Mental Health - N244

A nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you?" Whenever the nurse collects data from a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct.

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which of the following is the therapeutic nursing response?

"It must be hard to accept that she has passed away." The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and facilitates expression of feelings.

A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse makes which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

"Sometimes people hear things or voices others can't hear." It is important for the nurse to reinforce reality with the client.

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse makes which therapeutic response to the client?

"Tell me about your difficulty sleeping."

A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client?

"What is causing you to become agitated?" The best statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and will assist the nurse in planning appropriate interventions for the client

A nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is:

"What leads you to seek help now?" A nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found.

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Parkinson's disease Elder abuse is widespread and occurs among all subgroups of the population. It includes physical and psychological abuse, the misuse of property, and the violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be an appropriate choice as this client's roommate?

A client receiving diagnostic tests The client receiving diagnostic tests is an appropriate roommate. The client with anorexia is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which he or she can focus on the nutritional needs of others or be managed by others, because this may contribute to sublimation and suppression of his or her own hunger.

A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person. Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person, because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness.

Which behavior should the nurse expect a client diagnosed with agoraphobia to describe when discussing the disorder?

A fear of leaving the house Agoraphobia is a fear of open spaces (i.e., leaving the house); panic attacks may occur when doing so.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and plans to:

Assign a staff member to the client who will remain with him or her at all times. Hanging is a serious suicide attempt. The plan of care must reflect action that will promote the client's safety. Constant observation status (one on one) with a staff member who is never less than an arm's length away is the safest intervention.

A nurse is preparing a client for the termination phase of the nurse-client relationship. Which nursing task would the nurse appropriately plan for this phase?

Assist in making appropriate referrals. Tasks of the termination phase include evaluating client performance, evaluating achievement of expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common behaviors associated with termination.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to:

Call the nursing supervisor. A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Most health care facilities have documents that the client is asked to sign, which relate to the client's responsibilities when he or she leaves against medical advice (AMA)

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which of the following?

Client involvement in goal setting Milieu therapy provides a safe environment that is adapted to the individual client's needs and provides greater comfort and freedom of expression than has been experienced in the past by the client

A licensed practical nurse (LPN) enters a client's room, and the client is demanding release from the hospital. The LPN reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder, and that the admission was a voluntary admission. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Contact the health care provider (HCP). Generally, voluntary admission is sought by the client or client's guardian. Voluntary clients have the right to demand and obtain release. The best nursing action is to contact the HCP.

A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client?

Drawing Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to:

Examine and treat the wound sites. The initial nursing action is to examine and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions may follow after the client has been treated medically.

A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis.

A nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk. Clients with anorexia nervosa are frequently preoccupied with vigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise as well as place limits on vigorous activities.

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. The appropriate initial nursing intervention related to this concern is:

Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times. Change in appetite is one of the major symptoms of depression. Offering the client several small, frequent meals and the nurse's presence at that time to support, encourage, or perhaps even feed the client is the most appropriate intervention. A client with depression experiences poor concentration and will not understand the importance of an adequate nutritional intake.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client would plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated. Safety of the client, other clients, and staff is of prime concern. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? Select all that apply.

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback Some of the therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother:

Restrict the amount of chocolate and caffeine products in the home. Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety.

Which data collection finding would indicate the possibility of the sexual abuse of a child?

Swelling of the genitals

A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse would expect which of the following?

The client will participate in the treatment plan. Generally, voluntary admission is sought by the client or client's guardian. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program.

A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The nurse reviews the data obtained and identifies which of the following as a priority concern?

The client's report of suicidal thoughts The client's thoughts are extremely important when verbalized. Suicidal thoughts are the highest priority.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to:

Use a night light and turn off the television. It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." The nurse's best response is:

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?" When delusional, a person truly believes what he or she thinks to be real is real. The person's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience.

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on:

Weight loss All the options are possible issues to address; however, the weight loss is the first item that needs further data collection because ill-fitting clothing could indicate a problem with nutrition. The client has already told the nurse that the crying spells have been a problem.

A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within how much time after cessation or reduction of alcohol intake?

Within a few hours Early signs of alcohol withdrawal develop within a few hours after cessation or reduction of alcohol and peak after 24 to 48 hours.

A nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate initially for this client?

Writing Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities initially for a client who is aggressive.

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which clinical manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea Opioids are central nervous system (CNS) depressants. Withdrawal effects include yawning, insomnia, irritability, rhinorrhea, diaphoresis, cramps, nausea and vomiting, muscle aches, chills, fever, lacrimation, and diarrhea. Withdrawal is treated by methadone tapering or medication detoxification

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present at the time should respond by stating which of the following?

"Are you fearful and think that others may want to hurt you?" Option 3 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:

"I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone." There may be an increased risk for impulsive and/or aggressive behavior if a client is receiving command hallucinations to harm self or others. Talking about the auditory hallucinations can interfere with the subvocal muscular activity associated with a hallucination.

A psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following?

"I cannot discuss any client situation with you." A nurse is required to maintain confidentiality regarding clients and their care. Confidentiality is basic to the therapeutic relationship and is a client's right.

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

"It's okay to grieve and be angry with your daughter and anyone else for a time." The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest.

A nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?

"Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request." he therapeutic response is the one that reflects the client's feelings and offers the client control of care.

A nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. In the event that tardive dyskinesia occurs, the nurse would likely observe:

Abnormal movements and involuntary movements of the mouth, tongue, and face Tardive dyskinesia is a severe reaction associated with the long-term use of antipsychotic medication. The clinical manifestations are abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue, and face.

A client is attending a Gamblers Anonymous meeting for the first time. The model used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse understands that the first step in the 12-step program is which of the following?

Admitting to having a problem The first step in the 12-step program is to admit that a problem exists

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has:

Agoraphobia Agoraphobia is a fear of being alone in open or public places where escape might be difficult. Agoraphobia includes experiencing fear or a sense of helplessness or embarrassment if a phobic attack occurs.

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which of the following community groups?

Alcoholics Anonymous Alcoholics Anonymous is a major self-help organization for the treatment of alcoholism

A nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse determines that:

An informed consent needs to be obtained from the client. Clients who are involuntarily admitted do not lose their right to informed consent.

Therapy that involves pairing a stimulus attractive to the client with an unpleasant event is known as which of the following?

Aversion therapy Aversion therapy, also known as "aversion conditioning" or "negative reinforcement," is a technique used to change behavior. In this therapy, a stimulus attractive to the client is paired with an unpleasant event in hopes of associating the stimulus with negative properties. Milieu therapy provides positive environmental manipulation, both physical and social, to effect a positive change in the client. Desensitization is the reduction of intense reactions to a stimulus by repeated exposure to the stimulus in a weaker and milder form. Self-control therapy combines cognitive and behavioral approaches and is useful to deal with stress.

A nurse is assisting in a group therapy session. During this session, the members are identifying tasks and boundaries. The nurse understands that these activities are characteristic of which stage of group development?

Beginning stage In the beginning or initial stage, the members are identifying tasks and boundaries. Information is given and group norms are established. In the middle stage, members are confronting each other, groups develop cohesiveness, and a sense of trust is established. The termination stage is when members leave the group, the group decides that its work is done, and the group members feel that they have met their goals.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as:

Evidence of the client's altered and distorted body image Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of distorted body image

A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise. Excessive exercise is a characteristic of anorexia nervosa, not bulimia nervosa. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Monitoring for dehydration and electrolyte imbalance are important nursing actions.

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by:

Observing rigid rules and regulations Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?

One-to-one suicide precautions One-to-one suicide precautions are required for the client who has attempted suicide.

A nurse is assigned to care for a client who is experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat?

Open-ended questions and silence Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Should encourage the client to identify the reasons for the behavior.

A nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is:

Ping-pong A person who is experiencing mania is overactive, full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow him or her to use excess energy but not endanger others during the process

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves:

Re-experiencing recollections of the trauma The major trauma of rape or sexual assault involves the victim's emotional reaction to being physically forced to do something against his or her will. The life-threatening nature of the crime and feelings of helplessness, loss of control, and the experiencing of self as an object of the perpetrator's rage combine to produce the victim's overpowering fear and stress.

A nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which of the following?

Sit beside the client in silence and verbalize occasional open-ended questions. Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur

A nurse is monitoring a female client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business. Warning signs of suicide include talking about suicide, preoccupation with death and dying, behavioral changes, giving away special possessions and making arrangements to take care of unfinished business, decreased appetite, difficulty with sleep, and a loss of interest in usual activities.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a prized CD and a cherished autographed picture of the performer. A depressed, suicidal client often gives away that which is of value as a way of saying "goodbye" and wanting to be remembered.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse interprets the client's behavior as:

The client is at increased risk for suicide. The behaviors identified in the question may be manifested by the client who is contemplating suicide. In clients who are depressed, anger may be self-directed in the form of suicide. Many of these symptoms are those of the depressed client; however, with this client, these behaviors have increased.

A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by:

The death of a loved one A situational crisis is associated with a life event. External situations that could precipitate a situational crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, and severe illness.

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma." Clients who have learned they have a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with the chronic illness.

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." The therapeutic response by the nurse is:

"You're feeling angry that your family continues to hope for you to be 'cured'?" Reflection is the therapeutic communication technique that redirects the client's feelings back to validate what the client is saying.

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse makes which therapeutic response to the client?

"You've been feeling like a failure for a while?" Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The incorrect options block communication because they minimize the client's feelings and do not facilitate exploration of his or her expressed feelings.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

- Communicate expected behaviors to the client. - Assist the client in developing means of setting limits on personal behavior. - Assist the client in developing means of setting limits on personal behavior. - Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family. Select all that apply.

- Encourage expression of feelings, concerns, and fears. - Extend touch and hold the client's or family member's hand if appropriate. - Be honest and truthful and let the client and family know that you will not abandon them. The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears, as well as reminiscing. The nurse needs to be honest and truthful and let the client and family know that they will not be abandoned. It is important to extend touch and hold the client's or family member's hand if appropriate.

A nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following?

Suggest that the client stop talking and try listening to others. If a client is monopolizing the group, it is important that the nurse be direct and decisive. The best action is to suggest that the client stop talking and try listening to others.

A nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings related to loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase In the termination phase, the relationship comes to a close. Ending treatment may sometimes be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase

A nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response is which of the following?

"I cannot promise to keep a secret." The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship, but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills?

"I feel better able to care for my father now that I know where to obtain assistance." Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance in caring for aging family members can bring much-needed relief. Using these alternatives is a positive alternative coping strategy, which many families use.

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." The appropriate response by the nurse is:

"I hear what you are saying, but I don't share your belief." Paranoid beliefs are coping mechanisms and therefore not easily relinquished. It is important not to support the belief and not ridicule, argue, or criticize it.

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse appropriately responds by stating:

"What do you and your husband believe is the right thing for your children?" The therapeutic response is the one that encourages open expression of feelings and empowers the grieving individual. Values, beliefs, and practices will differ with ethnic and spiritual backgrounds, and the nurse should not push a decision based on his or her own personal belief system.

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be:

"What do you find difficult about this situation?" The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client nor should the nurse request that the client provide explanations.

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to:

Help the client identify and examine dysfunctional thoughts and beliefs.

A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not isolate himself or herself with a potentially violent client.

A nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research the disorder?

Body weight well below ideal range Clients with bulimia nervosa may not initially appear to be physically or emotionally ill. They are often at or slightly below ideal body weight

A nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. The finding that requires the nurse's immediate intervention is the:

Client's inadequate attention to activities of daily living (ADL) and poor nutritional intake Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. It is a period when the mood is predominantly elevated, expansive, or irritable.

Which data indicates to the nurse that a client may be experiencing ineffective coping?

Constantly neglects personal grooming Rationale: Coping mechanisms are behaviors that are used to decreased stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some instances may be harmful to the individual, physically, psychologically, or both. Option 1 is indicative of a behavior that identifies an ineffective coping behavior as part of the grieving process.

A client was admitted to a medical unit with acute blindness. Many tests are performed and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. The nurse suspects that the client may be experiencing a:

Conversion disorder A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind.

A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse monitors for which of the following?

Hypertension, disorientation, hallucinations he symptoms associated with alcohol withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, agitation, fever, and delusions.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right!" The best nursing action would be to:

Identify recent behaviors or accomplishments that demonstrate skill or ability. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care is to provide successful experiences for the client that are challenging but will not be met with failure to enhance the client's personal self-esteem

Which of the following are appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply.

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate. when the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming himself or herself or others. The nurse would provide a low stimulating environment to maintain the client in as calm a state as possible. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. Adequate nutritional and fluid intake needs to be maintained.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse likely expects that the client:

Presents a harm to self Involuntary admission is made without the client's consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment or physical care

A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as:

Denial Denial is refusal to admit to a painful reality and is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other people, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature way of behaving. Rationalization is justifying the unacceptable attributes about oneself.

In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following is best?

Encourage the client to participate in a structured daily program of activities. A depressed person suffers with depressed mood and is often withdrawn. Also, the person experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment.

The best rationale for using group therapy as an accepted way of treatment of clients in the milieu is because:

Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment. Group therapy is a method in which faulty perceptions can be corrected and more effective ways can be developed to help clients relate to each other. Many client problems are the result of interpersonal concerns, and group therapy is a useful framework that helps address potential solutions in a realistic environment.

A nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to:

Provide safety for the client and other clients on the unit. Safety of the client and other clients is the priority.

A nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by:

Psychomotor retardation and side effects of medication Constipation can be related to inadequate food intake, lack of exercise, and poor diet. In this situation, urinary retention is most likely caused by medications. Option 4 is the only option that addresses both constipation and urinary retention.

A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing:

Social phobia Social phobias are characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation. Fear of public speaking is the most common social phobia

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

"You sound very upset. Are you thinking of hurting yourself?" Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The client should be directly asked if a plan for self-harm exists

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it." Which of the following is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?" Focusing and verbalizing the implied concern is the therapeutic response because it assists the client to clarify thinking and re-examine what the client is really saying.

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to:

Escort the manic client to his or her room. The client is at risk for injury to self and others and therefore should be escorted out of the dayroom.

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:

Feed, bathe, and dress the client as needed until the client can perform these activities independently. The client with depression may not have the energy or interest to complete activities of daily living. Often, severely depressed clients are unable to perform even the simplest activities of daily living. The nurse assumes this role and completes these tasks with the client.

A nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. The best nursing action is to:

Keep the client talking and signal to another staff member to send help to the client. In a crisis, the nurse must take an authoritative, active role to promote the client's safety. A bottle of sleeping pills in front of a client who verbalizes he wants to kill himself is a "crisis." The client's safety is of prime concern. Keeping the client on the phone and getting help to the client is the best intervention

The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this—it's private and personal." Which statement by the nurse indicates a therapeutic response?

"I know that some of these questions are difficult for you, but, as a nurse, I must legally respect your confidentiality."

A nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say:

"I no longer feel that I deserve the beatings my husband inflicts on me." Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain suggestions about successful behavioral changes

Following a group therapy session, a client approaches the licensed practical nurse (LPN) and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Get a written prescription from the health care provider (HCP) and obtain an informed consent. A client may request to be secluded or restrained. Federal laws require the consent of the client, unless an emergency situation exists in which an immediate risk to the client or others can be documented. The use of seclusion and restraint is permitted only on the written prescription of the health care provider (HCP), which must be reviewed and renewed every 24 hours. It must also specify the type of restraint to be used.

A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point." The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The appropriate interpretation of the behavior is that the client:

Is displaying typical behaviors that can occur during termination In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.

tardive dyskinesia

Tardive dyskinesia is a disorder that involves involuntary movements. Most commonly, the movements affect the lower face. Tardive means delayed and dyskinesia means abnormal movement.

A nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which of the following?

The false belief that one is being singled out for harm by others A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is going out with other people.

A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client would best indicate to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

A nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for additional information about this self-help group?

"The leader of this self-help group is a nurse or psychiatrist." The leader of a self-help group is an experienced member of the group. A nurse or psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group. Options 2, 3, and 4 are characteristics of a self-help group.