Mental Health NCLEX prep

अब Quizwiz के साथ अपने होमवर्क और परीक्षाओं को एस करें!

Which behavior demonstrated by a client diagnosed with depression indicates a need for suicide precautions?

Asks about how to get a will notarized

The nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action? Refer the client to a psychiatrist. Encourage the client to move and use the arm. Assess the client for organic causes of the paralysis. Encourage the client to talk about his or her feelings.

Assess the client for organic causes of the paralysis

When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration? Encouraging social interactions Assessing all activities for safety risks Focus upon providing verbal stimulation Providing detailed instructions to ensure success

Assessing all activities for safety risks

The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply. Assist the client in selecting foods from the food menu. Offer high-calorie fluids throughout the day and evening. Allow the client to eat alone in the room if the client requests to do so. Offer small high-calorie, high-protein snacks during the day and evening. Select the foods for the client to be sure that the client eats a balanced diet.

Assist the client in selecting foods from the food menu Offer high-calorie fluids Offer small high-calorie, high-protein snacks

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression? Restrict the client smoking for 12 hours. Enforce nothing by mouth (NPO) status for 16 hours. Limit the client's participation in unit activities for 24 hours. Assure that an electrocardiogram is performed within 24 hours.

Assure that an EKG is performed within 24 hours

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include? Increase socialization of the client with peers. Avoid using a whisper voice in front of the client. Begin to educate the client about social supports in the community. Have the client sign a release of information to appropriate parties for assessment purposes.

Avoid using a whisper voice in front of the client

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia?

Noncompliance with medication therapy

When discussing an individual's tendency to substance abuse, the nurse should identify which assessment data as a primary biological factor? The client is a 25-year-old male. The client is employed as a firefighter. The client is of German ethnic background. The client has 2 family members who have abused.

The client has 2 family members who have abused

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? Use of confabulation Improvement in sleeping Absence of sundown syndrome Presence of personal hygienic care

Use of confabulation

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? "You need to stop that behavior now." "You will need to be placed in seclusion." "You seem restless; tell me what is happening." "You will need to be restrained if you do not change your behavior."

You seem restless; tell me what is happening

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? "You need to stop that behavior now." "You will need to be placed in seclusion." "You seem restless; tell me what is happening." "You will need to be restrained if you do not change your behavior."

You seem restless; tell me what is happening

Which statement by the nurse indicates a need for further teaching concerning family violence?

Abusers are more often from low-income families

During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response?

Have you shared your concerns with the police?

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.

I keep reliving the robbery I see his face everywhere I might have died over a few dollars

The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action?

Observing rigid rules and regs

The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar?

Progressive muscle relaxation techniques are useful for easing tension

The nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning care for the client, which action by the nurse should receive priority? Speaks slowly to the client Projects an attitude of calmness Bargains to prevent the violent episodes Moves quietly when approaching the client

Projects an attitude of calmness

The client asks the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which response is appropriate and assists the client in achieving the goal of optimal personal functioning?

When your psych arrives, I will let them know you have a question

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize which assessment finding as requiring immediate intervention? Grandiose delusions of being a czar of Russia Constant physical activity and poor oral intake Constant, incessant talking, with sexual innuendoes Outlandish behaviors and wearing odd, eccentric clothing

Constant physical activity and poor oral intake

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? Dementia Schizophrenia Seizure disorder Obsessive-compulsive disorder

Dementia

The nursing care plan indicates a problem of self-directed violence and the risk for suicide related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome? Displays less anxiety and agitation Denies presence of suicidal ideations Develops adequate problem-solving skills Establishes a relationship with staff and peers

Denies presence of suicidal ideations

A client who is exhibiting psychotic behaviors is admitted to the psychiatric unit. In developing a plan of care, the nurse should identify which as the priority client problem? Disturbed thought processes Lack of knowledge about the behavior Inability to care for self with bathing procedures Altered nutrition: inadequate consumption of food

Disturbed thought processes

During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia? Refusing to eat and excessive exercising Eating only vegetables and fruits and fasting Hoarding of food and difficulty controlling food intake Eating a lot of food in a short period of time and misuse of laxatives

Eating a lot of food in a short period of time...

The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support? Anxiety Agoraphobia Schizophrenia Post-traumatic stress disorder

PTSD

Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action?

Remain with the client until the anxiety decreases

Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication? Cirrhosis Delirium tremens Esophageal varices Wernicke-Korsakoff syndrome

Wernicke-Korsakoff syndrome

A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time?

What is causing you to become agitated?

A client with a diagnosis of 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." Which response by the nurse demonstrates therapeutic communication? "You have everything to live for." "Why do you see yourself as a failure?" "Feeling like this is all part of being depressed." "You've been feeling like a failure for a while?"

You've been feeling like a failure for a while?

A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention? Encouraging quiet reading and writing for the first few days Identification of physical activities that will provide exercise No socializing activities, until the client asks to participate in milieu A structured program of activities in which the client can participate

A structured program...

The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction?

Impaired wound healing

A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention? Turn off the television. Walk with the client around the unit. Discuss the possible hallucinatory triggers. Help him call his mother so he can speak with her.

Turn off the television

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? A client with pneumonia A client undergoing diagnostic tests A client who thrives on managing others A client who could benefit from the client's assistance at mealtime

A client undergoing diagnostic tests

Which client is at greatest risk for committing suicide? A client with metastatic cancer A client with a newly diagnosed cardiac disorder A client who just had an argument with her fiancé A newly divorced client who states she has custody of the children

A client with metastatic cancer

Which roommate choice is least appropriate for a client diagnosed with anorexia nervosa who is in a state of starvation? A client with pneumonia A client who had back surgery A client with a fractured pelvis A client who has had a myocardial infarction

A client with pneumonia

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?

A willingness to participate in in treatment planning and care

On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior? Fearfulness regarding treatment measures Anger and aggressiveness directed toward others An understanding of the pathology and symptoms of the diagnosis A willingness to participate in the planning of the care and treatment plan

A willingness to participate in the planning of the care and treatment plan

Which is the best therapeutic approach for the nurse to use in crisis counseling? Reassuring Passive listening Exploration of early life experiences Active, with focus on the current situation

Active, with focus on the current situation

Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate?

Always turns on an overhead light when entering a dark room

A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior? Institute the unit's suicide precaution protocol. Alert the client's psychiatrist of these changes immediately. Notify the staff of these observations at today's team meeting. Ask the client directly about the presence of any suicide-related thoughts.

Ask the client directly about the presence of any suicide-related thoughts

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 and 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. What action should the nurse take? Call the nursing supervisor. Call security to block all exit areas. Restrain the client until the primary health care provider (PHCP) can be reached. Tell the client that the client cannot return to this hospital again if the client leaves now.

Call the nursing supervisor

The husband of an alcohol-dependent wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic? "Did you know that more people identify with just what you are saying?" "Which of the features that describe codependence caused you to recognize that?" "Can you tell me more about that? You see yourself as being codependent with your wife?" "Have you discussed your feelings with your wife? What does your wife think about what you've said?"

Can you tell me more about that?

A client who is recovering from benzodiazepine dependence says, "I've lost so many people. First, my brother dies of cancer; then my husband leaves me for a 20-year-old. I wish I had 1 of those pills right now." Which statement by the nurse would be therapeutic? "Can you tell me what you think the pills can do for you?" "It sounds as if you feel that all of this has just happened to you." "It must have been a terrible loss for you when your brother died." "How did your husband's interest in a younger woman make you feel?"

Can you tell me what you think the pills can do for you?

A battered wife says, "My husband is a bully and a womanizer and certainly doesn't provide for his family, but he's never beat me up, so I don't think I can say he's abusive." Which response by the nurse is therapeutic?

Do you believe there are other forms of abuse besides physical

The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value? "Why do you think this is a wise decision?" "I don't understand. Only you can help you?" "You've decided not to take your medication. Is that right?" "Do you recall what it was like before you started your medication?"

Do you recall what it was like

During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primarycharacteristics of bulimia?

Eating a lot in short periods and misuse of laxatives

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?

Escort the client to their room with the assistance of other staff

The nurse should plan which goals of the termination stage of group development? Select all that apply. The group evaluates the experience. The real work of the group is accomplished. Group interaction involves superficial conversation. Group members become acquainted with one another. Some structuring of group norms, roles, and responsibilities takes place. The group explores members' feelings about the group and the impending separation.

Evaluates the experience Explores members' feelings

Which statement made by a severely depressed client requires the nurse's immediate attention? "Feeling better really isn't important to me anymore." "No one can really understand what I've had to deal with." "I really don't like the way that new depression pill makes me feel." "I've not been the least bit interested in socializing since my divorce."

Feeling better really isn't important to me anymore

A client asks the nurse about the meaning of behavioral therapy. Which description describes the purpose of behavioral therapy? Fosters positive behavioral change Develops structure and organizes time Creates insight into maladaptive behavior Decreases stress through relaxation training

Fosters positive behavioral change

The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? Hypotension, ataxia, hunger Stupor, lethargy, muscular rigidity Hypotension, coarse hand tremors, lethargy Hypertension, changes in level of consciousness, hallucinations

Hypertension, changes in LOC, hallucinations

The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction? Emboli Hypotension Thrombophlebitis Impaired wound healing

Impaired wound healing

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? "What makes you think that I am a vampire?" "I'll leave and come back later for the specimen." "Do you remember discussing the lab work earlier?" "It must be frightening to think that others want to hurt you."

It must be frightening to think that others want to hurt you

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation? Trusting the staff Socializing with other clients at a holiday party Making decisions about living arrangements after discharge Identifying ways to minimize the tendency to be self-centered

Making decisions about living arrangements after discharge

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? Milieu therapy Interpersonal therapy Behavior modification Support group therapy

Milieu therapy

Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning? "My husband tells me that I'm back to my old cheerful self." "My boss tells me that I'm being considered for a promotion and a raise." "When I find myself getting stressed, I immediately use the relaxation techniques I've learned." "I have a different perspective on life now. I'm more confident of my ability to handle any problem."

My boss tells me...

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? Provide authority, action, and participation. Display an attitude of detachment, confrontation, and efficiency. Demonstrate confidence in the client's ability to deal with stressors. Provide hope and reassurance that the problems will resolve themselves.

Provide authority, action, and participation

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?

Provide safety for the client and other clients

A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action? Assessing the clients' need for supportive therapy Evaluating the clients for signs of stress overload Providing the clients with shelter, clothing, and food Planning means for the clients to receive their medications

Providing the clients with shelter, clothing, and food

A client who has a history of being sexually assaulted is found sucking her thumb while rocking in her bed and does not respond to verbal communication. The nurse should recognize that this behavior demonstrates which coping mechanism? Fantasy Regression Displacement Compensation

Regression

Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply.

Related to abnormal melatonin Improves during the summer Is a result of the alteration in available sunlight A craving for carbs is lessened during the summer months

A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time? Remaining with the client Teaching the client deep-breathing techniques Encouraging the client to talk about her feelings Putting the client in a quiet room, away from other clients

Remaining with the client

During a group session, a client threatens to "punch every one of you." Which is the appropriate initial nursing action? Call security to come to the session immediately. Require the client to leave the group immediately. Remind the client that punching anyone is a reason for being placed into seclusion. Remind the client that talking about personal anger is appropriate, but acting on it is not.

Remind the client that talking about personal anger is appropriate, but acting on it is not

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? Adhering to the mandatory abuse-reporting laws Notifying the caseworker of the family situation Removing the client from any immediate danger Obtaining treatment for the abusing family member

Removing the client from any immediate danger

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.

Restating Listening Maintaining Providing

The nurse is creating a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care? Promote complete independence in the client. Strengthen the client's ability to manage stress. Reward the client when a desired behavior is performed. Provide consistent negative reinforcement to promote appropriate behaviors.

Reward the client when a desired behavior is performed

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit should expect to note which behaviors in the client? Sad and tearful Suspicious and hostile Frightened and delusional Rigidness in thought and inflexibility

Rigidness in thought and inflexibility

The nurse is developing a plan of care for a client with depression who is scheduled to have electroconvulsive therapy. Which problem is a priority for this client? Fear Anxiety Risk for aspiration Distorted body image

Risk for aspiration

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? Setting limits on the client's behavior Asking the client to leave the group session Asking another nurse to escort the client out of the group session Telling the client that he or she will not be able to attend any future group sessions

Setting limits on client's behavior

The nurse is creating a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to provide which priority information to the family? Brain anomalies that are responsible for this disorder Signs that indicate the client may be considering suicide The importance benzodiazepines play in the management of this disorder The possibility that the client will experience medication-induced tinnitus

Signs that indicate the client may be considering suicide

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention? Ask direct questions to encourage talking. Leave the client alone so as to minimize external stimuli. Sit beside the client in silence with simple open-ended questions. Take the client into the dayroom with other clients to provide stimulation.

Sit beside the client in silence with simple open-ended questions

Community mental health teams recognize that in the immediate postdisaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action?

Station mental health professional at established centers

The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to stop using drugs." Which response by the nurse would be therapeutic?

Tell me what makes you think you are ready

Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply. The average series involves 8 to 12 treatments. Some confusion may be noted after the procedure. Memory loss may occur but will resolve with time. This treatment is a permanent cure to the condition. This treatment is tried before the use of medications.

The average series involves 8 to 12 treatments. Some confusion may be noted after the procedure. Memory loss may occur but will resolve with time.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? When told that a beloved pet has died, the client responds, "OK." The client giggled while describing being physically abused as a child. The client's facial expressions are unchanged during the entire admission process. When staff members attempt to engage the client in conversation, the client only mumbles.

The client giggled...

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior?

The client is displaying typical behaviors

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? The client's noncompliance with medication therapy The community's opposition to outpatient mental health clinics The associated increased risk that the client may become homeless The family's negative reaction to transferring the client to community-based care

The client's noncompliance with medication therapy

During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries?

The focus of today's session is on your issues, so lets get started

The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle? Members should be of the same gender. The group will decide the focus of the sessions. The group should be limited to no more than 10 members. The focus of the group will determine when the group will meet.

The group should be limited to no more than 10

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? "This form of therapy can be applied to new situations." "An advantage of this technique is that change is likely to last." "Talking to oneself is a basic component of this form of therapy." "This form of therapy provides a negative reinforcement when the stimulus is produced."

This form of therapy provides a negative reinforcement

An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury? Turn off the television and radio, and use a night-light. Keep soft lighting and the television on during the night. Change the client's room to one nearer the nurses' station. Play soft instrumental music all night, and do not turn down the lights.

Turn off the television and radio, and use a night-light

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? Move the client next to the nurses' station. Use an indirect light source and turn off the television. Keep the television and a soft light on during the night. Play soft music during the night, and maintain a well-lit room.

Use an indirect light source and turn off the television

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study?

WBC

A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything." Which statement by the nurse is therapeutic? "It sounds as if everything you do is either all or nothing." "Talk to your counselor; maybe everything isn't ruined yet." "You will need to restart your recovery starting from the beginning." "We need to prepare you to recognize those things that trigger you to relapse."

We need to prepare you to recognize those things that trigger you to relapse

The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? "My medications will help my anxious feelings." "I'll go to support group and talk about what I am feeling." "When I have command hallucinations, I'll call a friend for help." "I need to get enough sleep and eat well to help prevent feeling anxious."

When I have command hallucinations, I'll call a friend for help

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? Chess Writing Ping pong Basketball

Writing

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? "Do you think that having asthma will kill you?" "You seem very distressed over learning you have asthma." "Asthma is a treatable condition when medications are taken properly, so let's practice with your inhalant." "It will be difficult to work with you if you can't view this as a challenge rather than a nail in your coffin."

you seem very distressed over learning you have asthma

A hospitalized client with a history of alcohol misuse 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 and 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. What action should the nurse take?

Call the Supervisor

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. Which action should the nurse take at this time? Call the nursing supervisor. Call security to block the exits to the nursing unit. Restrain the client, and call the primary health care provider. Tell the client that readmission is not possible after leaving against medical advice.

Call the nursing supervisor

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition? Psychosis Repression Conversion disorder Dissociative disorder

Conversion disorder

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. Dental decay Moist, oily skin Loss of tooth enamel Electrolyte imbalances Body weight well below ideal range

Dental decay Loss of tooth enamel Electrolyte imbalances

A client admitted to the mental health unit after attacking his father for disturbing him at his computer interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact?

I will be back to talk with you in 15 minutes...

I'm looking forward to leaving here...

A client whose wife recently died of cancer 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." What is the therapeutic nursing response?

It must be hard to accept that she has passed away

Which client behavior demonstrates denial of a sexual abuse event?

Sitting quietly and calm

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event? Witnessing a murder The death of a loved one A fire that destroyed the client's home A recent rape episode experienced by the client

The death of a loved one

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriatequestion?

What leads you to seek help now?

The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client? "You look lovely today." "You're wearing a new blouse." "Don't worry; everyone gets depressed once in a while." "You will feel better when your medication starts to work."

You're wearing a new blouse

The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse?

"**** off loser" or, our relationship is a therapeutic and helping one

A client diagnosed with depression is scheduled to receive 3 sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame? 1 week after the 3rd treatment session 3 weeks after the treatment sessions begin Midway between the 2nd and 3rd treatment session 8 weeks after the treatment sessions are completed

1 week after the 3rd treatment session

A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? "I don't believe this is true." "The guards are not out to kill you." "Do you feel afraid that people are trying to hurt you?" "What makes you think the guards were sent to hurt you?"

Do you feel afraid that people are trying to hurt you?

Which goal addresses the therapeutic management needs of a client experiencing hallucinations?

Facilitate that the client's awareness that the hallucinations are not the reality of the world.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal?

Identifying anxiety producing situations

A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis?

Somatization disorder

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. A birthday of March 30 A loss of interest in hobbies A suicide attempt 6 months ago Adopted by family at age 14 months Brain scan shows increased blood flow to the frontal lobes Magnetic resonance imaging shows temporal lobe atrophy

A birthday of March 30 (so weird!) A loss of interest in hobbies A suicide attempt 6 months ago MRI showing temporal lobe atrophy Rationale: A late winter, early spring birthday (viral theory); apathy and anhedonia (the inability to experience pleasure from activities usually found enjoyable); suicidal ideations; and atrophy of brain tissue are all common to individuals exhibiting symptomatology of schizophrenia. Blood flow within the brain is generally decreased; no data support that adoption itself increases the risk for schizophrenia.

When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement? "I hope I am going to like my new counselor." "I sure hope I will still be productive at work." "I am going to keep a close check on any stress I have in my life." "I will take the medicine until I am sure I can handle my own problems."

I will take the medicine until I am sure I can handle my own problems

The nurse is creating a plan of care for the client who is upset following the loss of a job and is verbalizing concerns regarding the ability to meet financial obligations. Which problem is the basis of the client's concerns? Anxiety Confusion about social roles Inability to meet role expectations Impairment of interactions among family members

Inability to meet role expectations

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. Neglecting personal grooming Looking at old photographs of family Participating in a senior citizens program Visiting the spouse's grave once a month Decorating a wall with the spouse's pictures and awards received

Looking Participating Visiting Decorating

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? Begin to teach relaxation techniques. Encourage the client to discuss the assault. Remain with the client until the anxiety decreases. Place the client in a quiet room alone to decrease stimulation.

Remain with the client until anxiety decreases

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client? Isolating self Inability to cope Low self-esteem Risk for self-harm

Risk for self-harm

The nurse is monitoring a stress management therapy group that is in the forming stage. Which activity is characteristic of this stage of group development? Expressing feelings about identifying stressors in their lives Providing examples of how stress has negatively affected relationships Setting the rules of conduct for members of the stress management group Providing a summary of the personal benefits stress management has provided

Setting the rules of conduct for members of the stress management group

A client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which response should the nurse make to the client? "It is very, very hard to get over these types of feelings after being raped." "What do you think you should do to reduce the likelihood that you will be raped again?" "Tell me more about what happened and what causes you to feel like the rape just occurred." "It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred."

Tell me more...

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all of the doctor's fault. I have done everything that he has asked me to do!" How should the nurse interpret the client's statement? An expected coping mechanism An ineffective coping mechanism A need to notify the hospital lawyer An expression of guilt on the part of the client

An expected coping mechanism

A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action? Assess the client's vital signs. Identify the client's activity during the pain. Assess for signs related to a panic disorder. Determine the client's use of relaxation techniques.

Assess the client's VS

A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem? "I've never drunk so much that I've passed out." "I'm just a social drinker. I seldom drink when I'm alone." "I don't have to drink to feel good. I drink because I like the way it tastes." "I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep."

I have a cocktail after work...

During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor? Apathy Impaired pain perception Distrust of authority figures Poor verbal communication skills

Impaired pain perceptions

When should the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior?

No aggressive behavior has been observed for 1 hour after two of the restraints have been removed.

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication? "I see." "Really?" "You're having difficulty sleeping?" "Sometimes I have trouble sleeping too."

You're having difficulty sleeping?

When planning care for a client with a history of violent behavior toward others, the nurse should include which interventions? Select all that apply.

Admit the client to a room near the nurses station Have security nearby but out of sight

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? Requesting that a peer remain with the client at all times. Removing the client's clothing and placing the client in a hospital gown. Assigning to the client a staff member who will remain with the client at all times. Admitting the client to a seclusion room where all potentially dangerous articles are removed.

Assigning to the client a staff member...

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for? Coarse hand tremor, agitation, hallucinations, and hypotension Hypotension, ataxia, muscular rigidity, and tactile hallucinations Hypotension, stupor, agitation, headache, and auditory hallucinations Fever, hypertension, changes in level of consciousness, and hallucinations

Fever, hypertension, changes in LOC, and hallucinations

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding?

Fist clenched, pounding table, fearful

Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving? Increased number of hours slept at 1 time and is increasingly alert Appears to be delirious but has stopped trying to pull out the nasogastric tube Tells his wife, "I do feel better, but why are snakes in the corner of my room?" Appears anxious whenever approached by staff but relaxes when family is present

Increased number of hours slept...

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions? Information regarding shelters Instructions regarding calling the police Instructions regarding self-defense classes Explaining the importance of leaving the violent situation

Information regarding shelters

A client diagnosed with a borderline personality disorder says to the nurse, "Sometimes I do things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the most appropriate nursing response? "Next time, pick less dangerous and expensive ways to explode." "What can you do to stop your behavior when it gets to that point the next time?" "It's a good thing that you don't abuse substances, or you might be dead because of your recklessness." "It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

It is scary when you feel out of control with such feelings...

A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy? "It uses positive reinforcement." "It uses negative reinforcement." "It increases social behaviors in the client." "It increases the level of self-care in the client."

It uses negative reinforcement

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide stimulation in the environment. Provide reality orientation as appropriate. Maintain NPO (nothing by mouth) status.

Monitor VS Provide a safe environment Address hallucination therapeutically Provide reality orientation as appropriate

A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement describes the nurse's obligation to the client? Arrange for the client to go to the local mental health center daily for counseling. Ask the client's permission to reveal the suicidal plans to the primary health care provider (PHCP). Assure the client that the confidence between nurse and client will be strictly adhered to. Share that the risk to the client's safety requires that the client's PHCP be notified.

Share that the risk to the client's safety requires that the client's PHCP be notified

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy? Daily medication therapy Involvement with a support group Intense stress management training Short exposure to the phobic object

Short exposure to the phobic object

Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli? The client remains in the same physical position for hours. The client is convinced that the curtains are actually ghosts. The client looks for a cat when someone says, "It's raining cats and dogs." The client repeatedly asks, "Can you see my dead sister over by the door?"

The client is convinced that the curtains are actually ghosts

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns? "This is not a good time to make that decision." "What would your spouse think about your decision?" "What aspects of this situation are the most difficult for you?" "You seem to have a good grip on this situation. You probably should get out."

What aspects of this situation are the most difficult for you

A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor? Development of tolerance for the drug Lack of naturally occurring endorphins Client's psychological dependency on opiates Typical abuse pattern for central nervous system depressants

Lack of naturally occurring endorphins

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time? Remain with the client. Put the client in a quiet room. Teach the client deep breathing. Encourage the client to talk about his or her feelings and concerns.

Remain with the client

Which client's death was achieved by what is considered a soft suicide method? Claimed to be going hunting and then shot himself while alone in the woods Hung himself after becoming aware that he would be arrested for domestic violence Sat in a running car parked in her locked garage to die of the carbon monoxide inhalation Left a suicide note sharing that she was planning to jump off the bridge into a secluded part of the river

Sat in a running car

A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on? The object of the crisis The client's physical condition The client's coping mechanisms The presence of support systems

The client's physical condition

A client diagnosed with terminal cancer 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." Which response by the nurse is therapeutic? "Have you shared your feelings with your family?" "I think we should talk more about your anger with your family." "You're feeling angry that your family continues to hope for you to be cured?" "You are probably very depressed, which is understandable with such a diagnosis."

You're feeling angry that your family continues to hope for you to be cured?

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which are the most realistic goals for this client? Select all that apply. The client will develop adaptive coping patterns. The client will identify a realistic perception of stressors. The client will cease to have negative feelings about the event. The client will express and share feelings regarding the present crisis. The client will identify effective coping patterns that have worked in the past.

develop adaptive coping patterns identify realistic perception of stressors express and share feelings regarding present crisis identify effective coping patterns that have worked in the past

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? "I no longer feel that I deserve the beatings my husband inflicts on me." "My attendance at the meetings has helped me to see that I provoke my husband's violence." "I enjoy attending the meetings because they get me out of the house and away from my husband." "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."

I no longer feel that I deserve the beatings my husband inflicts on me

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply. Initiate confinement measures. Acknowledge the client's behavior. Assist the client to an area that is quiet. Maintain a safe distance from the client. Allow the client to take control of the situation.

Acknowledge Assist Maintain

The nurse is assessing a client who has been admitted to the coronary care unit. The client seems to fluctuate in the ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect? Dementia as a result of isolation Dementia as a result of substance intoxication Acute confusion as a result of hospital-induced psychosis Interruption in the family as a result of alcohol withdrawal

Acute confusion as a result of hospital-induced psychosis

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? Admitting to having a problem Substituting other activities for gambling Stating that the gambling will be stopped Discontinuing relationships with people who gamble

Admitting to having a problem

Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate? Declines an invitation to walk around the park Never takes an elevator but rather climbs the stairs Always turns on the overhead light before entering a darkened room Refuses to engage in conversations when in the presence of more than 2 to 3 people

Always turns on the overhead light before entering a darkened room

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? Ask the client why he started taking illegal drugs. Ask the client about the amount of drug use and its effect. Ask the client how long he thought that he could take drugs without someone finding out. Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

Ask the client about the amount of drug use and its effects

A client who has shared with the group at a previous session now suddenly gets up and announces, "I'm leaving." How can the nurse initially meet the needs of both the client and the group? Offer to go with the client to his room to talk. Ask the client to refocus the group's discussion. End the therapy session for everyone immediately. Ask the client to stay and share what he is feeling.

Ask the client to stay

The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? "I took an extra pill for anxiety and got through the funeral fairly well." "I worry that if I don't take my anxiety pill on time, I'll have one of those attacks." "Taking my anxiety pills before I leave has helped me to cross the bridge and go to work every morning." "I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

I went to the movies...

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? Suppressing feelings of anxiety Identifying anxiety-producing situations Continuing contact with a crisis counselor Eliminating all anxiety from daily situations

Identifying anxiety-producing situations

During a group therapy session a client begins yelling, "I can't listen to this. You people are no different from the ones I have to deal with at home." What is the nurse's immediate action? Inform the yelling client to leave the group immediately. Call security personnel to the session to ensure everyone's safety. Ask the other clients to describe how the aggressive yelling made them feel. Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated.

Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated

A client asks the nurse about the meaning of behavioral therapy. Which description describes the purpose of behavioral therapy?

Fosters positive behavioral changes

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. Ensure that the client knows that they are not in charge of the nursing unit. Assist the client in identifying ways of setting limits on personal behaviors. Follow through about the consequences of behavior in a nonpunitive manner. Enforce rules by informing the client that he/she will not be allowed to attend therapy groups. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

Communicate Assist Follow through Have the client state

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit? Facing the client when providing care Assigning the client to a room at the end of the hall Ensuring that a security officer is available at all times if needed Keeping the door to the client's room open when providing care to the client

Assigning the client to a room at the end of the hall

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care? Monitor for repetitive behavior. Demand active participation in care. Educate the client about self-care needs. Establish a trusting nurse-client relationship.

Establishing a trusting nurse-client relationship

A client with depression 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." Which is the best nursing response? Tell the client that this is not true, that we all have a purpose in life. Identify recent behaviors or accomplishments that demonstrate the client's skills. Reassure the client that the nurse knows how the client is feeling and that things will get better. Remain with the client and sit in silence. This will encourage the client to verbalize feelings.

Identify recent behaviors or accomplishments...

Which is a primary behavior of a client diagnosed with antisocial personality disorder? Frequently expresses suicidal ideations Leaves the dayroom when anyone else enters Will take personal items from other clients' rooms Requires constant reassurance whenever required to make a decision

Will take personal items from other client's rooms

Which activity should the nurse include in the plan of care for a client with mania who is experiencing psychomotor agitation? Playing checkers with members of the staff Reading in a quiet, low-stimulus environment Engaging in a card game with other clients on the unit Attending a clay-molding class that is scheduled for today

Attending a clay-molding class

A client who has recently lost her spouse says, "No one cares about me anymore. All the people I loved are dead." Which response demonstrates an understanding of therapeutic communication when dealing with a grieving client? "I certainly care about you." "You must be feeling all alone at this point." "I don't believe that and neither should you." "It isn't unusual to feel alone when you are grieving."

You must be feeling all alone at this point

A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic? "I know just how you feel; I lost my husband last summer." "You need to grieve, and expressing anger can be part of grieving." "Although she means to help, you need to do what feels right for you." "Focusing on the many good years you both enjoyed together will help."

You need to grieve, and expressing anger can be part of grieving

The client who is actively hallucinating is fearful that the voices will direct him to kill himself. Which therapeutic statement should the nurse make at this time? "I can hear the voices too, but ignore them and just go to bed now." "I know whose voices you are hearing, and I told them not to hurt you." "I know you believe they are going to cause you harm, but it's not true." "I don't hear them, but it must be frightening to hear voices that others can't hear."

I don't hear them...

The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a priority basis? "I check my weight every day without fail." "I've been told that I am 10% below ideal body weight." "I exercise 3 to 4 hours every day to keep my slim figure." "My best friend was in the hospital with this disease a year ago."

I exercise 3 to 4 hrs every day

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? "Inner voices tell me to perform my rituals." "My behavior is a conscious attempt to punish myself." "I'm demonstrating control when I engage in my rituals." "My rituals are ways for me to control unpleasant thoughts or feelings."

My rituals are ways for me to control unpleasant thoughts or feelings

The nurse suspects that the client hospitalized with a diagnosis of depression could benefit from further development of coping strategies. Which client statement supports this suspicion? "I know now that I can't be all things to all people all the time." "It is important for me to take my medications just as prescribed." "It's been good to learn better ways to deal with the stresses in my life." "I know that I won't become depressed again as long as I reduce my stressors."

I know that I won't become depressed again as long as I reduce my stressors

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? Normal behavior Evidence of the client's disturbed body image Regression as the client is moving toward the community Indicative of the client's ambivalence about hospital discharge

Evidence of the client's disturbed body image

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply.

Panic disorder PTSD OCD

The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? A crisis state indicates that the client has a mental illness. A crisis state indicates that the client has an emotional illness. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

A client's response to a crisis is individualized...

The nurse is reviewing the medical record of a hospitalized client who received electroconvulsive therapy (ECT) 3 years ago for the treatment of depression. Which assessment data would support that the therapy resulted in retrograde amnesia in the client? The staff needs to frequently reorient the client to the rules of this current unit. The client has demonstrated difficulty remembering the address of the family's new home. The medical record states that the client experienced memory loss for 2 days after the ECT treatment. During the admission interview, the client can't remember why the ECT treatment was originally prescribed.

During the admission interview...

A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom? Teach self-grooming skills. Reward cleanliness with unit privileges. Monitor the adequacy of the antipsychotic dosage. Encourage frequent fluid intake and a high-fiber diet.

Encourage frequent fluid intake and a high-fiber diet

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? Engaging in immoral acts Always reinforcing self-approval Observing rigid rules and regulations Having the need always to make the right decision

Observing rigid rules and regulations

The nurse is developing a plan of care for a client who believes the unit's food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings?

Open ended questions and silence

The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client? Delay such planning until the client asks to participate in milieu. Encourage the client to play solitaire while providing a deck of cards. Provide a structured daily program of activities, and encourage the client to participate. Offer the client a menu of daily activities and insist that the client participate in all of them.

Provide a structured...

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? "With whom do you live?" "Who is available to help you?" "What leads you to seek help now?" "What do you usually do to feel better?"

What leads you to seek help now

The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? "This form of therapy can be applied to new situations." "An advantage of this technique is that change is likely to last." "Talking to oneself is a basic component of this form of therapy." "It provides a negative reinforcement when the stimulus is produced."

It provides a negative reinforcement...

The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse, "I can't sing," and refuses to attend. Which nursing response is most likely to meet the client's needs? "Why don't you want to attend? What is the real reason?" "You don't have to sing. Just listen and enjoy the music." "You must go. You have no choice if you want to get better." "Your primary health care provider has prescribed this therapy for you."

You don't have to sing. Just listen and enjoy the music

The client diagnosed with depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue? "The last few weeks?" "You haven't had an appetite at all?" "Have patience; it will take time for your appetite to improve." "When the medication begins to work, your appetite will return."

You haven't had an appetite at all?

Which is the primary goal of crisis intervention therapy? Introduce new, effective coping methods to the client. Assess the client to identify the causative stressors. Establish a sustainable therapeutic nurse-client relationship. Assist the client in returning to the level of precrisis functioning.

Assist the client to returning to the level of precrisis functioning

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia? Abnormally high blood flow to the frontal lobes Atrophy of both the limbic structures and cerebellum Abnormally small fissures on the surface of the brain Atrophy of the lateral and/or third ventricles of the brain

Atrophy of the lateral and/or third ventricles of the brain

What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget? Escort the client to a private, low-stimulus room. Engage the client in a nonthreatening conversation. Allow the client to pace unless the behavior becomes aggressive. Share the observation with the client so the behavior can be recognized.

Share the observation with the client so the behavior can be recognized

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response? "You need to try to be realistic. The rape did not just occur." "It will take some time to get over these feelings about your rape." "Tell me more about the incident that causes you to feel like the rape just occurred." "What do you think that you can do to alleviate some of your fears about being raped again?"

Tell me more

Tell me more (tell me more!)

Tell me more about what happened and what causes you to feel like the rape just occurred.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? Ask the client to leave the group for this session only. Refer the client to another group that includes other manic clients. Tell the client to stop monopolizing in a firm but compassionate manner. Thank the client for the input, but inform the client that others now need a chance to contribute.

Thank the client for the input, but inform the client that others now need a chance to contribute

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? The adolescent gives away a DVD and a cherished autographed picture of a performer. The adolescent runs out of the therapy group, swearing at the group leader, and to her room. The adolescent becomes angry while speaking on the telephone and slams down the receiver. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

The adolescent gives away a DVD and a cherished autographed picture of a performer

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior? The client will show the initial signs that coping methods are failing. The client will employ new coping methods that will resolve the problem. The client will experience severe anxiety as a result of failed coping methods. The client will begin to implement coping methods that have been successful in the past.

The client will employ new coping methods

Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply. Verbal communication is almost nonexistent. Gross motor skills are impacted by involuntary body movements. The client needs frequent redirection because of short attention span. Interpersonal relationships are negatively impacted because of delusional thoughts. Conversations are difficult to follow because of demonstration of loose associations of thought.

Verbal communication is almost nonexistent The client needs frequent redirection because of short attention span

A client states to the nurse, "My life has been such a failure. Nothing I do turns out right." Which response by the nurse will best address the client's low sense of self-esteem? "You can't really believe that about yourself." "I know just how you feel. I have those days myself once in a while." "I disagree with you; we all have some value and accomplishments in life." "You seem very discouraged. Let's identify something that you are proud of doing."

You seem very discouraged. Let's identify something that you are proud of doing

The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors? Signs of depression Reactions to a devastating event Evidence that the client is a high suicide risk Indicative of the need for hospital admission

Reactions to a devastating event

Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.

Male gender Abuses drugs History of suicide

During a support group session, a client says, "My husband hit me a lot, but when he threatened to start hitting our kids, I stabbed him. No jury will believe me because my husband can lie to anyone and be believed." If no one in the group responds, which statement is the therapeutic response by the nurse? "Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what she's feeling?" "Yes. Everyone here was ill-used and abused, but what makes you think that this is a reason to stab someone?" "Everyone agrees that you couldn't let him hurt your children. But is there anything you would do differently?" "Your story is very much like every woman's here. The problem is getting a jury to see that you were justified in stabbing him."

Abuse is a horribly difficult thing to experience...

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking 2 packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury? Developing lung cancer and/or other respiratory disorders Withdrawal symptoms triggering a stress-induced relapse Diminishing the effectiveness of psychotropic medication Developing gastrointestinal disorders, including bleeding ulcers

Diminishing the effectiveness of psychotropic medication

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? During the entire family visit, the client presented with an expressionless, blank look. The client demonstrated minimal response to the news that his discharge had been postponed. The client grimaced during the entire therapy session that focused on finding one's personal joy. During grief therapy, the client was observed laughing while another client described the death of a parent.

During the entire family visit, the client presented with an expressionless, blank look

What is the priority nursing action when admitting a client who has just attempted suicide? Ensure constant observation of the client at all times. Conduct a thorough mental health assessment of the client. Determine whether the client has ever attempted suicide previously. Remove all potentially dangerous articles from among the client's belongings.

Ensure constant observation of the client at all times

A client in a manic state presents to the dayroom only partially dressed and is making sexual remarks and gestures toward the staff and other clients. Which is the initial nursing action?

Escort the client to their room to get dressed

Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship? Facilitating behavioral change Promoting self-esteem in the client Promoting problem solving skills in the client Establishing the parameters of the relationship

Establishing the parameters of the relationship

The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. Have the client void. Obtain an informed consent. Administer tap water enemas. Avoid discussing the procedure. Remove dentures and contact lenses. Withhold food and fluids for 6 hours.

Have the client void Obtain an informed consent Remove dentures/contacts Withhold food and fluids for 6 hrs

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms? "Well, a picture paints a thousand words." "You just felt like destroying your textbooks?" "Your parents and teachers are very concerned about your drawings." "I am concerned about you. Are you now or have you ever been abused?"

I am concerned about you. Are you now or have you ever been abused?

The spouse of a client prescribed an antidepressant tells the home health nurse, "Now that the antidepressant is working, the suicidal risk is over and you can stop making these home visits." How does the nurse appropriately respond? "I need to continue with my visits since this disease tends to run in families." "I agree with you that the medication will greatly reduce the risk for suicidal behavior." "I agree with you that continuing to visit would reintroduce the possibility of suicidal ideations." "I need to continue visiting since the client may now have the energy to act on suicidal intentions."

I need to continue visiting since the client may now have the energy to act on a suicide intentions.

Which statement by the client best reflects the development of an effective coping response style and effective processing of information for a hospitalized client participating in Alcoholics Anonymous (AA)? "I know I'm ready to be discharged. I feel like I can say no and leave a group of friends if they are drinking. No problem." "I'll keep all my appointments and go to all my AA groups; I'll do everything I'm supposed to. Nothing will go wrong that way." "I'm looking forward to leaving here. 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 not everyone will be as helpful as you people." "This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family and friends will all help me like the people in this group have. They'll all help me. I know they will. They won't let me go back to old ways."

I'm looking forward to leaving here. 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 not everyone will be as helpful as you people.

The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply. Including the family in the medication planning process Arranging medication administration to occur once per day Working with the psychiatrist to find the right medication at the right dose Providing the client with the injectable, long-acting form of the medication if available Working with the psychiatrist to find the medication that provides the least side effects for the client

Include family Working with Providing the client Working with

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions?

Information regarding shelters

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? Interrupt the client and weigh her immediately. Interrupt the client and offer to take her for a walk. Allow the client to complete her exercise program. Tell the client that she is not allowed to exercise rigorously.

Interrupt the client and offer to take her for a walk

The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action should be the priority?

Interrupt the client, take her for a walk

The nurse orienting a new client to a residential treatment center prepares to explain to the client that the emphasis of the center involves milieu therapy. Which is the focus of this type of therapy? Helps identify and examine dysfunctional thoughts Involves increased exposure to an object or situation that causes anxiety Pairs an unpleasant event with a pleasant one to help minimize its impact Involves group and social interaction with rules and expectations mediated by peer pressure

Involves group and social interaction...

Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety? Believes the attacker is in the emergency department Detached, requiring gentle probing to respond to questions Is pacing while describing the situation using a rapid speech pattern Talks about being "panic stricken" that something else "bad" will happen

Is pacing while describing the situation using a rapid speech pattern

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind? "That doesn't sound like the real you talking!" "I'm sure you have someone if you think hard enough." "It sounds as though you are feeling all alone right now." "I don't believe that, and I really don't think you do either."

It sounds as though you are feeling all alone right now

An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse? "I need you to sign a form before leaving." "You will get sick if you go out in the rain." "How old are you? Your father must no longer be living." "Let's have a cup of coffee, and you can tell me about your father."

Let's have a cup of coffee

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? Monitor closely for harm to self or others. Assist in completing an application for admission. Supply the client with written information about her or his mental health problem. Provide an opportunity for the family to discuss why they felt the admission was needed.

Monitor closely for harm to self or others

An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic? "You think AA is for fanatics?" "It sounds as if you look for any reason to drink!" "Not any 1 strategy for remaining sober is best for everyone." "I agree. AA is definitely not for you if you find it is a trigger to drink."

Not any 1 strategy for remaining sober is best for everyone

The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT) to treat depression. Which medical diagnosis, if noted on the client's record, would indicate a need to contact the psychiatrist scheduled to perform the ECT? Type 2 diabetes mellitus Peripheral vascular disease Recent myocardial infarction Newly diagnosed hyperthyroidism

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