) can produce Serotonin Syndrome which can be fatal. The client should not take the St. John's Wort while taking Zoloft.

A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether to file a report, the nurse's next priority is to offer which of the following to the client? 1. Legal assistance. 2. Crisis intervention. 3. A rape support group. 4. Medication for disturbed sleep.

2. The experience of rape is a crisis. Crisis intervention services, especially with a rape crisis nurse, are essential to help the client begin dealing with the aftermath of a rape. Legal assistance may be recommended if the client decides to report the rape and only after crisis intervention services have been provided. A rape support group can be helpful later in the recovery process. Medications for sleep disturbance, especially benzodiazepines, should be avoided if possible. Benzodiazepines are potentially addictive and can be used in suicide attempts, especially when consumed with alcohol.

Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.

2. The most critical aspect when caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she's going crazy. Which of the following actions should the nurse use first? 1. Explain the effects of stress on the mind and body. 2. Reassure the client that her feelings are typical reactions to serious trauma. 3. Reassure the client that her symptoms are temporary. 4. Acknowledge the unfairness of the client's situation.

2. The nurse initially reassures the client that her feelings and behaviors are typical reactions to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress on the body may be helpful later. Telling the client that her symptoms are temporary is less helpful. Acknowledging the unfairness of the client's situation does not address the client's needs at this time.

A nurse on the Geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine (Namenda) to take "on top of his donepezil (Aricept)." The son then asks, "Why does he have to take extra medicines?" The nurse should tell the son: 1. "Maybe the Aricept alone isn't improving his dementia fast enough or well enough." 2. "Namenda and Aricept are commonly used together to slow the progression of dementia." 3. "Namenda is more effective than Aricept. Your father will be tapered off the Aricept." 4. "Aricept has a short half-life and Namenda has a long half-life. They work well together."

2. The two medicines are commonly given together. Neither medicine will improve dementia, but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.

After months of counseling, a client abused by her husband tells the nurse that she has decided to stop treatment. There has been no abuse during this time, and she feels better able to cope with the needs of her husband and children. In discussing this decision with the client, the nurse should: 1. Tell the client that this is a bad decision that she will regret in the future. 2. Find out more about the client's rationale for her decision to stop treatment. 3. Warn the client that abuse commonly stops when one partner is in treatment, only to begin again later. 4. Remind the client of her duty to protect her children by continuing treatment.

2. The nurse needs more information about the client's decision before deciding what intervention is most appropriate. Judgmental responses could make it difficult for the client to return for treatment should she want to do so. Telling the client that this is a bad decision that she will regret is inappropriate because the nurse is making an assumption. Warning the client that abuse commonly stops when one partner is involved in treatment may be true for some clients. However, until the nurse determines the basis for the client's decision, this type of response is an assumption and therefore inappropriate. Reminding the client about her duty to protect the children would be appropriate if the client had talked about episodes of current abuse by her partner and the fear that her children might be hurt by him.

A client with obsessive-compulsive disorder, who was admitted early yesterday morning, must make his bed 22 times before he can have breakfast. Because of his behavior, the client missed having breakfast yesterday with the other clients. Which of the following actions should the nurse institute to help the client be on time for breakfast? 1. Tell the client to make his bed one time only. 2. Wake the client an hour earlier to perform his ritual. 3. Insist that the client stop his activity when it's time for breakfast. 4. Advise the client to have breakfast first before making his bed.

2. The nurse should wake the client an hour earlier to perform his ritual so that he can be on time for breakfast with the other clients. The nurse provides the client with time needed to perform rituals because the client needs to keep his anxiety in check. The nurse should never take away a ritual, because panic will ensue. The nurse should work with the client later to slowly set limits on the frequency of the action.

1. A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, "He didn't really mean to hurt me, but I hate for the kids to see this. I'm so worried about them." Which of the following is the most crucial information for the nurse to determine? 1. The type and extent of abuse occurring in the family. 2. The potential of immediate danger to the client and her children. 3. The resources available to the client. 4. Whether the client wants to be separated from her husband.

2. The safety of the client and her children is the most immediate concern. If there is immediate danger, action must be taken to protect them. The other options can be discussed after the client's safety is assured.

A preadolescent child is suspected of being sexually abused because he demonstrates the self-destructive behaviors of self-mutilation and attempted suicide. Which common behavior should the nurse also expect to assess? 1. Inability to play. 2. Truancy and running away. 3. Head banging. 4. Over-control of anger.

2. Truancy and running away are common symptoms for young children and adolescents. The stress of the abuse interferes with school success, leading to the avoidance of school. Running away is an effort to escape the abuse and/ or lack of support at home. Rather than an inability to play or a lack of play, play is likely to be aggressive with sexual overtones. Children tend to act out anger rather than control it. Head banging is a behavior typically seen with very young children who are abused.

Which of the following client statements indicates the need for additional teaching about benzodiazepines? 1. "I can't drink alcohol while taking diazepam (Valium)." 2. "I can stop taking the drug anytime I want." 3. "Valium can make me drowsy, so I shouldn't drive for a while." 4. "Valium will help my tight muscles feel better."

2. Valium, like any benzodiazepine, cannot be stopped abruptly. The client must be slowly tapered off of the medication to decrease withdrawal symptoms, which would be similar to withdrawal from alcohol. Alcohol in combination with a benzodiazepine produces an increased central nervous system depressant effect and therefore should be avoided. Valium can cause drowsiness, and the client should be warned about driving until tolerance develops. Valium has muscle relaxant properties and will help tight, tense muscles feel better.

While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. The nurse should: 1. Tell her that she is very rude. 2. Ignore the vulgarity and distract her. 3. Tell her to stop swearing immediately. 4. Say nothing and leave the room.

2. Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand.

A client with acute stress disorder has avoided feelings of anger toward her rapist and cannot verbally express them. The nurse suggests which of the following activities to assist the client with expressing her feelings? 1. Working on a puzzle. 2. Writing in a journal. 3. Meditating. 4. Listening to music.

2. Writing in a journal can help the client safely express feelings, particularly anger, when the client cannot verbalize them. Safely externalizing anger by writing in a journal helps the client to maintain control over her feelings.

While interviewing a 3-year-old girl who has been sexually abused about the event, which approach would be most effective? 1. Describe what happened during the abusive act. 2. Draw a picture and explain what it means. 3. "Play out" the event using anatomically correct dolls. 4. Name the perpetrator.

3. A 3-year-old child has limited verbal skills and should not be asked to describe an event, explain a picture, or respond verbally or nonverbally to questions. More appropriately, the child can act out an event using dolls. The child is likely to be too fearful to name the perpetrator or will not be able to do so.

A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first? 1. Pick up the fork and feed the client slowly. 2. Say, "It's time for you to start eating your dinner." 3. Hand the fork to the client and say, "Use this fork to eat your green beans." 4. Save the client's dinner until her family comes in to feed her.

3. Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.

Which of the following observations by the nurse should suggest that a 15-month-old toddler has been abused? 1. The child appears happy when personnel work with him. 2. The child plays alongside others contentedly. 3. The child is underdeveloped for his age. 4. The child sucks his thumb.

3. An almost universal finding in descriptions of abused children is underdevelopment for age. This may be reflected in small physical size or in poor psychosocial development. The child should be evaluated further until a plausible diagnosis can be established. A child who appears happy when personnel work with him is exhibiting normal behavior. Children who are abused often are suspicious of others, especially adults. A child who plays alongside others is exhibiting normal behavior, that of parallel play. A child who sucks his thumb contentedly

The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.

3. Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.

During the third session with the nurse, a client who is being abused states, "I don't know what to do anymore. He doesn't want me to go anywhere while he's at work, not even to visit my friends." Which nursing diagnosis should the nurse formulate regarding this information? 1. Risk for other-directed violence related to an abusive husband, as evidenced by the victim's statement of being battered. 2. Situational low self-esteem related to victimization, as evidenced by not being able to leave the house. 3. Powerlessness related to control by husband, as evidenced by the inability to make decisions. 4. Ineffective coping related to victimization, as evidenced by crying.

3. Based on the client's statements, such as "I don't know what to do anymore," the data here best support the nursing diagnosis of Powerlessness related to control by husband, as evidenced by inability to make decisions. A nursing diagnosis of Risk for other-directed violence would be appropriate if the client had talked about being beaten up the previous night. A nursing diagnosis of Situational low self-esteem would be appropriate if the client verbalized feelings of embarrassment in leaving the house and worthlessness. A nursing diagnosis of Ineffective coping would be appropriate if the client was crying or talked about crying herself to sleep at night.

38. An anxious young adult is brought to the interviewing room of a crisis shelter, sobbing and saying that she thinks she is pregnant but does not know what to do. Which of the following nursing interventions is most appropriate at this time? 1. Ask the client about the type of things that she had thought of doing. 2. Give the client some ideas about what to expect to happen next. 3. Recommend a pregnancy test after acknowledging the client's distress. 4. Question the client about her feelings and possible parental reactions.

3. Before any interventions can occur, knowing whether the client is pregnant is crucial in formulating a plan of care. Asking the client about what things she had thought about doing, giving the client some ideas about what to expect next, and questioning the client about her feelings and possible parental reactions would be appropriate after it is determined that the client is pregnant.

One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which of the following behaviors is more likely to be used by the abusers? 1. Tying the child down. 2. Bribery with money. 3. Coercion as a result of the trusting relationship. 4. Asking for the child's consent for sex.

3. Coercion is the most common strategy used because the child commonly trusts the abuser. Tying the child down usually is not necessary. Typically the abusive person can control the child by his or her size and weight alone. Bribery usually is not necessary because the child wants love and affection from the abusive person, not money. Young children are not capable of giving consent for sex before they develop an adult concept of what sex is.

When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which of the following interventions should the nurse employ as the first step? 1. Using gentle touch to convey empathy. 2. Rephrasing questions the client doesn't understand. 3. Eliminating distracting stimuli such as turning off the television. 4. Asking the client to go for a walk while talking.

3. Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion.

Adolescents and adults who were sexually abused as children commonly mutilate themselves. The nurse interprets this behavior as: 1. The need to make themselves less sexually attractive. 2. An alternative to bingeing and purging. 3. Use of physical pain to avoid dealing with emotional pain. 4. An alternative to getting high on drugs.

3. Dealing with the physical pain associated with mutilation is viewed as easier than dealing with the intense anger and emotional pain. The client fears an aggressive outburst when anger and emotional pain increase. Self-mutilation seems easier and safer. Additionally, self-mutilation may occur if the client feels unreal or numb or is dissociating. Here, the mutilation proves to the client that he or she is alive and capable of feeling. The client may want to be less sexually attractive, but this aspect usually is not related to self-mutilation. Bingeing and purging is commonly done in addition to, not instead of, self-mutilation. Although a few clients report an occasional high with self-mutilation, usually the experience is just relief from anger and rage.

A nurse in an Employee Assistance Program (EAP) is seeing a woman who wants to report her boss to the police for sexual harassment. She states he says that she will never get a promotion unless she "works and plays at his house on weekends." After getting more details on the boss' statements and behaviors, the nurse should do which of the following? 1. Encourage the client to file a police report as soon as possible. 2. Tell the client to return to EAP if she is denied a promotion. 3. Show the client the company's Workplace Violence Policy and agree to help her follow the process. 4. Go with the client to confront her boss about his behaviors and possible consequences.

3. Employers are required to have a Workplace Violence Policy that outlines procedures related to this issue. Filing a police report may or may not be appropriate after the procedures of the policy are completed. Having the client only come back to EAP if a promotion is denied is an inappropriate suggestion. Confronting the boss with the client is only needed if other steps of the procedure are not effective.

In working with a rape victim, which of the following is most important? 1. Continuing to encourage the client to report the rape to the legal authorities. 2. Recommending that the client resume sexual relations with her partner as soon as possible. 3. Periodically reminding the client that she did not deserve and did not cause the rape. 4. Telling the client that the rapist will eventually be caught, put on trial, and jailed.

3. Guilt and self-blame are common feelings that need to be addressed directly and frequently. The client needs to be reminded periodically that she did not deserve and did not cause the rape. Continually encouraging the client to report the rape pressures the client and is not helpful. In most cases, resuming sexual relations is a difficult process that is not likely to occur quickly. It is not necessarily true that the rapist will be caught, tried, and jailed. Most rapists are not caught or convicted.

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.

3. In approximately 2 to 3 days, the client should be able to regain orientation and thus become oriented to time and place. Being able to explain the experience of having delirium is something that the client is expected to achieve later in the course of the illness, but ultimately before discharge. Resuming a normal sleep-wake cycle and establishing normal bowel and bladder function probably will take longer, depending on how long it takes to resolve the underlying condition.

Which of the following points should the nurse include when teaching a client about panic disorder? 1. Staying in the house will eliminate panic attacks. 2. Medication should be taken when symptoms start. 3. Symptoms of a panic attack are time limited and will abate. 4. Maintaining self-control will decrease symptoms of panic.

3. It is important for the nurse to teach the client that the symptoms of a panic attack are time limited and will abate. This helps decrease the client's fear about what is occurring. Clients benefit from learning about their illness, what symptoms to expect, and the helpful use of medication. A simple biologic explanation of the disorder can convince clients to take their medication. Telling the client to stay in the house to eliminate panic attacks is not correct or helpful. Panic attacks can occur "out of the blue," and clients with panic disorder can become agoraphobic because of fear of having a panic attack where help is not available or escape is impossible. Medication should be taken on a scheduled basis to block the symptoms of panic before they start. Taking medication when symptoms start is not helpful. Telling the client to maintain self-control to decrease symptoms of panic is false information because the brain and biochemicals may account for its development. Therefore, the client cannot control when a panic attack will occur.

When planning interventions for parents who are abusive, the nurse should incorporate knowledge of which factor as a common parental indicator? 1. Lower socioeconomic group. 2. Unemployment. 3. Low self-esteem. 4. Loss of emotional family attachments.

3. Parents who are abusive often suffer from low self-esteem, commonly because of the way they were parented, including not being able to develop trust in caretakers and not being encouraged or offered emotional support by parents. Therefore, the nurse works to bolster the parents' self-esteem. This can be achieved by praising the parents for appropriate parenting. Employment and socioeconomic status are not indicators of abusive parents. Abusive parents usually are attached to their children and do not want to give them up to foster care. Parents who are abusive love their children and feel close to them emotionally.

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Are they a nursing student.

3. Polypharmacy is much more common in the elderly. Drug interactions increase the incidence of intoxication from prescribed medications, especially with combinations of analgesics, digoxin, diuretics, and anticholinergics. With drug intoxication, the onset of the delirium typically is quick. Although cancer, impaired hearing, and heart failure could lead to delirium in the elderly, the onset would be more gradual.

The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? 1. Increase the client's confusion and disorientation. 2. Cause the client to become sad. 3. Decrease the client's feelings of isolation and loneliness. 4. Keep the client from participating in therapeutic activities.

3. Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing.

A client named Jana, with a long history of experiencing Dissociative Identity Disorder, is admitted to the unit after the cuts on her legs were sutured in the Emergency Department. During the admission interview, Jana tearfully states that she does not know what happened to her legs. Then a stronger, alter personality named Jason emerges. Jason states that Jana is useless, weak, and needs to be eliminated completely. The nurse should do which of the following first? 1. Explore Jason's attitudes toward Jana more thoroughly. 2. Place Jana in restraints when Jason emerges. 3. Contract with Jason to tell the nurse when he has the urge to harm Jana and the body they both share. 4. Keep Jana in a stress-free environment so that the stronger Jason does not get a chance to emerge.

3. The No Harm Contract with any destructive alters is essential along with the reminder that the alters share the same body. Later, Jason's attitudes about Jana can be explored in more depth. When alter personalities emerge, their behaviors are not predictable. Restraints could not be placed on the client soon enough. There are no behaviors to justify restraints at this point. Creating a stress-free environment is not possible.

The nurse discusses the possibility of a client's attending day treatment for clients with early Alzheimer's disease. Which of the following is the best rationale for encouraging day treatment? 1. The client would have more structure to his day. 2. Staff are excellent in the treatment they offer clients. 3. The client would benefit from increased social interaction. 4. The family would have more time to engage in their daily activities.

3. The best rationale for day treatment for the client with Alzheimer's disease is the enhancement of social interactions. More daily structure, excellent staff, and allowing caregivers more time for themselves are all positive aspects, but they are less focused on the client's needs.

After being discharged from the hospital with acute stress disorder, a client is referred to the outpatient clinic for follow-up. Which of the following is most important for the client to use for continued alleviation of anxiety? 1. Recognizing when she is feeling anxious. 2. Understanding reasons for her anxiety. 3. Using adaptive and palliative methods to reduce anxiety. 4. Describing the situations preceding her feelings of anxiety.

3. The client with anxiety may be able to learn to recognize when she is feeling anxious, understand the reasons for her anxiety, and be able to describe situations that preceded her feelings of anxiety. However, she is likely to continue to experience symptoms unless she has also learned to use adaptive and palliative methods to reduce anxiety.

A client is diagnosed with agoraphobia without panic disorder. Which type of therapy is most effective for this illness? 1. Insight therapy. 2. Group therapy. 3. Behavior therapy. 4. Psychoanalysis.

3. The nurse should suggest behavior therapy, which is most successful for clients with phobias. Systematic desensitization, flooding, exposure, and self-exposure treatments are most therapeutic for clients with phobias. Self-exposure treatment is being increasingly used to avoid frequent therapy sessions. Insight therapy, exploration of the dynamics of the client's personality, is not helpful because the process of anxiety underlies the disorder. Group therapy or psychoanalysis, which deals with repressed, intrapsychic conflicts, is not helpful for the client with phobias because it does not help to manage the underlying anxiety or disorder.

A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, "It's that school nurse again. She's done nothing but try to make trouble for our family since my son started school. And now you're in on it." The nurse should respond by saying: 1. "The school nurse is concerned about your son and is only doing her job." 2. "We see a number of children who go to your son's school. He isn't the only one." 3. "You sound pretty angry with the school nurse. Tell me what has happened." 4. "Let me tell you why your son was referred, and then you can tell me about your concerns."

3. The mother's feelings are the priority here. Addressing the mother's feelings and asking for her view of the situation is most important in building a relationship with the family. Ignoring the mother's feelings will hinder the relationship. Defending the school nurse and the school puts the client's mother on the defensive and stifles communication.

The nurse notices that a client diagnosed with Major Depression and Social Phobia must get up and move to another area when someone sits next to her. Which of the following actions by the nurse is appropriate? 1. Ignore the client's behavior. 2. Question the client about her avoidance of others. 3. Convey awareness of the client's anxiety about being around others. 4. Tell the other clients to follow the client when she moves away.

3. The nurse conveys empathy and awareness of the client's need to reduce anxiety by showing acceptance and understanding to the client, thereby promoting trust. Ignoring the behavior, questioning the client about her avoidance of others, or telling other clients to follow her when she moves are not therapeutic or appropriate.

The client with Alzheimer's disease may have delusions about being harmed by staff and others. When the client expresses fear of being killed by staff, which of the following responses is most appropriate? 1. "What makes you think we want to kill you?" 2. "We like you too much to want to kill you." 3. "You are in the hospital. We are nurses trying to help you." 4. "Oh, don't be so silly. No one wants to kill you here."

3. The nurse needs to present reality without arguing with the delusions. Therefore, stating that the client is in the hospital and the nurses are trying to help is most appropriate. The client doesn't recognize the delusion or why it exists. Telling the client that the staff likes him too much to want to kill him is inappropriate because the client believes the delusions and doesn't know that they are false beliefs. It also restates the word, kill, which may reinforce the client's delusions. Telling the client not to be silly is condescending and disparaging and therefore inappropriate.

When developing the plan of care for a client with acute stress disorder who lost her sister in a boating accident, which of the following should the nurse initiate? 1. Helping the client to evaluate her sister's behavior. 2. Telling the client to avoid details of the accident. 3. Facilitating progressive review of the accident and its consequences. 4. Postponing discussion of the accident until the client brings it up.

3. The nurse should facilitate progressive review of the accident and its consequences to help the client integrate feelings and memories and to begin the grieving process. Helping the client to evaluate her sister's behavior, telling the client to avoid details of the accident, or postponing the discussion of the accident until the client brings it up is not therapeutic and does not facilitate the development of trust in the nurse. Such actions do not facilitate review of the accident, which is necessary to help the client integrate feelings and memories and begin the grieving process.

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is the most likely occurrence that is disturbing to this client? 1. There is only one other client in the dayroom; the rest are in a group session in another room. 2. There are three staff members and one physician in the nurse's station working on charting. 3. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. 4. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom.

3. The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.

A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which of the following as characteristic of abusive families? 1. Tight, impermeable boundaries. 2. Unbalanced power ratio. 3. Role stereotyping. 4. Dysfunctional feeling tone.

3. The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families.

While a client is taking alprazolam (Xanax), which of the following should the nurse instruct the client to avoid? 1. Chocolate. 2. Cheese. 3. Alcohol. 4. Shellfish.

3. Using alcohol or any central nervous system depressant while taking a benzodiazepine, such as alprazolam, is contraindicated because of additive depressant effects. Ingestion of chocolate, cheese, or shellfish is not problematic.

A 40-year-old client who is quite anxious says that she would "rather die than be pregnant." Which of the following responses by the nurse is most helpful? 1. "Try not to worry until after the pregnancy test." 2. "You know, pregnancy is a normal event." 3. "You're only 40 years old and not too old to have a baby." 4. "I see you're upset. Take some deep breaths to relax a little."

4. Because people in an emotional crisis find it difficult to focus their thinking, the goal is to return the client to noncrisis functioning. Pointing out and decreasing the client's level of anxiety is the first step in attaining this goal. Telling an obviously distressed person not to worry is ineffective because it ignores the client's distress and concerns. Although pregnancy is a normal event, and 40 years of age may not be too old for a pregnancy, these responses also ignore the client's distress and feelings.

When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers.

4. Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe.

An adult client diagnosed with anxiety disorder becomes anxious when she touches fruits and vegetables. What should the nurse do? 1. Instruct the woman to avoid touching these foods. 2. Ask the woman why she becomes anxious in these situations. 3. Assist the woman to make a plan for her family to do the food shopping and preparation. 4. Teach the woman to use cognitive behavioral approaches to manage her anxiety.

4. Cognitive behavioral therapy is effective in treating anxiety disorders. The nurse can assist the client in identifying the onset of the fears that cause the anxiety and develop strategies to modify the behavior associated with the fears. Avoiding touching foods, asking about reasons for the anxiety, and providing ways to work around touching the foods do not deal with the anxiety and are not interventions that will help this client.

An elderly woman's husband died. When her brother arrives for the funeral, he notices her short-term memory problems and occasional disorientation. A few weeks later, she calls him to say that her husband just died. She says, "I didn't know he was so sick. Why did he die now?" She also complains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. A home care nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant. The nurse calls the woman's primary care physician to discuss the client's situation and background, and give his assessment and recommendations. The nurse concludes that the woman: 1. Is experiencing the onset of Alzheimer's disease. 2. Is having trouble adjusting to living alone without her husband. 3. Is having delayed grieving related to her Alzheimer's disease. 4. Is experiencing delirium and a urinary tract infection.

4. Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.

The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm so upset. The physician says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? 1. "Boy, I have a lot to think about before I see the social worker tomorrow." 2. "I think I can handle most of Dad's needs with the help of some home health care." 3. "I'm so afraid of making the wrong decision, but I can move him later if I need to." 4. "I want the social worker to make this decision so Dad won't blame me."

4. Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.

Which parental characteristic is least likely to be a risk factor for child abuse? 1. Low self-esteem. 2. History of substance abuse. 3. Inadequate knowledge of normal growth and development patterns. 4. Being a member of a large family.

4. From documented cases of child abuse, a profile has emerged of a high-risk parent as a person who is isolated, impulsive, impatient, and single with low self-esteem, a history of substance abuse, a lack of knowledge about a child's normal growth and development, and multiple life stressors. Just because a parent comes from a large family, there is no increase in the incidence of the parent abusing their own children unless they possess the other risk factors.

The mother of a school-aged child tells the nurse that, "For most of the past year my husband was unemployed and I worked a second job. Twice during the year I spanked my son repeatedly when he refused to obey. It has not happened again. Our family is back to normal." After assessing the family, the nurse decides that the child is still at risk for abuse. Which of the following observations best supports this conclusion? 1. The parents say they are taking away privileges when their son refuses to obey. 2. The child has talked about family activities with the nurse. 3. The parent's are less negative toward the nurse. 4. The child wears long sleeve shirts and long pants, even in warm weather.

4. Parental use of nonviolent discipline, the child's talk about what the family is doing and the easing of the parent's negativity toward the school nurse are all signs of progress. Avoidance and wearing clothes inappropriate for the weather implies that the child has something to hide, likely signs of physical abuse.

When obtaining a nursing history from parents who are suspected of abusing their child, which of the following characteristics about the parents should the nurse particularly assess? 1. Attentiveness to the child's needs. 2. Self-blame for the injury to the child. 3. Ability to relate the child's developmental achievements. 4. Difficulty with controlling aggression.

4. Parents of an abused child have difficulty controlling their aggressive behaviors. They may blame the child or others for the injury, may not ask questions about treatment, and may not know developmental information.

The client diagnosed with a fear of eating in public places or in front of other people has finished eating lunch in the dining area in the nurse's presence. Which of the following statements by the nurse should reinforce the client's positive action? 1. "It wasn't so hard, now was it?" 2. "At supper, I hope to see you eat with a group of people." 3. "You must have been hungry today." 4. "It is progress for you to eat in the dining room with me."

4. Saying, "It's a sign of progress to eat in the dining area with me," conveys positive reinforcement and gives the client hope and confidence, thus reinforcing the adaptive behavior. Stating, "It wasn't so hard, now was it," decreases the client's self-worth and minimizes his accomplishment. Stating, "At supper, I hope to see you eat with a group of people," will overwhelm the client and increase anxiety. Stating, "You must have been hungry today," ignores the client's positive behavior and shows the nurse's lack of understanding of the dynamics of the disorder.

A client with acute stress disorder states to the nurse, "I keep having horrible nightmares about the car accident that killed my daughter. I shouldn't have taken her with me to the store." Which of the following responses by the nurse is most therapeutic? 1. "Don't keep torturing yourself with such horrible thoughts." 2. "Stop blaming yourself. It's only hurting you." 3. "Let's talk about something that is a bit more pleasant." 4. "The accident just happened and could not have been predicted."

4. Saying, "The accident just happened and could not have been predicted," provides the client with an objective perception of the event instead of the client's perceived role. This type of statement reflects active listening and helps to reduce feelings of blame and guilt. Saying, "Don't keep torturing yourself," or "Stop blaming yourself," is inappropriate because it tells the client what to do, subsequently delaying the therapeutic process. The statement, "Let's talk about something that is a bit more pleasant," ignores the client's feelings and changes the subject. The client needs to verbalize feelings and decrease feelings of isolation.

116.A newly admitted 20-year-old client, diagnosed with Post Traumatic Stress Disorder (PTSD), reluctantly reveals that she escaped from a satanic cult 2 years ago. The mother has been in the cult since the client was 3 years old and refused to leave with the client. The client says, "Nobody will ever believe the horrible things the men did to me and my mother never stopped them." Which of the following responses is appropriate for the nurse to make? 1. "I'll believe anything you tell me. You can trust me." 2. "I can't understand why your mother didn't protect you. It's not right." 3. "Tell me about the cult. I didn't know there were any near here." 4. "It must be difficult to talk about what happened. I'm willing to listen."

4. Survivors of trauma/ torture have a lot of difficulty with trust and do not readily talk about the horrible events. Therefore, empathy and a willingness to listen without pressuring the client are crucial. Option 1 may or may not be possible and does not convey the empathy. It is sometimes difficult to believe what satanic cults can do to children. Option 2 diverts attention from the client to the mother. Option 3 shows more interest in the cult than the client.

While educating the daughter of a client with dementia about the illness, the daughter complains to the nurse that her mother distorts things. The nurse understands that the daughter needs further teaching about dementia when she makes which statement? 1. "I tell her reality, such as, 'That noise is the wind in the trees.'" 2. "I understand the misperceptions are part of the disease." 3. "I turn off the radio when we're in another room." 4. "I tell her she is wrong and then I tell her what's right."

4. Telling the client that she is wrong and then telling her what is right is argumentative and challenging. Arguing with or challenging distortions is least effective because it increases defensiveness. Telling the client about reality indicates awareness of the issues and is appropriate. Acknowledging that misperceptions are part of the disease indicates an understanding of the disease and an awareness of the issues. Turning off the radio helps to limit environmental stimuli and indicates an awareness of the issues.

A 90-year-old client diagnosed with major depression is suddenly experiencing sleep disturbances, inability to focus, poor recent memory, altered perceptions, and disorientation to time and place. Lab results indicate the client has a urinary tract infection and dehydration. After explaining the situation and giving the background and assessment data, the nurse should make which of the following recommendations to the client's physician? 1. An order to place the client in restraints. 2. A reevaluation of the client's mental status. 3. The transfer of the client to a medical unit. 4. A transfer of the client to a nursing home.

4. The client is showing symptoms of delirium, a common outcome of UTI in older adults. The nurse can request a transfer to a medical unit for acute medical intervention. The client's symptoms are not just due to a worsening of the depression. There are not indications that the client needs restraints or a transfer to a nursing home at this point.

When planning the care for a client who is being abused, which of the following measures is most important to include? 1. Being compassionate and empathetic. 2. Teaching the client about abuse and the cycle of violence. 3. Explaining to the client her personal and legal rights. 4. Helping the client develop a safety plan.

4. The client's safety, including the need to stay alive, is crucial. Therefore, helping the client develop a safety plan is most important to include in the plan of care to ensure the client's safety. Being empathetic, teaching about abuse, and explaining the person's rights are also important after safety is ensured.

A client with posttraumatic stress disorder needs to find new housing and wants to wait for a month before setting another appointment to see the nurse. The nurse interprets this action as which of the following? 1. A method of avoidance. 2. A detriment to progress. 3. The end of treatment. 4. A necessary break in treatment.

4. The nurse judges the client's request for an interruption in treatment as a necessary break in treatment. A "time-out" is common and necessary to enable the client to focus on pressing problems and solutions. It is not necessarily a method of avoidance, a detriment to progress, or the end of treatment. A problem like housing can be very stressful and require all of the client's energy and attention, with none left for the emotional stress of treatment.

The client diagnosed with agoraphobia refuses to walk down the hall to the group room. Which of the following responses by the nurse is appropriate? 1. "I know you can do it." 2. "Try holding onto the wall as you walk." 3. "You can miss group this one time." 4. "I'll walk with you."

4. The nurse should walk with the client to activate adaptive coping for the client experiencing high anxiety and decreased motivation and energy. Stating, "I know you can do it," "Try holding on to the wall," or "You can miss group this one time," maintains the client's avoidance, thus reinforcing the client's behavior, and does not help the client begin to cope with the problem.

After a client reveals a history of childhood sexual abuse, the nurse should ask which of the following questions first ? 1. "What other forms of abuse did you experience?" 2. "How long did the abuse go on?" 3. "Was there a time when you did not remember the abuse?" 4. "Does your abuser still have contact with young children?"

4. The safety of other children is a primary concern. It is critical to know whether other children are at risk for being sexually abused by the same perpetrator. Asking about other forms of abuse, how long the abuse went on, and if the victim did not remember the abuse are important questions after the safety of other children is determined.

The nurse determines that the son of a client with Alzheimer's disease needs further education about the disease when he makes which of the following statements? 1. "I didn't realize the deterioration would be so incapacitating." 2. "The Alzheimer's support group has so much good information." 3. "I get tired of the same old stories, but I know it's important for Dad." 4. "I woke up this morning expecting that my old Dad would be back."

4. The statement about expecting that the old Dad would be back conveys a lack of acceptance of the irreversible nature of the disease. The statement about not realizing that the deterioration would be so incapacitating is based in reality. The statement about the Alzheimer's group is based in reality and demonstrates the son's involvement with managing the disease. Stating that reminiscing is important reflects a realistic interpretation on the son's part.

When caring for a client who was a victim of a crime, the nurse is aware that recovery from any crime can be a long and difficult process depending on the meaning it has for the client. Which of the following should the nurse establish as a victim's ultimate goal in reconstructing his or her life? 1. Getting through the shock and confusion. 2. Carrying out home and work routines. 3. Resolving grief over any losses. 4. Regaining a sense of security and safety.

4. Ultimately, a victim of a crime needs to move from being a victim to being a survivor. A reasonable sense of safety and security is key to this transition. Getting through the shock and confusion, carrying out home and work routines, and resolving grief over any losses represent steps along the way to becoming a survivor.

In the process of dealing with the intense feelings about being raped, victims commonly verbalize that they were afraid they would be killed during the rape and wish that they had been. The nurse should decide that further counseling is needed if the client voices which of the following? 1. "I didn't fight him, but I guess I did the right thing because I'm alive." 2. "Suicide would be an easy escape from all this pain, but I couldn't do it to myself." 3. "I wish they gave the death penalty to all rapists and other sexual predators." 4. "I get so angry at times that I have to have a couple of drinks before I sleep."

4. Use of alcohol reflects unhealthy coping mechanisms. A client's report of needing alcohol to calm down needs to be addressed. Survival is the most important goal during a rape. The client's acknowledging this indicates that she is aware that she made the right choice. Although suicidal thoughts are common, the statement that suicide is an easy escape but the client would be unable to do it indicates low risk. Fantasies of revenge, such as giving the death penalty to all rapists, are natural reactions and are a problem only if the client intends to carry them out directly.