Mental Health Nursing exam 1 prac

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply: A. Monitor VS B. Provide safe environment C. Address hallucinations therapeuticlly D. Provide stimulation in the environment E. Provide reality orientation as appropriate F. Maintain NPO status

A,B,C,E When the client is experiencing withdrawal from alcohol, the priority care is to prevent harm of self and others.The nurse would monitor VS closely, provide low-stimulation environment and reorient client to reality frequently and address hallucinations therapeutically.

A client tells the nurse that psychotropic medicines are dangerous and refuses to take them. Which intervention should the nurse use first? A. Ask the client about any previous problems with psychotropic medications. B. Ask the client if an injection is preferable. C. Insist that the client take medication as prescribed. D. Withhold the medication until client is less suspicious.

A. Ask the client about any previous problems with psychotropic medications. The nurse needs to clarify the client's previous experience with psychotropic medication in order to understand the meaning of the client's statement.

A hospitalized client with a history of alcohol abuse tells the nurse "I am leaving now. I have to go. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic procedure in 1 hour. After the nurse discusses the client's concerns, the client dresses an begins to walk out of hospital room. What action should the nurse take? A. Call the nursing supervisor B. Call security to block all exits C. Restrain client until HCP can be reached D. Tell the client they cannot return to this hospital again if client leaves now.

A. Call nursing supervisor Most mental health facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves AMA, The client should be asked to wait and speak with HCP before leaving, and sign "AMA" document before leaving. The nurse can be charges with false imprisonment if client is made to believe wrongfully he/she cannot leave facility.

A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority? A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode

A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications.

The nurse observes a client pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations what is the nurses immediate priority? A. Provide safety for the client and other clients on the unit. B. Provide the clients on the unit with a sense of comfort and safety C. Assist the staff in caring for the client in a controlled environment. D. Offer the client less stimulating area in which to calm down and gain control.

A. Provide safety for the client and other clients on the unit Safety of the client and other clients is the immediate priority. This is the only option that addresses safety needs for client as well as other clients.

Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, the nurse should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D.Chest pain

A. Seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

After administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is the most appropriate? A. Sitting with the client at the bedside until medication takes effect. B. Engaging the client in interaction until the client falls asleep. C. Reading to the client with the lights turned down low. D. Encourage the client to watch TV till the client feels sleepy.

A. Sitting with the client at the bedside until medication takes effect. To promote adequate sleep and eliminate hyposomnia, the nurse should sit with the client at the bedside till the medication takes effect. The presence of a caring nurse provides the client with comfort and security and helps to decrease anxiety.

A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, Nurse Mary should: A. check the client frequently at irregular intervals throughout the night B. assure the client that the nurse will hold in confidence anything the client says C. repeatedly discuss previous suicide attempts with the client D. disregard decreased communication by the client because this is common in suicidal clients

A. check the client frequently at irregular intervals throughout the nigh Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times.

A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client's: A.Disturbed thought processes B. Imbalanced nutrition C. Self-care deficit D. Deficient knowledge

A.Disturbed thought processes Major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client's psychosis.Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option A is correct.

Rosana is in the second stage of Alzheimer's disease who appears to be in pain. Which question by Nurse Jenny would best elicit information about the pain? A. "Where is your pain located?" B. "Do you hurt? (pause) "Do you hurt?" C. "Can you describe your pain?" D. "Where do you hurt?"

B. "Do you hurt? (pause) "Do you hurt?" When speaking to a client with Alzheimer's disease, the nurse should use close-ended questions. Those that the client can answer with "yes" or "no" whenever possible and avoid questions that require the client to make choices. Repeating the question aids comprehension.

Which therapeutic communication technique should the nurse use when communicating with a client who is experiencing auditory hallucinations? A. "My sister has the same diagnosis as you and she also hears voices." B. "I understand that the voices seem real to you, but I do not hear any voices." C. "Why not turn up the radio so that the voices are muted." D. "I wouldn't worry about these voices. The medication will make them disappear."

B. "I understand that the voices seem real to you, but I do not hear any voices." This is an example of the therapeutic communication technique of presenting reality. Presenting reality is when the client has a misperception of the environment. The nurse defines reality or indicates his or her perception of the situation for the client.

Which medication can control the extra pyramidal effects associated with antipsychotic agents? A. Clorazepate (Tranxene) B. Amantadine (Symmetrel) C. Doxepin (Sinequan) D. Perphenazine (Trilafon)

B. Amantadine (Symmetrel) Amantadine is an anticholinergic drug used to relive drug-induced extrapyramidal adverse effects such as muscle weakness, involuntary muscle movements, pseudoparkinsonism and tardive dyskinesia.

A 48 year old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client's wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for: A. past history of depression B. Current plans to commit suicide C. The presence of marital difficulties D. Feelings of excessive failure

B. Current plans to commit suicide Whether there is a suicide plan is a criterion when assessing the client's determination to make another attempt.

The nurse educates the family about symptom management for when the schizophrenic client becomes upset or anxious. Which of the following would the nurse state is helpful? A. Call the therapist to request a medication change. B. Encourage the use of learned relaxation techniques. C. Request that the client be hospitalized until the crisis is over. D. Wait before the anxiety worsens before intervening.

B. Encourage the use of learned relaxation techniques. The client with schizophrenia can learn relaxation techniques, which help reduce anxiety. The family can be supportive and helpful by encouraging the client to use these techniques.

Cersei is diagnosed as having disorganized schizophrenia. Which behaviors would the nu rssemost likely assess in the client? A. Absence of acute symptoms, impaired role function B. Extreme social withdrawal, odd mannerisms and behavior C. Psychomotor immobility; presence of waxy flexibility D. Suspiciousness toward others, increased hostility

B. Extreme social withdrawal, odd mannerisms and behavior Disorganized schizophrenia is characterized by regressive behavior with extreme social withdrawal and frequently odd mannerisms. The absence of acute symptoms and impaired role function are more characteristic of residual-type schizophrenia. Psychomotor immobility and presence of waxy flexibility are more indicative of catatonic schizophrenia. Suspiciousness toward others and increased hostility is more characteristic of paranoid schizophrenia.

Malou with schizophrenia tells the nurse, "My intestines are rotted from worms chewing on them." This statement indicates a: A. Jealous delusion B. Somatic delusion C. Delusion of grandeur D. Delusion of persecution

B. Somatic delusion Somatic delusions focus on bodily functions or systems and commonly include delusion about foul odor emissions, insect manifestations, internal parasites and misshapen parts.

Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been plated in the unit walls. Which action would be the most therapeuic response? A. Confront the delusional material directly by telling Gio that this simply is not so. B. Tell Gio that this must seem frightening to him but that you believe he is safe here. C. Tell Gio to wait and talk about these beliefs in his one-on-one counselling sessions. D. Isolate Gio when he begins to talk about these beliefs.

B. Tell Gio that this must seem frightening to him but that you believe he is safe here. The nurse must realize that these perceptions are very real to the client. Acknowledging the client's feelings provides support; explaining how the nurse sees the situation in a different way provides reality orientation

Which goal is a priority for a client with a DSM-IV-TR diagnosis of delirium and the nursing diagnosis Acute confusion related to recent surgery secondary to traumatic hip fracture? A. The client will complete activities of daily living. B. The client will maintain safety. C. The client will remain oriented. D. The client will understand communication

B. The client will maintain safety. Maintaining safety is the priority goal for an acutely confused client who recently had surgery. All measures to promote physiologic safety and psychosocial wellbeing would be implemented.

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

B. Use indirect light source and turn off the TV Consistent daily routine and low stimulating environment is important when a client is disoriented. Noise, including TV, may add to the confusion and disorientation.

The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client? A. Ping pong B. Writing C. Chess D. Basketball

B. Writing Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension.

A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. The nurse realizes that these symptoms probably result from: A. acetate accumulation B. thiamine deficiency C. triglyceride buildup D. a below-normal serum potassium level

B. thiamine deficiency Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake.

A 39-year-old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. The nurse recognizes that the basis of O.C. disorder is often: A. Problems with being too conscientious B. Problems with anger and remorse C. Feelings of guilt and inadequacy D. Feeling of unworthiness and hopelessness

C. Feelings of guilt and inadequacy Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.

Which of the following drugs has been known to be effective in treating obsessive-compulsive disorder (OCD)? A. Divalproex (depakote) and Lithium (lithobid) B. Chlordiazepoxide (Librium) and diazepam (valium) C. Fluvoxamine (Luvox) and clomipramine (anafranil) D. Benztropine (Cogentin) and diphenhydramine (benadryl)

C. Fluvoxamine (Luvox) and clomipramine (anafranil) The antidepressants fluvoxamine and clomipramine have been effective in the treatment of OCD.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I am anxious, the only thing that calms me down is alcohol." Nurse: "Other than drinking, what alternatives have you explored to decrease anxiety?" A. Reflecting B. Making observations C. Formulating a plan of action D. Giving recognition

C. Formulating a plan The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking alcohol. The use of this technique, rather than direct confrontation regarding the client's poor coping choice, may serve to prevent anger or anxiety from escalating.

The nurse enters the room of a client with a cognitive impairment disorder and asks what day of the week it is; what the date, month, and year are; and where the client is. The nurse is attempting to assess A. confabulation. B. delirium. C. orientation. D. perseveration

C. Orientation. The initial, most basic assessment of a client with cognitive impairment involves determining his level of orientation (awareness of time, place, and person).

A client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to: A. begin after 7 days. B. not occur at all because the time period for their occurrence has passed. C. begin anytime within the next 1 to 2 days. D. begin within 2 to 7 days.

C. begin anytime within the next 1 to 2 days. Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.

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

D Thank the client for input, but inform the client that others now need a chance to contribute. If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolization in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client.

A client states, "You won't believe what my husband said to me during visiting hours. He has no right treating me that way." Which nursing response would best assess the situation that occurred? A. "Does your husband treat you like this very often?" B. "What do you think is your role in this relationship?" C. "Why do you think he behaved like that?" D. "Describe what happened during your time with your husband."

D. "Describe what happened during your time with your husband." This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

Which statement by the client taking lithium most indicates the need for more teaching? A. "My HCP tells me that my lithium level is 1.0 so I don't have to worry about my levels." B. "I have been getting a lot of good exercise playing on local soccer team." C. "I'm trying hard to watch my diet and eat healthy." D. "I have learned to take my lithium even when I am not feeling well, like when I had a stomach flu."

D. "I have learned to take my lithium even when I am not feeling well, like when I had a stomach flu." The therapeutic serum level fr lithium is 0.6-1.2 mEq/L. Levels do fluctuate with fluid intake and output. Therefore the most urgent matter for teaching is the excessive fluid loss during an episode of the "stomach flu" with diarrhea.

A hospitalized client is being considered for ECT. The client appears calm, but the family is anxious. The client's mother begins to cry and states "My son's brain will be destroyed. How can the doctor do this to him?" The nurses best response is: A. "It sounds as though you need to speak with the psychiatrist" B. "Your son has decided to have this treatment. You should be supportive to him." C. "Perhaps you'd like to see the ECT room and speak to the staff." D. "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."

D. "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." The nurse encourages the client and the family to verbalize fears and concerns. The other options avoid dealing with concerns and are blocks to communication.

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

D. "When I have command hallucinations, I'll call a friend and ask what I should do." The risk for impulsive or aggressive behavior may increase if a client is receiving a command hallucination to harm self or others. The nurse or health care professional should be contacted, not a friend. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with hallucinations.

Which nursing statement is a good example of the therapeutic communication technique of focusing? A. "Describe one of the best things that happened to you this week." B. "I'm having a difficult time understanding what you mean." C. "Your counseling session is in 30 minutes. I'll stay with you until then." D. "You mentioned your relationship with your father. Let's discuss that further."

D. "You mentioned your relationship with your father. Let's discuss that further." This is an example of the therapeutic communication technique of focusing. Focusing takes notice of a single idea or even a single word and works especially well with a client who is moving rapidly from one thought to another.

A 60-year-old female client who lives alone tells the nurse at the community health center "I really don't need anyone to talk to". The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as? A. Displacement B. Projection C. Sublimation D. Denial

D. Denial The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.

A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, nervousness

D. Diaphoresis, tremors, nervousness Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.

The family of a schizophrenic client asks the nurse if there is a genetic cause of this disorder. To answer the family, which fact would the nurse cite? A. Conclusive evidence indicates a specific gene transmits the disorder. B. Incidence of this disorder is variable in all families. C. There is a little evidence that genes play a role in transmission. D. Genetic factors can increase the vulnerability for this disorder.

D. Genetic factors can increase the vulnerability for this disorder. Research shows that family history statistically increases the risk for development of schizophrenia. However, no single gene has yet been identified.

To further assess a client's suicidal potential. The nurse should be especially alert to the client expression of: A. Frustration & fear of death B. Anger & resentment C. Anxiety & loneliness D. Helplessness & hopelessness

D. Helplessness & hopelessness The expression of these feeling may indicate that this client is unable to continue the struggle of life.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? A. Hypotension, ataxia, hunger B. Stupor, lethargy, muscular rigidity C. Hypotension, coarse hand tremors, lethargy D. Hypertension, changes in LOC, hallucinations

D. Hypertension, changes in LOC, hallucinations Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in LOC, agitation, fever and delusions

When nurse Hazel considers a client's placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client's: A. Perceptual field B. Delusional system C. Memory state D. Creativity level

A. Perceptual field Perceptual field is a key indicator of anxiety level because the perceptual fields narrow as anxiety increases.

A female client is admitted with a diagnosis of delusions of GRANDEUR. This diagnosis reflects a belief that one is: A. Being Killed B. Highly famous and important C. Responsible for evil world D. Connected to client unrelated to oneself

B. Highly famous and important Delusion of grandeur is a false belief that one is highly famous and important.

Which ability should the nurse expect from a client in the mild stage of dementia of the Alzheimer's type? A. Remembering the daily schedule B. Recalling past events C. Coping the anxiety D. Solving problems of daily living

B. Recalling past events Recent memory loss is the characteristic sign of cognitive difficulty in early Alzheimer's disease. The ability to recall past events is usually retained until the later stages of this disorder.

Mrs. Mendoza is a 75-year-old client who has dementia of the Alzheimer's type and confabulates. The nurse understands that this client: A. Denies confusion by being jovial. B. Pretends to be someone else. C. Rationalizes various behaviors. D. Fills in memory gaps with fantasy.

D Fills in memory gaps with fantasy. Confabulation is a communication device used by patients with dementia to compensate for memory gaps.

A nurse is providing information to a community group about violence in the family. Which statement by a group member would indicate a need to provide additional information? A. "Abuse occurs more in low-income families" B. "Abuser Are often jealous or self-centered" C. "Abuser use fear and intimidation" D. "Abuser usually have poor self-esteem"

A. "Abuse occurs more in low-income families" Personal characteristics of abuser include low self-esteem, immaturity, dependence, insecurity and jealousy.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "My father spanked me often." Nurse: "Your father was a harsh disciplinarian." A. Restatement B. Offering general leads C. Focusing D. Accepting

A. Restatement The nurse is using the therapeutic communication technique of restatement. Restatement involves repeating the main idea of what the client has said. The nurse uses this technique to communicate that the client's statement has been heard and understood.

When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? A. The injury isn't consistent with the history or the child's age B. The mother and father tell different stories regarding what happened C. The family is poor D. The parents are argumentative and demanding with emergency department personnel

A. The injury isn't consistent with the history or the child's age When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring. The parents may tell different stories because their perception may be different regarding what happened. If they change their story when different health care workers ask the same question, this is a clue that child abuse may be a problem

The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese

B. Aftershave lotion Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms.

A nurse is caring for a client who reminds her of a negative person in her past. These memories cause the nurse to unconsciously displace negative feelings towards the client. The nurse should recognize that she is demonstrating which of the following behaviors? A. Supression B. Counter-transference C. Transference D. Assertiveness

B. Counter-transference The nurse demonstrates counter-transference by unconsciously attributing feelings, positive or negative, about another towards a client.

A client on an inpatient psychiatric unit tells the nurse, "I should have died because I am totally worthless." In order to encourage the client to continue talking about feelings, which should be the nurse's initial response? A. "How would your family feel if you died?" B. "You feel worthless now, but that can change with time." C. "You've been feeling sad and alone for some time now?" D. "It is great that you have come in for help."

C. "You've been feeling sad and alone for some time now? This nursing statement is an example of the therapeutic communication technique of reflection. When reflection is used, questions and feelings are referred back to the client so that they may be recognized and accepted.

Jose who is receiving monoamine oxidase inhibitor antidepressant should avoid tyramine, a compound found in which of the following foods? A. Figs and cream cheese B. Fruits and yellow vegetables C. Aged cheese and Chianti wine D. Green leafy vegetables

C. Aged cheese and Chianti wine Aged cheese and Chianti wine contain high concentrations of tyramine.

During which phase of alcoholism is loss of control and physiologic dependence evident? A. Prealcoholic phase B. Early alcoholic phase C. Crucial phase D. Chronic phase

C. Crucial phase The crucial phase is marked by physical dependence. Option A: The prealcoholic phase is characterized by drinking to medicate feelings and for relief from stress. Option B: The early phase is characterized by sneaking drinks, blackouts, rapidly gulping drinks, and preoccupation with alcohol. Option D: The chronic phase is characterized by emotional and physical deterioration.

A nurse could evaluate that the staff's approach to setting limits for a demanding, angry client was effective if the client: A. Apologizes for disrupting the unit's routine when something is needed B. Understands the reason why frequent calls to the staff were made C. Discuss concerns regarding the emotional condition that required hospitalizations D. No longer calls the nursing staff for assistance

C. Discuss concerns regarding the emotional condition that required hospitalizations This would document that the client feels comfortable enough to discuss the problems that have motivated the behavior.

Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mmHg and pulse is 92 bpm. Which of the medications would the nurse expect to administer? A. Naloxone (Narcan) B. Benztropine (Cogentin) C. Lorazepam (Ativan) D. Haloperidol (Haldol)

C. Lorazepam (Ativan) The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client's experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

When developing a teaching plan for a client about the medications prescribed for depression, which component is most important for the nurse to include. A. Pharmocakinetic of medication B. Current research related to the medications C. Management of common adverse effects D. Dosage regulation and adjustment

C. Management of common adverse effects Compliance with medication therapy is crucial for the client with depression. Medication noncompliance is the primary cause f relapse among psychiatric clients. Therefore, the nurse needs to teach the client about managing the adverse effects of medication.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. The symptom presented by the client that requires the nurse's immediate intervention is the client's: A. Outlandish behaviors and inappropriate dress B. Grandiose delusions of being a royal descendant of King Arthur. C. Nonstop physical activity and poor nutritional intake D. Constant, incessant talking that includes sexual innuendoes and teasing the staff

C. Nonstop physical activity 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. Mania is a period when the mood is predominately elevated, expansive, or irritable. All options reflect a client's possible symptomatology. Option C, however, clearly presents a problem that compromises one's physiological integrity and needs to be addressed immediately.

A 75-year-old client is admitted to the hospital with the diagnosis of dementia of the Alzheimer's type and depression. The symptom that is unrelated to depression would be? A. Apathetic response to the environment B. "I don't know" answer to questions C. Shallow of labile effect D. Neglect of personal hygiene

C. Shallow of labile effect With depression, there is little or no emotional involvement therefore little alteration in affect.

The nurse asks a newly admitted client, "What can we do to help you?" What is the purpose of this therapeutic communication technique? A. To reframe the client's thoughts about mental health treatment B. To put the client at ease C. To explore a subject, idea, experience, or relationship D. To communicate that the nurse is listening to the conversation

C. To explore a subject, idea, experience, or relationship This is an example of the therapeutic communication technique of exploring. The purpose of using exploring is to delve further into the subject, idea, experience, or relationship. This technique is especially helpful with clients who tend to remain on a superficial level of communication.

Jaime has a diagnosis of schizophrenia with negative symptoms. In planning care for the client, Nurse Brienne would anticipate a problem with: A. auditory hallucinations. B. bizarre behaviors. C. ideas of reference. D. motivation for activities.

D. motivation for activities. In a client demonstrating negative symptoms of schizophrenia, avolition, or the lack of motivation for activities, is a common problem. All of the other symptoms listed are the positive symptoms of schizophrenia.

Which interventions should the nurse include in the plan of care to prepare a client for ECT? Select all that apply A. Maintain NPO status B. Verify if consent has been signed C. Orient client to place and tie D. Remove dentures E. Request client to void F. Assess client VS Q30 minutes

A,B,D,E NPO status, signed consent, removal of dentures and preprocedure voiding are all preperations prior to a procedure involving anesthesia, such as ECT. Orientation and frequent assessments is done after the procedure.

The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse attempts to engage the client in an interaction, but does not respond to the nurse. Which response by the nurse is most appropriate? A. "I will sit with you for 15 minutes." B. "I will come back a little bit later to talk." C. "I will find someone else for you to talk with." D. "I will get you something to read."

A. "I will sit with you for 15 minutes." The client with severe depression may be unable to engage in an interaction with the nurse because the client feels worthless and lacks the necessary energy to do so. The nurse's presence conveys acceptance and caring, thus helping to increase the client's self-worth.

A client is struggling to explore and solve a problem. Which nursing statement would verbalize the implication of the client's actions? A. "You seem to be motivated to change your behavior." B. "How will these changes affect your family relationships?" C. "Why don't you make a list of the behaviors you need to change." D. "The team recommends that you make only one behavioral change at a time."

A. "You seem to be motivated to change your behavior." This is an example of the therapeutic communication technique of verbalizing the implied. Verbalizing the implied puts into words what the client has only implied or said indirectly.

The most critical factor for the nurse to determine during crisis intervention would be the client's: A. Available situational supports B. Willingness to restructure the personality C. Developmental theory D. Underlying unconscious conflict

A. Available situational supports Personal internal strength and supportive individuals are critical factors that can be employed to assist the individual to cope with a crisis

When assessing a client for suicidal risk, which method of suicide is the most lethal? A. Aspirin overdose B. Use of a gun C. Head banging D. Wrist cutting

B. Use of a gun A crucial factor in determining the lethality of a method is the amount of time that occurs between initiating the method of delivery of the lethal impact of method. The more detailed the suicide plan, the more lethal and accessible the method, and the more effort exerted to block rescue, the greater the chance is for the suicide to be completed.

A client slammed a door on the unit several times. The nurse responds, "You seem angry." The client states, "I'm not angry." What therapeutic communication technique has the nurse employed and what defense mechanism is the client unconsciously demonstrating? A. Making observations and the defense mechanism of suppression B. Verbalizing the implied and the defense mechanism of denial C. Reflection and the defense mechanism of projection D. Encouraging descriptions of perceptions and the defense mechanism of displacement

B. Verbalizing the implied and the defense mechanism of denial This is an example of the therapeutic communication technique of verbalizing the implied. The nurse is putting into words what the client has only implied by words or actions. Denial is the refusal of the client to acknowledge the existence of a real situation, the feelings associated with it, or both.

A nurse is communicating with a male client with substance-induced persisting dementia; the client cannot remember facts and fills in the gaps with imaginary information.The nurse is aware that this is typical of? A. Flight of ideas B. Associative looseness C. Confabulation D. Concretism

C. Confabulation Confabulation or the filling in of memory gaps with imaginary facts is a defense mechanism used by people experiencing memory deficits.

The nurse reviews the activity schedule for the day and plans which activity for the manic client? A. Brown-bag luncheon and book review B. Tetherball C. Paint-by-number activity D. Deep breathing and progressive relaxation group

B. Tetherball A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow use of excess energy yet not endanger others during the process.

Erlinda, age 85, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find: A. Permanent short-term memory loss and hypertension B. Permanent long-term memory loss and hypomania C. Transitory short-term memory loss and permanent long-term memory loss D. Transitory short and long-term memory loss and confusion

D. Transitory short and long-term memory loss and confusion ECT commonly causes transitory short and long-term memory loss and confusion, especially in geriatric clients. It rarely results in permanent short and long-term memory loss

Ramsay is diagnosed with schizophrenia paranoid type and is admitted in the psychiatric unit of Nurseslabs Medical Center. Which of the following nursing interventions would be most appropriate? A. Establishing a non demanding relationship B. Encouraging involvement in group activities C. Spending more time with Ramsay D. Waiting until Ramsay initiates interaction

A. Establishing a non demanding relationship A nonthreatening, non demanding relationship helps decrease the mistrust that is common in a client with paranoid schizophrenia. Encouraging involvement in group activities and spending more time with the client would be threatening for a client who is suspicious of other people's motives. This client is unlikely to initiate interaction; the nurse is responsible for initiating a relationship with the client.

Nursing preparation for a client undergoing electroconvulsive therapy (ECT) resemble those used for: A. General anesthesia B. Cardiac stress testing C. Neurologic examination D. Physical therapy

A. General anesthesia The nurse should prepare a client for ECT in a manner similar to that for general anesthesia.

A client with bipolar disorder is being treated with lithium for the first time. The nurse should observe the client for which common adverse effect of lithium? A. Polyuria B. Seizures C. Constipation D. Sexual dysfunction

A. Polyuria Polyuria commonly occurs early in the treatment with lithium and could result in fluid volume deficit.

A nurse is assessing a client who is currently taking perphenazine. Which of the following findings should the nurse identify as an extrapyramidal symptom (EPS)? Select all that apply A. Decrease in LOC B. Drooling C. Involuntary arm movements D. Urinary retention E. Continual pacing

B,C,E Drooling is an indication of pseudoparkinsonism, involuntary arm movements are an indication of tardive dyskinesia, and continual pacing is indicative of akathisia, which are all EPS.

A 32-year-old male graduate student, who has become increasingly withdrawn and neglectful of his work and personal hygiene, is brought to the psychiatric hospital by his parents. After detailed assessment, a diagnosis of schizophrenia is made. It is unlikely that the client will demonstrate: A. Low self-esteem B. Concrete thinking C. Effective self-boundaries D. Weak ego

C. Effective self-boundaries A person with this disorder would not have adequate self-boundaries.

A nurse is developing a care plan for a female client with post-traumatic stress disorder. Which of the following would she do initially? A. Instruct the client to use distraction techniques to cope with flashbacks. B. Encourage the client to put the past in proper perspective. C. Encourage the client to verbalize thoughts and feelings about the trauma. D. Avoid discussing the traumatic event with client.

C. Encourage the client to verbalize thoughts and feelings about the trauma. Planning care for a client with post-traumatic stress disorder would involve helping the client to verbalize thoughts and feelings about the trauma. This will help the client work through the strong emotions connected with the trauma and, therefore foster the belief that she is able to cope.

A client with depression has been hospitalized for treatment after taking a leave of absence from work. The client's employer expects the client to return to work following inpatient treatment. The client tells the nurse, "I'm no good. I'm a failure". According to cognitive theory, these statements reflect: A. Learned behavior B. Punitive superego and decreased self-esteem C. Faulty thought processes that govern behavior D. Evidence of difficult relationships in the work environment

C. Faulty thought processes that govern behavior The client is demonstrating faulty thought processes that are negative and that govern his behavior in his work situation - issues that are typically examined using a cognitive theory approach.

A client is experiencing anxiety attack. The most appropriate nursing intervention should include? A. Turning on the television B. Leaving the client alone C. Staying with the client and speaking in short sentences D. Ask the client to play with other clients

C. Staying with the client and speaking in short sentences Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.

Nurse John is aware that the therapy that has the highest success rate for people with phobias would be: A. Psychotherapy aimed at rearranging maladaptive thought process B. Psychoanalytical exploration of repressed conflicts of an earlier development phase C. Systematic desensitization using relaxation technique D. Insight therapy to determine the origin of the anxiety and fear

C. Systematic desensitization using relaxation technique The most successful therapy for people with phobias involves behavior modification techniques using desensitization.

Marco approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Alcoholics Anonymous (A.A.) C. Total abstinence D. Aversion Therapy

C:Total abstinence Total abstinence is the only effective treatment for alcoholism.

During electroconvulsive therapy (ECT) the client receives oxygen by mask via positive pressure ventilation. The nurse assisting with this procedure knows that positive pressure ventilation is necessary because? A. Anesthesia is administered during the procedure B. Decrease oxygen to the brain increases confusion and disorientation C. Grand mal seizure activity depresses respirations D. Muscle relaxations given to prevent injury during seizure activity depress respirations.

D. Muscle relaxations given to prevent injury during seizure activity depress respirations. A short-acting skeletal muscle relaxant such as succinylcholine (Anectine) is administered during this procedure to prevent injuries during seizure.

The nurse is aware that the symptoms that distinguish post-traumatic stress disorder from other anxiety disorder would be: A. Avoidance of situation & certain activities that resemble the stress B. Depression and a blunted affect when discussing the traumatic situation C. Lack of interest in family & others D. Re-experiencing the trauma in dreams or flashback

D. Re-experiencing the trauma in dreams or flashback Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post-traumatic stress disorder from other anxiety disorder.

To establish an open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should? A. Encourage the staff to have frequent interaction with the client B. Share an activity with the client C. Give client feedback on behavior D. Respect client's need for personal space

D. Respect client's need for personal space Moving to a client's personal space increases the feeling of threat, which increases anxiety.

Upon Sam's admission for acute psychiatric hospitalization, the nurse documents the following: Client refuses to bathe or dress, remains in room most of the day, speaks infrequently to peers or staff. Which nursing diagnosis would be the priority at this time? A. Anxiety B. Decisional conflict C. Self-care deficit D. Social isolation

D. Social isolation These behaviors indicate the client's withdrawal from others and possible fear or mistrust of relationships. Although the client refuses to bathe or dress, Self-care deficit would not be the priority nursing diagnosis in this situation.

A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nursemost likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium)

D. chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Naloxone (Narcan) is administered for narcotic overdose. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include: A. dilated pupils and slurred speech. B. rapid speech and agitation. C. dilated pupils and agitation. D. euphoria and constricted pupils.

D. euphoria and constricted pupils. Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.

Tony with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobia include: A. Severe anxiety and fear B. Withdrawal and failure to distinguish reality from fantasy C. Depression and weight loss D. Insomnia and inability to concentrate

A. Severe anxiety and fear Phobias cause severe anxiety (such as panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia and elevated B.P

The nurse is reviewing the laboratory report the client's lithium level prior to administration for 1700 hour doasage. The lithium level is 1.8 mEq/L. The nurse should: A. administer the 1700 dose B. hold the 1700 dose C. give the client 240 mL of water with the lithium D. give lithium after the client's supper.

B. hold the 1700 dose The nurse should hold the dose because 1.8 mEq/L can cause adverse reactions, including diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination, which are early signs of toxicity.

80-year-old Mr. Stevens is accompanied to the clinic by his son, who tells the nurse that the client's constant confusion, incontinence, and tendency to wander are intolerable. The client was diagnosed with chronic cognitive impairment disorder. Which nursing diagnosis is most appropriate for the client's son? A. Risk for other-directed violence B. Disturbed sleep pattern C. Caregiver role strain D. Social isolation

C. Caregiver role strain The son's description exemplifies some of the problems commonly encountered by a primary caregiver who is caring for someone with a cognitive impairment disorder.

A nurse is caring for a client with borderline personality disorder. The nurse enters the clients room and finds the client cutting into flesh with a paperclip. After providing first aid, which action should the nurse take first? A. Encourage the client to discuss feelings about self-injurious behavior in group. B. Fill out an incident report about the self-injurious behavior. C. Document behavior in the medical record D. Identify the clients feelings that led to self-injurious behavior

D. Identify the clients feelings that led to self-injurious behavior The nurse should use the priority setting framework of the nursing process. Therefore the first action the nurse should take is to assist the client to identify events or feelings that led to self-harm.

A 20-year-old client was diagnosed with dependent personality disorder. Which behavior is not most likely to be evidence of ineffective individual coping? A. Recurrent self-destructive behavior B. Avoiding relationship C. Showing interest in solitary activities D. Inability to make choices and decision without advise

D. Inability to make choices and decision without advise Individual with dependent personality disorder typically shows indecisiveness submissiveness and clinging behavior so that others will make decisions with them.

A student nurse was asked which of the following best describes dementia. A. Memory loss occurring as part of the natural consequence of aging B. Difficulty coping with physical and psychological change C. Severe cognitive impairment that occurs rapidly D. Loss of cognitive abilities, impairing ability to perform activities of daily living

D. Loss of cognitive abilities, impairing ability to perform activities of daily living The impaired ability to perform self-care is an important measure of a client's dementia progression and loss of cognitive abilities. Difficulty or impaired ability to perform normal activities of daily living, such as maintaining hygiene and grooming, toileting, making meals, and maintaining a household, are significant indications of dementia. Slowing of processes necessary for information retrieval is a normal consequence of aging.

Which therapeutic communication technique is being used in this nurse-client interaction? Client: "When I get angry, I get into a fistfight with my wife or I take it out on the kids." Nurse: "I notice that you are smiling as you talk about this physical violence." A. Encouraging comparison B. Exploring C. Formulating a plan of action D. Making observations

D. Making observations The nurse is using the therapeutic communication technique of making observations when noting that the client smiles when talking about physical violence. The technique of making observations encourages the client to compare personal perceptions with those of the nurse.