Mental Health Prep-U Questions

An adolescent is hospitalized with anorexia nervosa. The nurse enters the client's room and finds her doing sit-ups. The nurse should: A) Wait until she finishes and ask her why she feels the need to exercise. B) Remind her that if she loses weight, she will lose privileges. C) Ask her to stop doing the sit-ups and direct her to a quiet activity. D) Leave the room and allow her to exercise in private.

c (he primary goal with severe anorexia is to promote weight gain and stop starvation. This involves actively monitoring and interrupting undesirable behaviors, such as exercise, even against the client's protests. Waiting for the client to finish exercising may be polite but exacerbates weight loss as more calories are burned. Threatening future loss of privileges does not motivate a client who is in the middle of a compulsion. Active intervention is required to prevent continued weight loss)

A client with a diagnosis of avoidant personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: A) Unpredictable behavior and intense interpersonal relationships. B) Inability to function as a responsible parent. C) Somatic symptoms. D) Coldness, detachment, and lack of tender feelings.

c (somatic symptoms)

The nurse in a mental health clinic is conducting group therapy. The nurse leads the clients into the working phase of the group therapy. During this phase, which of the following is the most important strategy for the nurse to use to facilitate progress with the clients? A) Encourage group cohesiveness. B) Explain the purpose and goals of the group. C) Offer advice to help resolve conflicts. D) Discuss feelings of loss regarding termination.

a (During the working phase (middle phase) of a group, the nurse continues to encourage cohesiveness among its members. During the orientation phase (initial phase), the nurse leading the group should explain the purpose and goals of the group. During the termination phase (final phase), the leader encourages a discussion of feelings associated with termination. When leading a group, the nurse should act as facilitator; offering advice isn't appropriate. The group members should work together to resolve conflicts)

The client, who is a veteran and has posttraumatic stress disorder, tells the nurse about the horror and mass destruction of war. He states, "I killed all of those people for nothing." Which response by the nurse is appropriate? A) "You did what you had to do at that time." B) "Maybe you did not kill as many people as you think." C) "How many people did you kill?" D) "War is a terrible thing."

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

The nurse is collecting data to determine whether a client is experiencing dementia or depression. Which findings indicate dementia? (Select all that apply): A) The progression of symptoms is slow. B) The client answers questions with, "I don't know." C) The client acts apathetic and pessimistic. D) The family cannot identify when symptoms first appeared. E) The client's basic personality has changed. F) The client has great difficulty paying attention to others.

a, d, e, & f

The client with mania is skipping up and down the hallway, nearly running into other clients. The nurse should include which activity in the client's plan of care? A) Leading a group activity B) Watching television C) Reading the newspaper D) Cleaning the dayroom tables

d

A well-known client suffers a psychotic break and is admitted to the psychiatric unit. A large group of reporters with cameras is camped out in the hospital parking lot. As a nurse walks to the employee parking after her shift, a reporter asks if she knows anything about the client's condition. What is the most appropriate response? A) "I didn't have an opportunity to assess this client." B) "All I can say is that the client is safe and stable." C) "Get away from me and don't take any pictures." D) "I can't answer your question."

d ("I can't answer your question")

A painter who recently fractured his tibia worries about his finances because he can't work. To treat his anxiety, his physician orders buspirone, 5 mg by mouth three times per day. Which drugs interact with buspirone? A) Beta-adrenergic blockers B) Antineoplastic drugs C) Antiparkinsonian drugs D) Monoamine oxidase (MAO) inhibitors

d (Buspirone interacts only with MAO inhibitors, producing a hypertensive reaction. Administration of beta-adrenergic blockers, antineoplastic drugs, or antiparkinsonian drugs wouldn't cause an interaction, so they can be administered simultaneously with buspirone)

A client taking paroxetine 40 mg PO every morning tells the nurse that her mouth "feels like cotton." Which statement by the client necessitates further assessment by the nurse? A) "I am sucking on ice chips." B) "I am using sugarless gum." C) "I am sucking on sugarless candy." D) "I am drinking 12 glasses of water every day."

d (Dry mouth is a common, temporary side effect of paroxetine. The nurse needs to further assess the client's water intake when the client states she is drinking lots of water. Excessive intake of water could be harmful to the client and could lead to electrolyte imbalance. Dry mouth is caused by the medication, and drinking a lot of water will not eliminate it. Sucking on ice chips or using sugarless gum or candy is appropriate to ease the discomfort of dry mouth associated with paroxetine)

A client with schizophrenia hears a voice telling him that he is evil and must die. The nurse understands that this client is experiencing: A) Delusion. B) Flight of ideas. C) Ideas of reference. D) A hallucination.

d (a hallucination)

A client is being admitted to the hospital following an inadvertent overdose with oxycodone. He reveals that he has chronic back pain that resulted from an injury on a construction site. He states, "I know I took too much oxycodone at once, but I cannot live with this pain without them. You cannot take them away from me." Which response by the nurse is most appropriate? A) "Once you are tapered off the oxyocodone, you will find that non-addictive pain medicines will be enough to control your pain." B) "You are going to be switched from the oxyocodone to methadone for long-term pain management. C) The oxyocodone will be stopped tomorrow, but you will have lorazepam to help you with the withdrawal symptoms. D) Your pain will be controlled by tapering doses of oxyocodone with other pain management strategies and medicines.

d (tapering doses of oxycodone, pain management strategies, and other pain control medicines are found to be the most helpful with opiate addictions resulting from chronic pain. Nonaddictive (over-the-counter) medicines alone are generally insufficient for chronic pain management. Methadone is an addictive opioid that involves substituting one addiction with another, so now clients are being detoxed off methadone as well. Lorazepam may help with anxiety during withdrawal from opiates, but it does not control the other symptoms of opiate withdrawal)

The client with a diagnosis of posttraumatic stress disorder tells the nurse he wishes that he had been on the airplane that crashed and killed his wife and children a month ago. The nurse assesses the client's statement to be an example of which symptom? A) Suicidal ideation B) Survivor guilt C) Dysfunctional grieving D) Numbing of responsiveness

b (With posttraumatic stress disorder, the client experiences survivor guilt or feelings of guilt related to being alive)

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? A) Hepatitis B) Infection C) Granulocytopenia D) Systemic dermatitis

c (Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly. Hepatitis, infection, and systemic dermatitis aren't adverse reactions to clozapine therapy)

The nurse is planning care for a client who has been experiencing a manic episode for 6 days and is unable to sit still long enough to eat meals. Which choice will best meet the client's nutritional needs at this time A) Offer a green salad topped with chicken pieces. B) Offer a bowl of vegetable soup. C) Offer a peanut butter sandwich D) Offer to have the family bring in favorite foods.

c (Giving the client finger foods that have protein, carbohydrates, and calories supplies energy and allows the client to eat while on the move. A salad or soup is very difficult for the client to eat while moving and may not supply the nutrients needed. Favorite foods from home may or may not be appropriate to eat while walking)

The basis for building a strong, therapeutic nurse-client relationship begins with a nurse's: A) Sincere desire to help others. B) Acceptance of others. C) Self-awareness and understanding. D) Sound knowledge of psychiatric nursing.

c (The nurse must be aware of herself and understand personal feelings before she can understand and help others. Although wanting to help others, accepting others, and being knowledgeable of psychiatric nursing are desirable traits, self-awareness and understanding are the basis of a therapeutic nurse-client relationship)

In group therapy, a client angrily speaks up and responds to a peer, "You're always whining, and I'm getting tired of listening to you! Here is the world's smallest violin playing for you." Which role is the client playing? A) Blocker B) Monopolizer C) Recognition seeker D) Aggressor

d (The aggressor is negative and hostile and uses sarcasm to degrade others. The role of the blocker is to resist group efforts. The monopolizer controls the group by dominating conversations. The recognition seeker talks about accomplishments to gain attention)

The nurse interviews the family of a client who is hospitalized with severe depression and suicidal ideation. Which family assessment information is essential to formulating an effective plan of care? Select all that apply. A) Client's experience with physical pain B) Personal responsibilities C) Employment skills D) Communication patterns E) Role expectations F) Current family stressors

d, e, & f (When working with the family of a depressed client, it is helpful for the nurse to be aware of the family's communication style, the role expectation for its members, and current family stressors. This information can help to identify difficulties and teaching points that could benefit the client and the family. Information concerning physical pain, personal responsibilities, and employment skills would not be helpful, because these areas are not directly related to their experience of having a family member with depression)

A client has been receiving chlorpromazine, an antipsychotic, to treat his psychosis. Which findings should alert the nurse that the client is experiencing pseudoparkinsonism? A) Tremors, shuffling gait, and masklike face B) Restlessness, difficulty sitting still, and pacing C) Involuntary rolling of the eyes D) Extremity and neck spasms, facial grimacing, and jerky movements

a (Tremors, shuffling gait, and mask-like face)

In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using? A) Denial B) Identification C) Compensation D) Rationalization

a (A client who states that he doesn't have a drug problem and can quit using drugs at any time — despite evidence to the contrary — is denying drug addiction. Identification is a defense mechanism in which an individual unconsciously assumes the mannerisms of another person or group. In compensation, the client emphasizes positive attributes to compensate for negative ones. In rationalization, the client uses faulty logic to justify his behaviors)

Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? A) Evaluate the client for voluntary admission to a mental health facility. B) Discuss what the family can do to chemically restrain the client at home. C) Tell the parents that the client's behavior releases them from the duty of care. D) Arrange for respite care; family members could be aggravating the client's condition.

a (A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical restraints would violate the client's rights to freedom from the use of restraints and seclusion. The duty of care is a legal concept that applies only to the nurse-client relationship, not to family relationships. Respite care isn't an appropriate recommendation at this time. The nurse must address the safety issue and institute effective treatment and care. At a later time, it would be prudent for the nurse to talk with the client's family about caregiver burden and the option of using respite care)

As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They will see you!" Which response by the nurse would be best? A) "Who are 'they'?" B) "No one will see me." C) "You have no reason to be afraid." D) "What will happen if they do see me?"

a (Asking the client who "they" are when he is fearful helps the nurse understand his behavior and is least demanding of the client. The client is unlikely to accept statements that indicate that no one will see the nurse. The client is unlikely to accept statements that there is no reason to be afraid. Asking the client what will happen if someone sees the nurse is also unlikely to be acceptable and validates the client's delusion)

A client struggling with a binge eating disorder tells a nurse, "I don't know why I eat the way I do each night." What question would be most helpful for the nurse to ask this client? A) "What do you do when you feel stressed or upset?" B) "Do you worry that bad things will happen to you?" C) "Are there periods of time at night that you can't account for?" D) "Have you experienced changes in your leisure activities?"

a (Asking what the client does when he feels stressed or upset is appropriate because clients with binge eating disorder commonly use eating as a distraction from unpleasant or negative feelings. Asking if a client worries that bad things will happen to him indirectly asks about his anxiety. Such a question doesn't focus on exploring the client's statement. A nurse should use a question related to being unable to account for elapsed periods of time to assess a dissociative identity disorder. Asking about a change in the client's leisure activities doesn't relate to the client's statement. This question could apply to any psychiatric disorder that alters the client's lifestyle)

A nurse is assigned to care for a recently admitted client who has attempted suicide. What should the nurse do? A) Search the client's belongings and his room carefully for items that could be used to attempt suicide. B) Express trust that the client won't harm himself while in the facility. C) Respect the client's privacy by not searching his belongings. D) Remind all staff members to check on the client frequently.

a (Because a client who has attempted suicide could try again, the nurse should search his belongings and his room to remove any items that could be used in another suicide attempt. Expressing trust that the client won't cause harm to himself may increase the client's feelings of guilt and pain if he can't live up to that trust. The nurse should search the client's belongings because the need to maintain a safe environment supersedes the client's right to privacy. Although frequent checks by staff members are helpful, they aren't enough. The client may attempt suicide between checks)

A 40-year-old client is admitted for a surgical biopsy of a suspicious lump in her left breast. When the nurse arrives to take the client to surgery, she is tearfully completing a letter to her two children. She tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic? A) "In case anything goes wrong? What are your thoughts and feelings right now?" B) "I can understand that you're nervous, but this really is a minor procedure. You'll be back in your room before you know it." C) "Try to take a few deep breaths and relax. I have some medication that will help." D) "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours."

a (By acknowledging how the client feels, this response encourages the client to say more about what she is thinking and feeling. Minimizing the client's feelings or offering empty reassurances isn't therapeutic or helpful. Deep breathing and preoperative medication would be appropriate only after the client has expressed her fears and dealt with them)

During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I am so worried about my daughter. I am afraid to leave her alone in the house. What if something should happen while I am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care? A) Caregiver role strain B) Anxiety C) Fear D) Disturbed sleep pattern

a (Caregiver role strain)

A client recently admitted to the hospital with sharp, substernal chest pain suddenly reports palpitations. The client ultimately admits to using cocaine 1 hour before admission. The nurse should immediately assess the client's: A) Pulse rate and character. B) Level of consciousness. C) Neurobehavioral functioning. D) Anxiety level.

a (Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites. Consequently, the drug is likely to cause tachyarrhythmias. Although neurobehavioral deficits are common in neonates born to cocaine users, these deficits are rare in adults. As craving for the drug increases, a person who's addicted to cocaine typically experiences euphoria followed by depression, not anxiety)

A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do his laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on: A) Consistently enforcing unit rules and facility policy. B) Isolating the client to decrease contact with easily manipulated clients. C) Engaging in power struggles with the client to minimize manipulative behavior. D) Using behavior modification to decrease negative behavior by using negative reinforcement.

a (Firmness and consistency regarding rules are the hallmarks of a care plan for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and client manipulation)

During an insight group on a mental health unit, a client is demanding attention, interrupting others, and talking most of the time. What would be the best response by the nurse? A) "I invite you to summarize your point briefly so that we can then hear from others." B) "I imagine I speak for the group when I say I am frustrated with your behavior." C) "I'm going to ignore your behavior and allow others to speak." D) "I find your behavior drains the group."

a (Inviting the client to summarize assists in refocusing and making a point, and acknowledges that others require time for the group as well. Ignoring the behavior does not facilitate group communication and process. The other options are judgmental and focus more on the client's opinions than on the group process)

As the nurse helps the client prepare for discharge, the client says, "You know, I have been in lots of hospitals, and I know when I am sick enough to be there. I am not that sick now. You do not need to worry about me." What would be the most therapeutic response by the nurse? A) "We are concerned about you. How can we help you before you leave?" B) "We could have helped you more if you had told us more." C) "Is there any information you need before you leave the hospital?" D) "Okay, you know what you need better than I do."

a (It is most therapeutic to let the client know of the staff's continued concern and to ask her what might be useful to her. Making the point that she did not use the hospital well is not therapeutic on discharge. Asking if the client needs any information is certainly helpful but is not as therapeutic as demonstrating concern and offering help. Stating that the client knows what she needs better than the nurse does dismisses the client and does not foster further interaction with the nurse about any additional concerns)

The nurse hands the medication cup to a client who is psychotic and exhibiting concrete thinking, and tells the client to take his medicine. The client takes the cup, holds it in his hand, and stares at it. What should the nurse do next? A) Tell the client to put the medicine in his mouth and swallow it with some water. B) Instruct the client to sit in the dayroom and wait for the nurse to assist him. C) Ask another staff member to stay with the client until he takes the medication. D) Say nothing and wait for the client to put the medication in his mouth and swallow it.

a (The nurse instructs the client clearly and directly to put the medication in the mouth and then to swallow it with some water. Clear, step-by-step directions assist the client to process what the nurse is saying. Telling the client to sit in the dayroom and wait, asking another staff member to stay with the client, or saying nothing is not helpful)

During an appointment with the nurse, a client says, "I could hate God for that flood." The nurse responds, "Oh, do not feel that way. We are making progress in these sessions." The nurse's statement demonstrates a failure to do what? A) Look for meaning in what the client says. B) Explain to the client why he may think as he does. C) Add to the strength of the client's support system. D) Give the client credit for solving his own problems.

a (The nurse's response fails to identify the meaning in what the client has said. The nurse needs to explore the client's statement about hating God for that flood because the meaning of the client's statement is unclear. Also, clichés such as, "Do not feel that way," are not helpful because they ignore the client's feelings and his interpretation of the situation in which he finds himself. Explaining to the client why he may think as he does (offering a rationale) is inappropriate. The nurse's response fails to identify the meaning in what the client has said and is not supportive. There is no evidence that the client is solving his problems)

A nurse admits a client with a preliminary diagnosis of acute stress disorder to the mental health unit. Which assessment requires the nurse's immediate action? A) The client states she has a desire to not live anymore B) The client was not given the opportunity to talk. C) There are bruises on the client's body. D) The client reports not eating or sleeping for 2 days.

a (The presence of suicidal thinking warrants the highest priority of care. The nurse must now determine the client's level of suicide risk by asking if she or he has a plan and the means to follow through with the plan. Although the bruises on the client's body are suspicious and definitely warrant further questioning, the nurse should focus on the client's immediate safety needs in regard to the suicide risk. The nurse will interview the client alone since the client was not given the opportunity to talk. This is commonly seen in abuse situations, but it is not the the priority at this time. The client's report of not eating or sleeping is consistent with the diagnosis; this issue isn't an immediate concern. Client safety is always the care priority)

Which principle of the psychoanalytic model is particularly useful to psychiatric nurses? A) All behavior has meaning. B) Behavior that is reinforced will be perpetuated. C) The first 6 years of a person's life determine personality. D) Behavioral deviations result from an incongruence between verbal and nonverbal communication.

a (The principle that all behavior has meaning is of particular importance to the psychiatric nurse. It serves as the basis for the nurse's assessment and analysis of the client's behavior, which reflects the client's needs. Psychoanalytic theory also proposes that the first 6 years of a person's life determine personality; these early influences are difficult, if not impossible, to counteract. However, this assumption is less useful to the nurse in planning interventions that meet the client's current needs. Reinforcement as a means of perpetuating behavior is associated with behavioral theory — not the psychoanalytic model. Incongruence between verbal and nonverbal communications is an element of communications theory)

The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The healthcare provider prescribes tranylcypromine sulfate because the client did not respond positively to a tricyclic antidepressant. If the client's diet includes foods containing tyramine, the nurse should teach the client about which possible reaction? A) Hypertensive crisis B) Heart block C) Generalized tonic-clonic seizure D) Respiratory arrest

a (Tranylcypromine sulfate is a monoamine oxidase (MAO) inhibitor. A client taking this drug in combination with foods or beverages rich in tyramine can have a hypertensive crisis. Tyramine, a precursor to norepinephrine, is usually deactivated in the GI tract, but MAO inhibitors block the deactivation. Tyramine is then absorbed systemically, causing a sudden release of large amounts of norepinephrine)

The nurse is meeting weekly with an adolescent recently diagnosed with depression to monitor progress with therapy and antidepressant medication. The nurse should be most concerned when the client reports what information? A) An acquaintance hanged herself two days ago. B) She is experiencing intermittent headaches as a side effect of taking the antidepressant. C) She received a low score on her last history test. D) Her younger brother has been starting fights with her for the last week.

a (While all the occurrences could upset the client in the early stage of treatment, the one involving the most risk to safety is the suicide completion of a peer. Adolescents are susceptible to "copycat" suicides. The fact that she knows the method of suicide of the acquaintance and is at a critical period in treatment, when her antidepressant may have given her increased energy while still experiencing low self-esteem, can put her at significant risk for suicide)

A client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: A) Unpredictable behavior and intense interpersonal relationships. B) Inability to function as a responsible parent. C) Somatic symptoms. D) Coldness, detachment, and lack of tender feelings.

a (client with borderline personality disorder displays a pervasive pattern of unpredictable behavior, mood, and self-image. His interpersonal relationships may be intense and unstable, and his behavior may be inappropriate and impulsive)

A client with schizophrenia is withdrawn and suspicious of others, and projects blame. The client's behavior reflects problems in which stage of development as identified by Erikson? A) Trust versus mistrust B) Autonomy versus shame and doubt C) Initiative versus guilt D) Intimacy versus isolation

a (the client who is withdrawn, is suspicious, and projects blame is exhibiting problems in trust versus mistrust. Shame and doubt would be reflected as low self-esteem and suspiciousness. Guilt would be reflected in self-blame for all problems. Isolation would be reflected in a lack of long-term relationships)

A client with a diagnosis of schizophrenia is admitted to the inpatient unit of the mental health center. He's shouting that the government of France is trying to assassinate him. Which response is most appropriate? A) "I think you're wrong. France is a friendly country. The French government wouldn't try to kill you." B) "I don't see evidence that a foreign government or anyone else is trying to hurt you. You must feel frightened by this." C) "You're wrong. Nobody is trying to kill you." D) "A foreign government is trying to kill you? Please tell me more about it."

b

The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which statement by the mother indicates that she understands her daughter's illness and management? A) "I know that I will have to do everything for my daughter when she comes home." B) "Tasks as simple as getting out of bed and showering in the morning may be difficult for her." C) "I know that visits from her friends at home should be discouraged for a while." D) "She will not experience a relapse as long as she takes her prescribed medication."

b ("Tasks as simple as getting out of bed and showering in the morning may be difficult for her.")

A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse? A) "With whom do you want to do things?" B) "What activities did you enjoy in the past?" C) "What kind of transportation do you use?" D) "How much money can you spend?"

b ("What activities did you enjoy in the past?")

A client with early dementia exhibits disturbances in mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which other area? A) Speech B) Judgment C) Endurance D) Balance

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

A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first? A) Place the client in a chair with a waist restraint. B) Provide one-to-one supervision of the client until detoxification treatment can begin. C) Ask the client to sit in a chair next to the nurses' station. D) Decrease stimuli by putting the client in bed with the room door closed.

b (One-to-one supervision provides safety until appropriate detoxification can be given. Restraints are the last intervention after less restrictive alternatives have been tried. It is unlikely that the client can cooperate with staying in a chair. Putting the client in bed in his room puts him at risk for falling and a closed door prevents close observation)

A client is disruptive to other clients and constantly walks about the unit interrupting others. Which plan should the nurse institute first? A) Escort the client to his room and explain that he cannot come out until he gets permission. B) Set limits on the client's behavior; explain what is expected and what the consequences will be if limits are violated. C) Ask another staff member to take the client to watch television for the next hour. D) Bargain with the client; explain which privileges he can attain if he can control his behavior.

b (Setting limits on behavior and explaining consequences if the limits are violated informs the client about unacceptable behaviors and encourages him to take responsibility for his actions. Taking the client to his room and telling him that he can come out when permitted does not teach him acceptable behavior, give him the opportunity to accept responsibility for himself, or clearly define the consequences of the inability to control himself. Asking a staff member to take the client to watch television is not appropriate because, in addition to the above, the client most likely cannot sit for an hour. The television also may be too stimulating. The nurse should never bargain or argue with a client. Rather, the nurse states what the limits are, what is expected, and what will occur if limits are not observed)

Which statement about the initial care of a suspected abuse victim, when documented on the chart, would be most helpful for others when caring for the client? A) "States that she is not employed outside the home." B) "Seems fearful to discuss how bruises on her body had been caused." C) "Asks that her husband not be called at work, stating that he is very busy." D) "Refuses a follow-up appointment, stating that she does not have time."

b (Stating that a client seems fearful to discuss what caused the bruises on her body is most helpful. A victim of partner abuse tends to conceal her victimization because disclosure could be met with denial; minimization by her partner, friends, and relatives; and increased abuse by her partner)

A client with borderline personality disorder tells a nurse, "You're the only nurse who really understands me. The others are mean." The client then asks the nurse for an extra dose of anti-anxiety medication because of increased anxiety. How should the nurse respond? A) "You will have to talk with your physician." B) "I'll have to discuss your request with the team. Let's talk about how you're feeling." C) "I don't want to hear you say negative things about the other nurses." D) "You know you can't have extra medication in your plan of care."

b (Telling the client that it is important for him/her to talk about how he/she is feeling is an appropriate response, as it focuses on the emotional content of the client's message and helps the client identify his/her feelings. Focusing on the request for extra medication would allow the client to ignore the underlying emotional issues. Clients with borderline personality disorder commonly split the staff into "good guys" and "bad guys" to meet their needs; staff members must maintain consistency and a united front at all times. The nurse should not take the client's statements personally, as doing so would interfere with the nurse's ability to maintain a therapeutic relationship)

The nurse is caring for a 15-year-old client with anorexia nervosa and a body mass index (BMI) of 17. Which statement made by the client, would indicate to the nurse that the North America Nursing Diagnosis Association (NANDA) diagnosis or patient priority of Body image altered is appropriate? A) "Skinny is the best body type." B) "I'm too ugly and fat." C) "I like being a small size." D) "I do not want to gain weight."

b (The NANDA diagnosis of Body image altered is defined as the confusion in the mental picture of one's physical self. This is consistent with the patient priority linking body image with the client diagnosis. The client with a BMI of 17 is underweight, but the client sees herself as fat and ugly. The other three responses do not fit the NANDA diagnosis/patient priority because they project a positive image)

A nurse is counselling a client at a crisis center after her house burned down and her daughter was killed. Which action by the nurse is a priority? A) To solve the client's problems for her B) To assist in psychological resolution of the immediate crisis C) To establish a basis for long-term therapy D) To provide a basis for admission to an acute care facility

b (The goal of crisis intervention is to resolve the immediate problem. The client must learn to resolve her own issues. Although some clients do enter long-term therapy or are admitted to an acute care facility, long-term therapy is not the goal of crisis intervention)

A client with depression is ready for discharge from the hospital and tells the nurse, "It would be good for me if we could meet for coffee if I start feeling down again." Which of the following statements indicates that the nurse understands the boundaries of the therapeutic relationship? A) "That would be fine as long as we go to a public place. Where would you like to meet?" B) "Before you leave the hospital, I will make sure you have information about the crisis center." C) "We could go to the gym together. Exercise can be very therapeutic for clients with depression." D) "I often meet with people after they are discharged. Sometimes it is difficult to deal with situations after you leave the hospital."

b (The nurse realizes that meeting for coffee would cross the boundaries of the therapeutic relationship and would not be consistent with promoting health and wellness. Providing the number for a crisis center to contact is an example of promoting a healthy strategy that the client can use if symptoms of depression develop again. The other options do not describe actions that would be consistent with the therapeutic nurse--client relationship)

While pacing in the hall, a client with schizophrenia runs to a nurse and asks, "Why are you poisoning me? I know you work for Central Thought Control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? A) "I'm a nurse. I'm not poisoning you. That would be a violation of the nursing code of ethics." B) "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." C) "I'm not poisoning you. And how could I possibly steal your soul?" D) "I sense anger. Are you feeling angry today?"

b (The nurse should directly orient a delusional client to reality, especially to place and person. Denying poisoning and offering delusion-related information may encourage further delusions related to the delusion. Validating the client's feelings occurs during a later stage in the therapeutic process)

A client diagnosed with major depression spends most of the day lying in bed with the sheet pulled over his head. Which approach by the nurse is most therapeutic? A) Wait for the client to begin the conversation. B) Initiate contact with the client frequently. C) Sit outside the client's room. D) Question the client until he responds.

b (The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client's self-esteem. The nurse's action conveys acceptance of the client as a worthwhile person and provides some structure to the seemingly monotonous day. Waiting for the client to begin the conversation with the nurse is not helpful because the depressed client resists interaction and involvement with others. Sitting outside of the client's room is not productive and not necessary in this situation. If the client were actively suicidal, then a one-on-one client-to-staff assignment would be necessary. Questioning the client until he responds would overwhelm him because he could not meet the nurse's expectations to interact)

A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. When assessing the client on admission, the nurse should first ask the client: A) How he sleeps at night. B) If he is thinking about hurting himself. C) About recent stresses. D) How he feels about himself.

b (The nurse's highest priority is to ask the client if he is thinking about hurting himself or to assess for suicide. Questioning the client about his sleep pattern, about recent stresses, and about his feelings regarding himself are all important areas of assessment for the depressed client, but they are not as immediate a priority as assessing the risk for suicide)

After the nurse teaches a client with bipolar disorder about lithium therapy, which client statement indicates the need for additional teaching? A) "It is important to keep using a regular amount of salt in my diet." B) "It is okay to double my next dose of lithium if I forget a dose." C) "I should drink about 8 to 10 eight-ounce glasses (240 mL) of water each day." D) "I need to take my medicine at the same time each day."

b (The therapeutic and toxic range of lithium is very narrow. If the client forgets to take a scheduled dose of lithium, the client needs to wait until the next scheduled time to take it because taking twice the amount of lithium can cause lithium toxicity. The client needs to maintain a regular diet and regular salt intake. Lithium and sodium are eliminated from the body through the kidneys. An increase in salt intake leads to decreased plasma lithium levels because lithium is excreted more rapidly. A decrease in salt intake leads to increased plasma lithium levels. The client needs to drink 8 to 10 eight-ounce (240 mL) glasses of water daily to maintain fluid balance and decrease thirst. Decreased water intake can lead to an increase in the lithium level and consequently a risk of toxicity. Lithium must be taken on a regular basis at the same time each day to ensure maximum therapeutic effect)

The nurse is teaching a group of unlicensed assistive personnel (UAP) about providing care to clients with depression. Which approach by one of the UAPs indicates an understanding of the most effective approach to a depressed client? A) Cheerful B) Empathetic C) Serious D) Humorous

b (To care effectively for clients with depression, the nurse should teach the importance of demonstrating empathetic concern. Caregivers must accept clients as they are even though many will be angry and negative, acknowledge their emotional pain, and offer to help them work through their pain. For the client who is depressed, using a cheerful demeanor or a humorous, light-hearted approach may be overwhelming because the client will be unable to meet the caregiver's expectations, subsequently leading to decreased self-worth. A serious, business-like affect may threaten the client and inhibit the development of trust)

Which nursing intervention is most appropriate if a client develops orthostatic hypotension while taking amitriptyline hydrochloride? A) Consulting the physician about substituting a different type of antidepressant B) Advising the client to sit up for 1 minute before getting out of bed C) Instructing the client to halve the dosage until the problem resolves D) Informing the client that this adverse reaction should disappear within 1 week

b (To minimize the effects of amitriptyline-induced orthostatic hypotension, the nurse should advise the client to sit up for 1 minute before getting out of bed. Orthostatic hypotension commonly occurs with tricyclic antidepressant therapy. In these cases, the physician may decrease the dosage or order nortriptyline, another tricyclic antidepressant. It isn't appropriate for the nurse to change the dosage without discussing it with the physician. Orthostatic hypotension disappears only when the drug is discontinued)

A client with a diagnosis of antisocial personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: A) Unpredictable behavior and intense interpersonal relationships. B) Inability to function as a responsible parent. C) Somatic symptoms. D) Coldness, detachment, and lack of tender feelings.

b (inability to function as a responsible parent)

A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride p.o qid. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take? A) Give the client his next dose of fluphenazine, call the physician, and monitor the client's vital signs. B) Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. C) Give the client his next dose of fluphenazine and restrict him to his room to decrease stimulation. D) Withhold the client's next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.

b (withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs)

A nurse is caring for a client with borderline personality disorder. Which interventions are appropriate for clients with this disorder? (Select all that apply): A) Providing antianxiety medications. B) Providing emotional consistency. C) Exploring anger in appropriate ways. D) Encouraging independence as soon as possible. E) Promoting gradual separation and individuation. F) Ensuring the client's safety.

b, c, e, & f (In clients with borderline personalities, the primary goal is to ensure a safe environment. As the client begins to learn how to manage his/her behavior, suicide still remains a risk. A key intervention includes providing emotional support that is consistent. The client needs to learn how to manage anger effectively and typically begins needing less support as he/she separates and develops individual coping behaviors. Antianxiety drugs are reserved for clinical emergencies)

A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. A behavior contract is planned. To promote client compliance the nurse should anticipate that the contract will be written: A) By the nurse alone. B) By the client alone. C) Jointly by the client and the nurse. D) Jointly by the physician and the nurse.

c (A contract written jointly by the client and the nurse most successfully promotes cooperation and consistent behavior. The most effective contract — and the type least likely to allow for manipulation and misinterpretation — describes the behavioral terms as concretely as possible. A contract written solely by the client may not be acceptable to staff members; one written by the physician and the nurse may not be acceptable to the client)

The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining a this client? A) Reviewing facility policy regarding how long the client may be restrained B) Preparing an as-needed dose of the client's psychotropic medication C) Checking that the restraints have been applied correctly D) Asking if the client needs to use the bathroom or is thirsty

c (A nurse must determine whether the restraints have been applied correctly to make sure that the client's circulation and respiration are not restricted, and that adequate padding has been used. The nurse should document the client's response and status carefully after the restraints are applied. All staff members involved in restraining clients should be aware of facility policy before using restraints. If an as-needed medication is ordered, it should be administered before the restraints are in place and with the assistance of other team members. The nurse should attend to the client's elimination and hydration needs after the client is properly restrained)

A client states the following to the nurse: "I am a failure, and I wish I had died." Which of the following statements by the nurse demonstrates a therapeutic response? A) "I think you have had many successes in your life and you should focus on them." B) "You are depressed right now, so feeling like a failure is a normal manifestation." C) "You feel like a failure; would you like to talk more about the way you feel?" D) "I am glad to hear you speak about your feelings and I am glad you did not die."

c (Acknowledging the client's feelings by repeating what the client states is therapeutic. It is also therapeutic for the nurse to offer to discuss the client's feelings further. The other options are incorrect because they dismiss the client's feelings)

The nurse is aware that further teaching is needed for a client receiving alprazolam by the following statement? A) "I should avoid drinking grapefruit juice during therapy." B) "Someone else will need to drive for me." C) "If I drink early, having of couple glasses of wine should be fine." D) "Prolonged use may cause dependence."

c (Alprazolam should be avoided with mind altering substances, alcohol, narcotic, or depressants because a side effect of alprazolam is drowsiness. Prolonged use will cause dependency. Grapefruit juice will alter how the medication is absorbed)

A nurse is planning interventions for a victim of physical abuse. On what principle should the nurse base the plan? A) A woman in crisis is unlikely to be receptive to professional help. B) The client generally can control the batterer. C) Assessing the client's level of danger is a prerequisite to intervention. D) The victim will want to leave the abuser immediately.

c (Assessing the client's level of danger is extremely important. The client and the children may be in serious danger if the perpetrator has threatened to kill them if they leave. Such an assessment is a prerequisite to intervention, which usually requires a multidisciplinary approach. A woman is more open to change and more receptive to professional intervention during a crisis. At other times, it is easier for her to deny the problems and maintain usual patterns of interaction. The client cannot control the batterer. She can only control her responses to the batterer and to the situation. The victim of abuse cannot be persuaded, rushed, or coerced into leaving the abuser before she is ready. This is often difficult for health care providers to understand)

A client with a diagnosis of bipolar disorder is energetic, impulsive, and verbalizes loudly in the community room. To prevent injury while complying with the principle of the least-restrictive environment, which action should the nurse take to prevent escalation of the client's mood? A) Place the client in seclusion with the door open. B) Obtain a court mandate for a higher level of treatment. C) Try to channel the client's energy into appropriate activities. D) Monitor the client for escalation of manipulative behavior.

c (Constructive activities, such as painting, are a positive way to prevent inappropriate or destructive use of the client's excessive energy. Placing the client in seclusion with the door open allows the client to leave the seclusion room; this action doesn't comply with the principle of providing the least-restrictive environment. It isn't appropriate for the nurse to obtain a court order for a higher level of treatment. Monitoring the client's behavior isn't as effective as intervening before a crisis occurs)

A nurse is preparing for the discharge of a client who has been hospitalized for schizophrenia. The client's husband expresses concern over whether his wife will continue to take her daily ordered medication. The nurse should inform him that: A) His concern is valid, but his wife is an adult and has the right to make her own decisions. B) He can easily mix the medication in his wife's food if she stops taking it. C) His wife can be given a long-acting medication that is administered every 1 to 4 weeks. D) His wife knows she must take her medication as ordered to avoid future hospitalizations.

c (His wife can be given a long-acting medication that is administered every 1 to 4 weeks)

A client with schizophrenia started risperidone 2 weeks ago. Today, he tells the nurse he feels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: A) The flu. B) Malignant hyperthermia. C) Neuroleptic malignant syndrome. D) Septicemia.

c (Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to an antipsychotic or neuroleptic. The cardinal symptom is a high temperature. Other commonly observed symptoms include altered mental status and autonomic dysfunction. Although fever may be present with the flu, it doesn't normally cause altered mental status or autonomic dysfunction. Malignant hyperthermia is a complication associated with general anesthesia. These findings don't suggest the client has septicemia. Findings in septicemia include severe hypotension, fever, tachycardia, and a history of a recent infection)

A woman has become increasingly afraid to ride in elevators. While in an elevator one morning, she experiences shortness of breath, palpitations, dizziness, and trembling. A physician can find no physiological basis for these symptoms and refers her to a psychiatric clinical nurse specialist for outpatient counselling sessions. Which type of therapy is most likely to reduce the client's anxiety level? A) Psychoanalytically oriented psychotherapy B) Group psychotherapy C) Systematic desensitization D) Referral for evaluation for electroconvulsive therapy

c (Phobias are commonly viewed as learned responses to anxiety that can be unlearned through certain techniques such as behavior modification. Systematic desensitization, a form of behavior modification, attempts to reduce anxiety, and thereby eradicate the phobia, through gradual exposure to anxiety-producing stimuli. Psychoanalytically oriented therapy also may be effective in this situation, but years of treatment are required to achieve results. Group psychotherapy could be used as an adjunct treatment to increase the client's self-esteem and reduce generalized anxiety. Electroconvulsive therapy is reserved primarily for clients with severe depression or psychosis who respond poorly to other treatments; it's rarely indicated for phobic disorders)

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? A) Cancer of any kind B) Impaired hearing C) Prescription drug intoxication D) Heart failure

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

Which statement by a client taking trazodone as prescribed by the health care provider (HCP) indicates to the nurse that further teaching about the medication is needed? A) "I will continue to take my medication after a light snack." B) "Taking trazodone at night will help me to sleep." C) "My depression will be gone in about 5 to 7 days." D) "I won't drink alcohol while taking trazodone."

c (Symptom relief can occur during the first week of therapy, with optimal effects possible within 2 weeks. For some clients, 2 to 4 weeks is needed for optimal effects. The client's statement that the depression will be gone in 5 to 7 days indicates to the nurse that clarification and further teaching is needed. Trazodone should be taken after a meal or light snack to enhance its absorption. Trazodone can cause drowsiness, and therefore the major portion of the drug should be taken at bedtime. The depressant effects of central nervous system depressants and alcohol may be potentiated by this drug)

The client tells the nurse at the outpatient clinic that she does not need to attend groups because she is "not a regular like these other people here." The nurse should respond to the client by saying: A) "Because you are not a regular client, sit in the hall when the others are in group." B) "Your family wants you to attend, and they will be very disappointed if you do not." C)"You say you are not a regular here, but you are experiencing what others are experiencing." D) "I will have to mark you absent from the clinic today and speak to the health care provider about it."

c (The best response is, "You say you are not a regular here, but you are experiencing what others are experiencing." This statement helps the client to identify factors that precipitate denial by helping her to confront that which inhibits compliance. Denial is used to help a client feel better and more secure when a situation provokes a high level of anxiety and is threatening to the client. The statement, "Because you are not a regular client, sit in the hall when the others are in group," agrees with and promotes denial in the client and interferes with treatment. The statement, "Your family wants you to attend and they will be disappointed if you do not," causes the client to feel guilty and decreases her self-esteem. The statement, "I will have to mark you absent from the clinic today and speak to the health care provider about it," is punitive and threatening to the client, subsequently decreasing her self-esteem)

A client suffers from depression following the accidental death of her daughter. After a suicide attempt, the client is admitted to the psychiatric unit. During the admission interview, the client tells the nurse that she no longer wants to die. The nurse should: A) Suggest that the client no longer requires close observation. B) Place the client in a private room, away from the nurses' station, so that she has privacy to work through the stages of the grieving process. C) Inspect the client's personal belongings for potentially dangerous objects. D) Avoid any further discussion of suicide unless the client brings up the topic.

c (The client must be protected from harming herself. This includes checking all personal items that she brought to the hospital, such as a suitcase or pocketbook. The client must be closely observed until she has been evaluated and receives treatment. A client who's suicidal should be placed in a room near the nurses' station in full view of a nurse or other observer. The nurse shouldn't ignore the client's suicide attempt. The client may feel relief talking about the suicide attempt and knowing that she'll be protected from harm)

The client who has been taking venlafaxine 25 mg PO three times a day for the past 2 days states, "This medicine is not doing me any good. I am still so depressed." Which response by the nurse is most appropriate? A) "Perhaps we will need to increase your dose." B) "Let us wait a few days and see how you feel." C) "It takes about 2 to 4 weeks to receive the full effects." D) "It is too soon to tell if your medication will help you."

c (The client needs to be informed of the time lag involved with antidepressant therapy. Although improvement in the client's symptoms will occur gradually over the course of 1 to 2 weeks, typically it takes 2 to 4 weeks to get the full effects of the medication. This information will help the client be compliant with medication and will also help in decreasing any anxiety the client has about not feeling better. The client's dose may not need to be increased; it is too early to determine the full effectiveness of the drug. Additionally, such a statement may increase the client's anxiety and diminish self-worth. Telling the client to wait a few days discounts the client's feelings and is inappropriate. Although it is too soon to tell whether the medication will be effective, telling this to the client may cause the client undue distress. This statement is somewhat negative because it is possible that the medication will not be effective, possibly further compounding the client's anxiety about not feeling better)

A nurse is caring for a client with illness anxiety disorder. Which behavior is the nurse most likely to encounter? A) Ready acceptance of the physician's explanation that all medical and laboratory tests are normal B) Expression of fear of dying after being diagnosed with advanced breast cancer C) Expression of fear of colorectal cancer following 3 days of constipation D) Lack of concern about having a serious disease

c (The client with illness anxiety disorder is preoccupied with having a serious disease. She may convince herself that a relatively minor symptom, such as constipation, is a sign of a serious disorder. The client's fear of serious illness persists, even after a physician reassures her that all medical and laboratory tests are normal. The fear of dying after receiving a diagnosis of advanced breast cancer would be an expected response. A client with somatic symptom disorder shows an exaggerated level of anxiety, rather than a lack of concern about having a serious disease or illness)

The nurse meets with a client in the outpatient clinic who is suicidal and refuses to sign a "no suicide" contract. What should the nurse do next? A) Arrange for the client to be sent back to the group home. B) Refer the client to a partial program until the client is no longer suicidal. C) Arrange for immediate hospitalization on a locked unit. D) Arrange for admission to a subacute unit for 2 weeks.

c (The nurse should arrange for immediate hospitalization on a locked unit for the client who is suicidal and refuses to sign a "no suicide" contract. A psychiatric intensive care unit or locked unit is the appropriate setting and least restrictive environment to provide safety for a high-risk client. When clients are treated in an outpatient area, procedures must be in place for swift admission to an inpatient area that has a locked unit. The group home, a partial program, or a subacute unit would not provide the maximum safety that the client needs)

The client with acute mania has been admitted to the inpatient unit voluntarily. The nurse approaches the client with medication to be taken orally as prescribed by the health care provider (HCP). The client states, "I do not need that stuff." Which response by the nurse is best? A) "You cannot refuse to take this medication." B) "If you do not take it orally, I will give you a shot." C) "The medication will help you feel calmer." D) "I will get you some written information about the medication."

c (The nurse should first attempt a collaborative approach to increasing adherence to the prescribed medication regimen. Giving written medication information to a client with acute mania is poor nursing judgment because a client with acute mania cannot benefit from written information as a result of impaired ability to focus and concentrate. The client was a voluntary admission and has the right to refuse any medication. Giving the medication as an injection against the client's consent constitutes battery)

Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling? A) She becomes upset when talking about the rape to anyone. B) She seeks support from formerly ignored relatives and friends. C) Her parents show shame and suspicion about her part in the rape. D) Her life becomes focused on helping other rape victims like herself.

c (The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims)

While a client is taking alprazolam, which food should the nurse instruct the client to avoid? A) Chocolate B) Cheese C) Alcohol D) Shellfish

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

The director of an outpatient rehab program tells the nurse that the client with schizophrenia had done well for 6 months until last week, when a new person started the program. This new person worked faster than the client did and took his place as leader of the group. Based on this information, which intervention is most appropriate? A) Make a home visit, and tell the client that if he does not return to the program, he will lose his place there. B) Ask the director to assign the client to another group when he returns to the program. C) Make an appointment to meet the client at the mental health center, and ask him about the situation. D) Arrange for the placement of the client in a skill-training program.

c (he most therapeutic action at this time is for the nurse to make an appointment with the client at the mental health center to explore his feelings and behavior. Doing so acknowledges the client's importance and makes him a partner in resolving the problem. The nurse needs to determine what is going on in the situation first, and then plan accordingly. Threatening the client with loss of the position, asking for a new assignment for the client, or arranging for the placement of the client in a skill-training program is inappropriate and premature)

An 18-year-old is highly dependent on her parents and fears leaving home to attend college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits the woman to the psychiatric unit, where she is diagnosed with functional neurologic symptom disorder. She asks the nurse, "Why has this happened to me?" What is the nurse's best response? A) "You've developed this paralysis so you will have a reason to stay with your parents. You must deal with this conflict if you want to walk again." B) "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical." C)"Your problem is real but, there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." D) "It's common for someone with your personality to develop a conversion disorder during times of stress."

c (he nurse must be honest by telling the client that her paralysis has no physiologic cause while also conveying empathy and acknowledging that her symptoms are real. The client will benefit from psychiatric treatment, which will help her understand the underlying cause of her symptoms. After her psychological conflict is resolved, her symptoms will disappear. Telling the client that being unable to move her legs must be awful wouldn't answer the client's question; knowing that the cause is psychological rather than physical wouldn't necessarily make her feel better. Telling the client that she has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't help her understand and resolve the underlying conflict)

At an outpatient visit 3 months after discharge from the hospital, a client says he has stopped his olanzapine even though it controls his symptoms of schizophrenia better than other medications. "I have gained 20 lb (9.1 kg) already. I cannot stand anymore." Which response by the nurse is most appropriate? A) "I do not think you look fat; why do you think so?" B) "You can be switched to another medicine." C) "Your weight gain will level off if you stay on the medication 3 more months." D) "I can help you with a diet and exercise plan to keep your weight down."

d ("I can help you with a diet and exercise plan to keep your weight down")

A nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." This statement describes the client's: A) Feelings. B) Blocking. C) Mood. D) Affect.

d (Affect refers to a person's emotional expression (in this case, the manner in which the client talks about her experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the affect)

A client on the behavioral health unit tells a nurse that she experiences palpitations, trembling, and nausea while traveling alone, outside her home. These symptoms have severely limited the client's ability to function and have caused her to avoid leaving home whenever possible. The nurse recognizes that this client has symptoms of what disorder? A) Generalized anxiety B) Depression C) Schizoaffective disorder D) Agoraphobia

d (Agoraphobia is a phobia, or fear, and avoidance of open spaces accompanied by the concern that escape to safety would be difficult or embarrassing. Agoraphobia is commonly accompanied by physical symptoms, such as palpitations, trembling, nausea, and shortness of breath. It is also commonly accompanied or preceded by panic attacks. Thanatophobia is the fear of death; aerophobia, the fear of air; and hodophobia is the fear of traveling)

A client seeking help at a community mental health center complains of fatigue, sensitivity to criticism, decreased libido, and feeling self-conscious. He also has aches and pains. A nursing diagnosis for this client might include: A) Delayed growth and development. B) Ineffective role performance. C) Posttrauma syndrome. D) Situational low self-esteem.

d (All symptoms define a disturbance in self-esteem. There isn't enough information to determine delayed growth and development. The client's complaints don't involve his ability to perform in his roles. Posttrauma syndrome occurs after experiencing a traumatic event and doesn't coincide with the data obtained from this client)

A nurse discovers that a client with obsessive-compulsive disorder (OCD) is attempting to resist his compulsion. Based on this finding, the nurse should assess the client for: A) Feelings of failure. B) Depression. C) Excessive fear. D) Increased anxiety.

d (An obsessive-compulsive client who attempts to resist his compulsion must be evaluated for increased anxiety. A compulsion is a repetitive, intentional behavior that the client performs in response to a certain obsession; it's aimed at neutralizing or decreasing anxiety. Resisting the compulsion may increase the client's anxiety. Although a client with OCD may experience a sense of failure, depression, and excessive fear, these feelings aren't responses to resisting the compulsion)

The client diagnosed with borderline personality disorder who is to be discharged soon threatens to "do something" to herself if discharged. The nurse should first: A) Request that the client's discharge be canceled. B) Ignore the client's statement because it is a sign of manipulation. C) Ask a family member to stay with the client at home temporarily. D) Discuss the meaning of the client's statement with her.

d (Any suicidal statement must be assessed by the nurse. The nurse should discuss the client's statement with her to determine its meaning in terms of suicide, overwhelming feelings of anxiety, abandonment, or other need that the client cannot express appropriately. It is not uncommon for a client with borderline personality disorder to make threatening comments before discharge. Extending the hospital stay is inappropriate because it would encourage dependency and manipulation. Ignoring the client's statement on the assumption that it is a sign of manipulation is an error in judgment. Asking a family member to stay with the client temporarily at home is not appropriate and places the responsibility for the client on the family instead of the client)

A nurse is caring for a client diagnosed with antisocial personality disorder. This client has a history of fighting, cruelty to animals, and stealing. Which trait is the nurse likely to uncover during assessment? A) History of gainful employment B) Frequent expression of guilt regarding antisocial behavior C) Demonstrated ability to maintain close, stable relationships D) A low tolerance for frustration

d (Clients with antisocial personality disorder exhibit emotional immaturity, a lack of impulse control, and a low tolerance for frustration. Most have a history of unemployment, miss work repeatedly, and quit work without plans for other employment. They don't feel guilt about their behavior and they commonly perceive themselves as victims. They also display a lack of responsibility for the results of their actions. Because of a lack of trust in others, clients with antisocial personality disorder commonly have difficulty developing stable, close relationships)

The client is laughing and telling jokes to a group of clients. Suddenly, the client is crying and talking about a death in the family. A moment later, the client is laughing and joking again. The nurse should: A) Call the health care provider (HCP) for a prescription for lorazepam as needed. B) Place the client in seclusion and call the HCP for a prescription for the seclusion. C) Ignore the client's behavior in order not to give the client too much attention. D) Ask the client to come to a quiet area to talk to the nurse individually.

d (Decreasing external stimuli is the intervention most likely to decrease the emotional lability and minimize its effect on other clients. While the client is displaying emotional lability, this behavior has not reached the level where involuntary isolation (seclusion) or physical restraint is needed. The client is not totally out of control or threatening others. However, ignoring the behavior will not result in a decrease in the lability. Lorazepam can be used, but benzodiazepines can lead to dependence and should not be used before other measures have been tried)

A nurse is planning care for a regressed, chronically ill client diagnosed with schizophrenia. What is the most appropriate milieu? A) Confrontation and peer pressure to break down the client's denial B) Reminder that all clients must participate fully in unit self-governance C) Required attendance at group activities with equal participation from all clients D) Nurturance and supportive interaction focusing on individual needs

d (Due to the client's psychosis and difficulties coping, a positive, supportive environment is essential to limit further regression and help the client engage in her own treatment. Confrontation and peer pressure are the type of milieu more suited to a chemically dependent client. While involvement in self-governance can be therapeutic, forcing a psychotic client to participate in self-governance before she is ready could actually hinder treatment and recovery. Although group activities are commonly required in treatment programs, a client who is very disturbed or confused is not forced to attend. Also, the client must participate when and how she feels comfortable, rather than mandating a specific amount of participation. Equal participation by clients does not ensure a therapeutic milieu or speed the client's recovery)

A nurse is explaining medication benefits and adverse effects to a client with a history of psychosis. The client's brother tells the nurse that she's wasting her time explaining things to the client. What information about informed consent should the nurse use to respond to the brother's negative statement? A) Informed consent doesn't apply to clients who experience psychosis. B) The nurse may assume that the client understands at least some of the information. C) A third party must be present when a nurse informs clients about treatment options. D) Informed consent is an important part of effective client care that helps accomplish treatment goals.

d (Informed consent allows the client and the nurse to work together in developing and accomplishing treatment goals. Even clients with a history of psychosis have the right to be informed about risks and benefits of their treatment. It isn't appropriate for the nurse to assume that a client understands information without obtaining some feedback from the client. A third party needn't be present when the nurse informs the client about treatment options unless the client can't give informed consent. In the case of a minor or legally incompetent client, a guardian or parent must give informed consent for treatment)

A client with posttraumatic stress disorder states, "You do not know what I have been through. What can you do?" The nurse should respond: A) "I need to refer you to a survivors' group where you will feel more comfortable." B) "Perhaps you will feel better if you can become interested in a hobby once again." C) "I would like to help you if you will let me." D) "I have not been through what you have, but I will be better able to understand if you tell me more about it."

d (Saying that the nurse has not been through what the client has is nonjudgmental, supportive, and conveys honesty and empathy to the client. Telling the client he will feel more comfortable in a survivors' group dismisses the client. However, a survivors' group may be needed later. Stating that the client should become interested in a hobby dismisses his feelings and is not helpful. Saying that the nurse would like to help if the client would allow it implies that the client is not being cooperative; it may alienate him)

A 28-year-old client with a diagnosis of major depression and dependent personality disorder has been living at home with very supportive parents. The client is thinking about independent living on the recommendation of the treatment team. The client states to the nurse, "I do not know if I can make it in an apartment without my parents." The nurse should respond by saying to the client: A) "You are a 28-year-old adult now, not a child who needs to be cared for." B) "Your parents will not be around forever. After all, they are getting older." C) "Your parents need a break, and you need a break from them." D) "Your parents have been supportive and will continue to be even if you live apart."

d (Some characteristics of a client with a dependent personality are an inability to make daily decisions without advice and reassurance and the preoccupation with fear of being alone to care for oneself. The client needs others to be responsible for important areas of his life. The nurse should respond, "Your parents have been supportive of you and will continue to be supportive even if you live apart," to gently challenge the client's fears and suggest that they may be unwarranted. Stating, "You are a 28-year-old adult now, not a child who needs to be cared for," or "Your parents need a break, and you need a break from them," is reprimanding and would diminish the client's self-worth. Stating, "Your parents will not be around forever; after all, they are getting older," may be true, but it is an insensitive response that may increase the client's anxiety)

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? A) Talking with the client's family about his angry feelings B) Performing an assessment for tardive dyskinesia C) Learning to effectively express needs to staff and others D) Demonstrating control over aggressive behavior

d (The client must demonstrate control over his aggressive behavior so that he won't hurt himself or others or destroy property in the hospital setting. A discussion of angry feelings with the family can occur at a later time. Performing an assessment for tardive dyskinesia isn't a priority in the situation described. If the client were taking neuroleptic medication, a baseline assessment for tardive dyskinesia would already have been performed. The client's learning of effective communication and coping skills is a later goal, but not of primary importance

The client with a diagnosis of bipolar disorder, manic phase, states to the nurse, "I am the Queen of England. Bow before me." The nurse interprets this statement as important to document as which area of the mental status examination? A) Psychomotor behavior B) Mood and affect C) Attitude toward the nurse D) Thought content

d (The client's statement, "I am the Queen of England. Bow before me," is an example of a grandiose delusion and refers to thought content of the mental status examination. Examples of psychomotor behavior to be documented would include excited, typically exaggerated and repetitive physical movements, and excessive talking and gesturing. Mood is a subjective state, and affect is an observable expression of emotion. Mood is what a client tells you she is feeling, and affect is what you see the client feeling. For example, the client may state that she feels sad or happy in reference to mood. Affect refers to the display of physical emotion, commonly described as "appropriate" or "flat." Attitude toward the nurse refers to the client's behavior in the presence of the nurse during the mental status examination - pleasant and cooperative, irritable, and guarded)

The client with bipolar disorder, manic phase, appears at the nurse's station wearing a transparent shirt, miniskirt, high heels, 10 bracelets, and eight necklaces. Her makeup is overdone and she is not wearing underwear. The nurse should: A) Tell the client to dress appropriately while out of her room. B) Ask the client to put on hospital pajamas until she can dress appropriately. C) Instruct the client to go to her room and change clothes. D) Escort the client to her room and assist with choosing appropriate attire.

d (The nurse escorts the client to her room and assists with choosing appropriate attire to preserve the client's dignity and self-esteem and prevent ridicule from others on the unit. It is common for a client with bipolar disorder, manic phase, to exhibit poor judgment, provocative behavior, and hyperactivity. The client in the manic phase commonly dresses inappropriately and changes clothes many times throughout the day. The nurse needs to assist the client with hygiene, grooming, and proper attire until her judgment improves. Telling the client to dress appropriately while out of her room may be perceived by the client as an attack. Additionally, the client may be incapable of making that decision. Asking the client to put on hospital pajamas until she can dress appropriately is punitive and demeaning. Because of the client's cognitive difficulties, the client may not understand the instructions to go to her room to change clothes. Additionally, the client may become distracted by stimuli on the unit and may not reach her room)

During therapy, a client on the mental health unit is restless and is starting to make sarcastic remarks to others in the therapy session. The nurse responds by saying, "you look angry." Which of the following communication techniques is the nurse using? A) Reaffirming B) Clarification C) Mirroring D) Making observations

d (The nurse has provided direct feedback as an observation to the client and the group. The nurse is not mirroring the behavior or seeking clarification or an explanation of the behavior. This is not an open-ended question. Making direct observations and providing feedback in this manner is useful in demonstrating attention and concern for group members as well as providing an external vantage point on behaviors exhibited in a group setting. While such a statement makes a space for later clarification, this statement itself if not a statement of clarification, it is simply an observation)

An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober? A) Give the client black coffee to drink. B) Walk the client around the unit. C) Have the client take a cold shower. D) Provide the client with a quiet room to sleep in.

d (The nurse should provide the client with a quiet room to sleep in. Alcohol is destroyed and oxidized in the body at a slow, steady rate. The rate of alcohol metabolism is not influenced by drinking black coffee, walking around the unit, or taking a cold shower. Therefore, it is best to have the client sleep off the effects of the alcohol)

A client in an acute care mental health program refuses his morning dose of an oral antipsychotic medication and believes he's being poisoned. The nurse should respond by taking which action? A) Administering the medication by injection B) Omitting the dose and trying again the next day C) Crushing the medication and putting it in his food D) Consulting with the physician about a care plan.

d (To determine a care plan for clients who are noncompliant with medications, the nurse should consult with the physician. Unless the client presents a danger to himself or others, he can't be forced to take medications. Crushing the medication and putting it in food might make the client suspicious. The nurse shouldn't omit the dose and try again the next day. The nurse should instead make another attempt to administer the drug to avoid decreased drug levels)

A client enters the crisis unit complaining of increased stress from her studies as a medical student. She states that she has been increasingly anxious for the past month. Her physician orders alprazolam, 0.25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client's medication history. Which drug can produce additive effects when taken concomitantly with alprazolam? A) Levodopa B) Famotidine C) Norgestrel D) Diphenhydramine

d (Using benzodiazepines with other central nervous system depressants such as diphenhydramine produces additive effects. Alprazolam doesn't cause clinically significant drug interactions with levodopa, famotidine, or hormonal contraceptives such as norgestrel)

When the client is involuntarily committed to a hospital because he is assessed as being dangerous to himself or others, which client rights are lost? A) The right to access healthcare B) The right to send and receive uncensored mail C) Freedom from seclusion and restraints D) The right to leave the hospital against medical advice

d (When a client is committed involuntarily, the right to leave against medical advice is forfeited. All the other rights are preserved unless there is further court action or a case of imminent danger to self or others such as hitting staff, cutting self)

A client with major depression and suicidal ideation is suddenly calmer and more energetic. Which conclusion should the nurse reach? A) The client is improving. B) The client's medication dosage is too high. C) The client is overstimulated. D) The client is imminently suicidal.

d (When a client with major depression and suicidal ideation displays a sudden elevation in mood, seems calmer, has more energy, and is more peaceful, the nurse should judge these behaviors as an indication that a suicide attempt is imminent. These symptoms may indicate relief from ambivalent thoughts about suicide and that the client has an immediate plan for killing himself)

A client with a diagnosis of schizotypical personality disorder is admitted to the psychiatric unit. The nurse expects the assessment to reveal: A) Unpredictable behavior and intense interpersonal relationships. B) Inability to function as a responsible parent. C) Somatic symptoms. D) Coldness, detachment, and lack of tender feelings.

d (as well as with typify schizoid personality disorder)

A client whose symptoms of schizophrenia are under control with olanzapine, and who is functioning at home and in her part-time employment, states that she is very concerned about her 20-lb (9.1-kg) weight gain since she started taking the medication 6 months ago. The nurse should: A) Suggest that the client talk with her healthcare provider about changing to another antipsychotic. B) Advise the client to decrease her dosage by one-half. C) Tell the client not to worry because she should stop gaining weight. D) Discuss nutrition, daily diet, and exercise with the client.

d (the nurse should discuss nutrition, daily diet, and exercise with the client concerned about her weight gain while taking olanzapine. Weight gain is common with this drug therapy. The client would benefit from nutrition and exercise teaching, and the nurse should provide the client with an initial course of action)