mental health

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A nurse recalls that language development in the autistic child resembles: A nurse recalls that language development in the autistic child resembles: Echolalia Stuttering Scanning speech Pressured speech

Echolalia -The autistic child repeats sounds or words spoken by others

How can a nurse minimize agitation in a disturbed client? By ensuring constant staff contact By increasing environmental sensory stimulation By limiting unnecessary interactions with the client By discussing the reasons for the client's suspicions

By limiting unnecessary interactions with the client -Limiting unnecessary interactions will decrease stimulation and therefore agitation

A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention? A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention? Focusing on the present Identifying past stressors Discussing a referral for psychotherapy Exploring the client's history of mental health problems

1. Focusing on the present **Crisis intervention deals with the here and now; the past is not important except in building on client strengths.

A nurse is evaluating a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? A nurse is evaluating a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 2 years 6 years 6 months 1 to 3 months

2 years Rationale By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.

A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? (Select all that apply.) A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? (Select all that apply.) Eating a heavy snack near bedtime Reading in bed before shutting out the light Leaving the bedroom when unable to sleep Drinking a cup of warm coffee with milk at bedtime Exercising in the afternoon rather than in the evening Counting backward from 100 to 0 when his mind is racing

3. Leaving the bedroom when unable to sleep 5. Exercising in the afternoon rather than in the evening 6 . Counting backward from 100 to 0 when his mind is racing

What should a nurse consider when planning care for a client who is using ritualistic behavior? What should a nurse consider when planning care for a client who is using ritualistic behavior? The nurse must try to limit the ritualistic behavior. Clients need to realize that ritualistic behavior serves no purpose. The nurse should try to stop the ritual immediately after it is started. Clients do not want to repeat their rituals but feel compelled to do so.

Clients do not want to repeat their rituals but feel compelled to do so. Rationale The repeated thought or act defends the client against even higher, more severe levels of anxiety. To deny the client the ritual may precipitate a panic level of anxiety. Usually clients who engage in ritualistic behavior recognize that the ritual serves little purpose.

A client with a long history of alcohol dependence spends 28 days in an alcohol-rehabilitation unit. What type of referral does the nurse anticipate will be included in the discharge plan? A client with a long history of alcohol dependence spends 28 days in an alcohol-rehabilitation unit. What type of referral does the nurse anticipate will be included in the discharge plan? Halfway house Family therapist Psychoanalytic therapy group Community-based self-help group

Community-based self-help group Rationale Referral to a community-based self-help group is an essential component of the discharge plan to provide ongoing support. The client probably does not need a halfway house. Although some forms of therapy may be helpful, the most successful intervention for alcohol abuse is Alcoholics Anonymous .

One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." The nurse identifies that this as an example of: One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." The nurse identifies that this as an example of: Hallucinations Paranoid thinking Depersonalization Autistic verbalization

Depersonalization =The state in which the client feels unreal or believes that parts of the body are distorted is known as depersonalization or loss of personal identity.

The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care? The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care? Engages in many rituals Feels independent of others Exhibits lack of empathy for others Possesses limited communication skills

Exhibits lack of empathy for others -Self-motivation and self-satisfaction are of paramount concern to people with antisocial personality disorder, and they have little or no concern for others.

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children: A nurse knows that children with attention deficit–hyperactivity disorder (ADHD) may be learning disabled. This means that these children: Will probably not be self-directed learners Have intellectual deficits that interfere with learning Experience perceptual difficulties that interfere with learning Are usually performing two grade levels below their age norm

Experience perceptual difficulties that interfere with learning -ADHD interferes with the ability to perceive and respond to sensory stimuli, resulting in a deficit in interpreting new sensory data. This makes learning difficult. It is not true that children with ADHD have intellectual deficits that interfere with learning; there is no cognitive impairment present.

A client is admitted with a conversion disorder. What is the primary nursing intervention? A client is admitted with a conversion disorder. What is the primary nursing intervention? Talking about the physical problems Exploring ways to verbalize feelings Explaining how stress caused the physical symptoms Focusing on the client's concerns regarding the symptoms

Exploring ways to verbalize feelings -The priority is getting the client to express feelings appropriately rather than through the use of physical symptoms. Focusing on symptoms will encourage their use by the client. An expression of feelings, not an intellectual understanding of the cause of the symptoms, is required.

A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse's objective for this client be? A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse's objective for this client be? Feeling comfortable with the nurse Investigating new leisure activities Participating in small group activities Initiating conversations about feelings

Feeling comfortable with the nurse -Before therapy can begin, a trusting relationship must be developed. A client with major depression will not have the impetus or energy to investigate new leisure activities. Participating in small group activities is not appropriate initially; the client does not have the physical or emotional energy to interact with a small group of people. Initiating conversations about feelings will not be successful unless the client develops a trusting, comfortable relationship with the nurse.

A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed? A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed? Benztropine (Cogentin) Amantadine (Symmetrel) Fluvoxamine (Luvox) Diphenhydramine (Benadryl)

Fluvoxamine (Luvox) -Fluvoxamine (Luvox) blocks the uptake of serotonin, which leads to a decrease in obsessive-compulsive behaviors. Benztropine (Cogentin) is an antiparkinsonian agent, not an antianxiety agent. Amantadine is an antiparkinsonian agent, not an antianxiety agent. Diphenhydramine (Benadryl) is an antihistamine, not an antianxiety agent.

A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem? A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem? Low self-esteem Deficient memory Intolerance of activity Disturbed personal identity

Low self-esteem

During an interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing? During an interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing? Insomnia Narcolepsy Sleep terror Sleep apnea

Narcolepsy Rationale Narcolepsy is overwhelming sleepiness that results in irresistible attacks of sleep, loss of muscle tone (cataplexy), and hallucinations or sleep paralysis at the beginning or end of sleep episodes; the person usually awakens from the sleep feeling refreshed. Insomnia is difficulty initiating or maintaining sleep. Sleep terrors are recurrent episodes of abrupt awakening from sleep accompanied by intense fear, screaming, tachycardia, tachypnea, and diaphoresis with no detailed dream recall. Sleep apnea is a breathing-related sleep disorder caused by disrupted respirations or airway obstruction; sleep is disrupted numerous times throughout the night.

A client with a diagnosis of bipolar disorder, manic episode, is admitted to the mental health unit. Because the environment is important, what should the nurse do? Place the client in a private room to provide a quiet atmosphere Assign the client to a room near the dayroom to provide access to activities Schedule multiple activities with other clients to keep the client socially engaged Ensure that there are colorful drapes in the client's room to provide a cheerful environment

Place the client in a private room to provide a quiet atmosphere The excited, overactive client needs a calm environment; external stimulation only serves to cause further excitation. It would be difficult for another client to share the room. The client needs reduced, not increased, external stimulation.

A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child? A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child? Play Group Family Psychodrama

Play Rationale It will be most effective for the child to play out feelings; when feelings are allowed to surface, the child can then learn to face them by controlling, accepting, or abandoning them. Group, family, and psychodrama therapies are not child-specific and are generally better suited to adolescents, young adults, and adults.

A client with a generalized anxiety disorder is hospitalized. The nurse determines that an environment conducive to reducing emotional stress and providing psychological safety for this client is one in which: A client with a generalized anxiety disorder is hospitalized. The nurse determines that an environment conducive to reducing emotional stress and providing psychological safety for this client is one in which: Needs are met Realistic limits and controls are set The client's requests are met promptly The client's environment is kept neat and orderly

Realistic limits and controls are set Rationale Setting realistic limits and controls makes the environment as emotionally nonthreatening as is realistically possible. All needs cannot be met; the person must learn how to cope with delaying gratification. It is not possible or realistic to meet all of a person's requests. Order in the environment is of less importance; providing a nonthreatening environment is the priority action.

An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. The nurse identifies that these problems as the result of: An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. The nurse identifies that these problems as the result of: Receptive aphasia Impaired judgment Decreased attention span Clouding of consciousness

Receptive aphasia -Receptive aphasia interferes with interpreting and defining words in addition to following directions and selecting clothes. Following directions does not require skill in judgment or decision-making.

A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When setting goals it is important for this client to understand the need to: Plan to avoid people who drink Accept that he is a fragile person Develop new social drinking skills Restructure his life without alcohol

Restructure his life without alcohol

What childhood problem has legal as well as emotional aspects and cannot be ignored? What childhood problem has legal as well as emotional aspects and cannot be ignored? School phobia Fear of animals Fear of monsters Sleep disturbances

School phobia Rationale School phobia is a disorder that cannot legally be ignored for long because children must attend school. It requires intervention to alleviate the separation anxiety and promote the child's increasing independence. Fear of animals and monsters and sleep disturbances all require parents to comfort the child, to reorient the child to reality, and to help the child regain self-control. Legally there are no requirements mandating treatment for these common childhood problems.

At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse? At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse? Reflecting feelings Making observations Seeking consensual validation Attempting to place events in sequence

Seeking consensual validation -Seeking consensual validation is a technique that prevents misunderstanding so that both the client and the nurse can work toward a common goal in the therapeutic relationship.

What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa? What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa? Set limits Maintain control Demonstrate empathy Focus on a healthy diet

Set limits The client's security is increased by the setting of limits; guidelines remove responsibility for behavior from the client and increase compliance with the regimen.

What characteristic of an environment should the nurse consider important for a confused older adult with socially aggressive behavior? Sets limits Has variety Is group oriented Allows freedom of expression

Sets limits Having poor control, these individuals cannot set limits for themselves and require an environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others because the client may be unable to control impulses.

A 6-year-old child who has autism exhibits frequent spinning and hand-flapping behaviors. What should the nurse teach the parents to do to limit these actions? A 6-year-old child who has autism exhibits frequent spinning and hand-flapping behaviors. What should the nurse teach the parents to do to limit these actions? Hold the child Place the child in time-out Use another activity to distract the child Determine the reason for the child's behavior

Use another activity to distract the child Rationale Providing a constructive distraction will help redirect the autistic child's behavior. Physical contact is anxiety provoking for the autistic child. A time-out is punitive and is not constructive. The reason for this repetitive behavior is unknown.

A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care? A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care? Suffers from extreme anxiety Rapidly learns by experience if punished Usually is unable to postpone gratification Has a great sense of responsibility toward others

Usually is unable to postpone gratification(희열) Individuals with antisocial personality disorder tend to be self-centered and impulsive. They lack judgment and self-control and are unable to postpone gratification. Generally they do not suffer from anxiety. These individuals believe that the rules do not apply to them, and they do not profit from their mistakes. These people are too self-centered to have a sense of responsibility to anyone.

A client with schizophrenia reports having ongoing auditory hallucinations that he describes as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse? A client with schizophrenia reports having ongoing auditory hallucinations that he describes as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse? "Try to ignore the voices." "What are the voices saying to you?" "Do you believe what the voices are saying?" "They're only voices, so just try not to be afraid."

"Try to ignore the voices." -Clients can sometimes learn to push auditory hallucinations aside, particularly within the framework of a trusting relationship; it may provide the client with a sense of power to manage the voices.

During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be? During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be? "Let's discuss this concern a little more." "Be sure to tell your doctor about this problem." "There is medication available for erectile dysfunction." "This is an expected physiological response to getting older."

"Let's discuss this concern a little more." Rationale "Let's discuss this concern a little more" communicates to the client that the nurse is willing and able to explore this concern. It is an open-ended statement that allows the client to control the direction of the conversation. By saying, "Be sure to tell your doctor about this problem," the nurse abdicates responsibility to the health care provider. The nurse is capable of and legally responsible for collecting information and exploring the client's feelings and concerns. The response "There is medication available for erectile dysfunction" is premature; it moves immediately to a solution before adequate information has been collected. Also, the term erectile dysfunction is related to a medical diagnosis and its use at this time may increase client anxiety. Although sexual function diminishes as men age, many other factors (e.g., physiological problems, interpersonal conflicts, emotional stress) also influence sexual function.

What is the greatest difficulty for nurses caring for the severely depressed client? What is the greatest difficulty for nurses caring for the severely depressed client? Client's lack of energy Negative cognitive processes Contagious quality of depression Client's psychomotor retardation

. Contagious quality of depression **Depression is contagious; it affects the nurse as well as the client.

What should nurses consider when working with depressed young children? What should nurses consider when working with depressed young children? It is important to include the family in the treatment plan. The goal of therapy is for the child to gain insight into problems. Depressed children are treated in much the same way as depressed adults. Antidepressant medication is the treatment of choice for depressed children.

It is important to include the family in the treatment plan. Rationale When a young child demonstrates symptoms of emotional discord, usually this is a response to some type of family dysfunction. Because of their cognitive development, children are usually incapable of insight into their problems. Psychiatric interventions are different for children than for adults. Psychotropic medications are not the treatment of choice for children because their side effects are more dangerous in children than in adults.

A constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome is: A constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome is: Role experimentation Adherence to peer standards Sublimation through schoolwork Development of dependence on parents

Role experimentations -Adolescents learn about who they are by assuming and experiencing a variety of roles; experimentation results in the retention or rejection of behavior and roles.

A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? Double bind Ambivalence Loose association Inappropriate affect

Ambivalence

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider that clients with OCD: A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider that clients with OCD:

Do not want to repeat the ritual but feel compelled to do so Rationale The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.

The parents of a child with attention deficit-hyperactivity disorder ask the nurse about using medication. What is the most frequently prescribed medication for this disorder? Lorazepam (Ativan) Haloperidol (Haldol) Methylphenidate (Ritalin) Methocarbamol (Robaxin)

Methylphenidate (Ritalin) Methylphenidate (Ritalin) appears to act by stimulating release of norepinephrine from nerve endings in the brainstem. Lorazepam (Ativan) is a benzodiazepine used to treat anxiety and insomnia. Haloperidol (Haldol) is an antipsychotic medication. Methocarbamol (Robaxin) is a muscle relaxant.

A client's admitting history indicates signs of akathisia. What clinical finding should the nurse expect when observing for this condition? Facial tics Motor restlessness Maintaining a body position for hours Repeating the movements of another person

Motor restlessness With akathisia the client exhibits a constant state of movement; this is characterized by restlessness and difficulty sitting still, including constant jiggling of the arms or legs. The distortion of voluntary movements, such as tics, spasms, or myoclonus, is known as dyskinesia. Maintaining a body position for hours is a form of catatonia known as waxy flexibility. Repeating the movements of another person is known as echopraxia.

A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? (Select all that apply.) A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? (Select all that apply.) Labiality of affect Specific food cravings Neglect of personal hygiene "I don't know" answers to questions Apathetic response to the environment

Neglect of personal hygiene "I don't know" answers to questions Apathetic response to the environment

What is essential for the nurse to do when approaching a client during a period of overactivity? Using a firm but caring and consistent approach Anticipating and physically controlling the hyperactivity Allowing the client to choose the activities in which to participate Letting the client know that the staff will not tolerate destructive behavior

Using a firm but caring and consistent approach Using a firm but caring and consistent approach will help reduce the client's anxiety, thereby reducing hyperactivity. It is not possible to physically control hyperactivity. The client is not capable of choosing activities at this time. The client may not be capable of controlling overactive behavior; setting verbal limits may not be effective.

A client is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After a 1-month hospitalization the client is discharged home with instructions to continue the antipsychotic and a referral for weekly mental health counseling. The picture illustrates the client's physical status as observed by the nurse on the client's first visit to the community mental health clinic. What extrapyramidal side effect has developed? Dystonia Akathisia Tardive dyskinesia Pseudoparkinsonism

Akathisia

What client response should the nurse anticipate when an attempt is made to prevent a client from carrying out ritualistic behavior? What client response should the nurse anticipate when an attempt is made to prevent a client from carrying out ritualistic behavior? Relief Anger Gratitude Embarrassment

Anger Rationale Clients use ritualistic behavior to control anxiety; when the defense is taken away, the client experiences anxiety and becomes angry with the person who stopped the defense against the anxiety. Because the anxiety increases discomfort, the client will not feel relief or gratitude when the behavior that controlled the anxiety is interrupted. Although these clients recognize that the ritualistic behavior is not necessary, they are unable to stop it and usually are not embarrassed by it.

Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat: Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat: Clinical depression Substance abuse disorders Antisocial personality disorder Psychosis occurring in schizophrenia

Clinical depression -ECT is used to treat clinical depression in clients who do not respond well to a trial of psychotropic medications or are so severely depressed that immediate intervention is needed.

At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. The nurse, recognizing the client's ambivalence, assists by using: At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. The nurse, recognizing the client's ambivalence, assists by using: Nonverbal communication Simple declarative statements Basic questions requiring simple choices Rewards for each of the food items chosen

Simple declarative statements Rationale Ambivalence makes decision-making difficult, if not impossible; simple, easy-to-follow declarative statements limit the choices available for the indecisive client. The client will be unable to interpret nonverbal communication and will experience increased confusion and indecision. Asking basic questions to elicit simple choices or giving a reward for each item chosen is inappropriate because the pressure to make choices may increase the client's ambivalence and discomfort.

When talking with a female client who displays many of the emotional and physiological symptoms of panic disorder, the nurse should: When talking with a female client who displays many of the emotional and physiological symptoms of panic disorder, the nurse should: Use short sentences and an authoritative voice Describe to her the possible reasons for her anxiety Keep asking questions because she is probably not going to volunteer much information Suggest that she refrain from crying because most of the time crying makes matters worse

. Use short sentences and an authoritative voice Rationale During a panic attack the attention span is shortened, making it difficult to follow long sentences. An authoritative voice lets the client know that the nurse is in control of the situation; the client is unable to set controls because of her anxiety level. Describing to her the possible reasons for her anxiety may increase the client's anxiety level further. Asking questions may increase the client's anxiety level further. Crying is an outlet and should not be discouraged; telling someone not to cry usually worsens the crying and the anxiety.

A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that apply.) A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that apply.) Polydipsia Drowsiness Diaphoresis Tachycardia Hypertension

3. Diaphoresis 4. Tachycardia 5. Hypertension

A delusional client verbalizes the belief that others are out to harm him. A nurse notes the client's worsening pacing and agitation. What is the best nursing intervention? A delusional client verbalizes the belief that others are out to harm him. A nurse notes the client's worsening pacing and agitation. What is the best nursing intervention? Advising the client to use a punching bag Moving the client to a quiet place on the unit Encouraging the client to sit down for a while Allowing the client to continue pacing with supervision

Moving the client to a quiet place on the unit Rationale A client losing control feels frightened and threatened; he or she needs external controls and a reduction in external stimuli. Advising the client to use a punching bag is helpful if the client is holding back aggressive behavior but is not useful in easing agitation associated with delusions. The client is unable, at this time, to sit in one place; his agitation is building. The client may get completely out of control if the pacing is allowed to continue.

A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse's primary concern while working with clients withdrawing from cocaine? A client is admitted to the drug detoxification unit for cocaine withdrawal. What is the nurse's primary concern while working with clients withdrawing from cocaine? Risk for self-injury Potential for seizure Danger of dehydration Probability of injuring others

Risk for self-injury -The greatest risk in cocaine withdrawal is risk for self-injury. The risk for seizure is increased while a person is under the influence of cocaine, not during withdrawal. Although dehydration may occur during cocaine use and withdrawal, it is not the priority concern. People in cocaine withdrawal, although irritable, are more apt to hurt themselves than others.

A male client with paranoid schizophrenia wraps his legs in toilet paper, believing that this will protect him from deadly germs contaminating the floor. What is the best nursing intervention?

Talking with the client about anxiety that focuses on health Exploring the feelings expressed in the delusion is more therapeutic than discussing specific content. Limiting the client's access to toilet paper may frustrate the client, who will probably seek other ways to "protect" himself. Providing the client with antimicrobial soap reinforces the client's delusion about deadly germs. Trying to talk this client out of his delusion will not be effective and may precipitate hostility. A

What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program? What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program? Alcoholism involves the entire family. Alcoholics try to hide their drinking from their families. Family members provide insights into the dynamics behind the drinking. Family members have been most successful in providing necessary support.

Alcoholism involves the entire family. Rationale Research indicates that alcoholism is a family disease, with its roots in the family of origin. Although alcoholics may try to hide their drinking from their families, this is not the reason for including the family in the treatment program. Family members often have no understanding of the dynamics behind the drinking and often need assistance with coping and counseling. Family members often do not understand the dynamics behind the drinking and often are enablers; they also need assistance with coping and counseling.

For which clinical indication should a nurse observe a child in whom autism is suspected? For which clinical indication should a nurse observe a child in whom autism is suspected? Lack of eye contact Crying for attention Catatonia-like rigidity Engaging in parallel play

Lack of eye contact Rationale Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.

A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member? Regression Repression Dissociation Displacement

Regression Rationale Regression is the return to an earlier and more comfortable developmental level. Repression is the unconscious and involuntary forgetting of painful ideas, events, or conflicts. Dissociation is the unconscious separation of painful feelings and emotions from an unacceptable idea, situation, or object. Displacement is discharging pent-up feelings to a less threatening object or person.

A hospitalized client with an obsessive-compulsive disorder tells the nurse that coworkers and roommates get upset because she spends at least 30 minutes in the bathroom six times a day. The client says, "It keeps me from getting nervous." What is the most appropriate response by the nurse? "That's not a problem now, because you have your own bathroom here." "Tell me how spending time in the bathroom helps you avoid becoming nervous." "Tell me more about what you do in the bathroom during those 30-minute periods." "Let's start by cutting down the time you spend in the bathroom to 20 minutes three times a day."

"Tell me how spending time in the bathroom helps you avoid becoming nervous." The response "Tell me how spending time in the bathroom helps you avoid becoming nervous" encourages the client to explore the defenses employed to cope with anxiety. The response "That's not a problem now, because you have your own bathroom here" is a nontherapeutic response that denies the importance of a problematic area of behavior. The response "Tell me more about what you do in the bathroom during those 30-minute periods" focuses on tasks rather than feelings; also, it may be perceived as threatening or judgmental. The response "Let's start by cutting down the time you spend in the bathroom to 20 minutes three times a day" is a nontherapeutic response because it will worsen the client's anxiety. It is too early to start changing the behavior.

Which should the nurse include in the plan of care for the client with vascular dementia: A. A reeducation program B. Details for supportive care C. An introduction of new leisure-time activities D. Plans to involve the client in group therapy sessions

B. Details for supportive care Damaged brain cells do not regenerate. Care is therefore directed towards preventing further damage and providing protection and support.

A nurse concludes that a client's withdrawn behavior may temporarily provide a: A nurse concludes that a client's withdrawn behavior may temporarily provide a: Defense against anxiety Basis for emotional growth Time for internal problem-solving Delay to organize personal resources

Defense against anxiety Rationale Withdrawal provides a temporary defense against anxiety because it limits contact with reality and reduces the client's world. Withdrawal does not provide a basis for emotional growth, time for internal problem-solving, or a delay in which the client can organize personal resources because feelings and anxieties are still present and little attempt is made to work through problems.

A nurse is interviewing a child with attention deficit disorder. For which major characteristic should the nurse evaluate this child? A nurse is interviewing a child with attention deficit disorder. For which major characteristic should the nurse evaluate this child? Overreaction to stimuli Continued use of rituals Delayed speech development Inability to use abstract thought

Overreaction to stimuli Rationale A universal characteristic of children with attention deficit disorder is distractibility. They are highly reactive to any extraneous stimuli, such as noise and movement, and are unable to inhibit their responses to such stimuli. Rituals are uncommon, although these children do use repetition in language and movement. Delayed development of language skills is not the major problem, but children with attention deficit disorder may exhibit dyslexia (reading difficulty), dysgrammatism (speaking difficulty), dysgraphia (writing difficulty), or delayed speech. Loss of abstract thought is not a universal characteristic associated with children with attention deficit disorder.

What clinical findings may be expected when a nurse cares for an individual with an anxiety disorder? (Select all that apply.) What clinical findings may be expected when a nurse cares for an individual with an anxiety disorder? (Select all that apply.) Worrying about a variety of issues Acting out with antisocial behavior Converting the anxiety into a physical symptom Displacing the anxiety onto a less threatening object Demonstrating behavior common to an earlier stage of development

Worrying about a variety of issues Converting the anxiety into a physical symptom Displacing the anxiety onto a less threatening object Demonstrating behavior common to an earlier stage of development Rationale Excessive anxiety and worry about a number of events, topics, or activities for a 6-month duration are the hallmark of generalized anxiety disorder. Converting anxiety into a physical symptom is an example of a conversion disorder, which eases anxiety. Displacing the anxiety onto a less threatening object, which eases anxiety, is typical of a phobic disorder. Regression is an attempt during periods of stress to return to behavior that has been satisfying and is appropriate at an earlier stage of development. Acting out anxiety with antisocial behavior is most commonly found in individuals with personality rather than anxiety disorders.

Encouragement and appropriate praise should be given to hyperactive clients to help them increase their feelings of self-esteem. When they have acted appropriately, what is the best statement for the nurse to make in an effort to let them know of their improvement? Encouragement and appropriate praise should be given to hyperactive clients to help them increase their feelings of self-esteem. When they have acted appropriately, what is the best statement for the nurse to make in an effort to let them know of their improvement? "You behaved well today." "I knew you could behave." "Everyone likes you better when you behave like this." "Your behavior today was much better than it was yesterday."

You behaved well today." Rationale "You behaved well today" simply states a fact and delivers praise without making demands. "I knew you could behave" puts the total responsibility for control on a client who needs to have external controls set. "Everyone likes you better when you behave like this" does not help the client separate the self from the behavior; it tells the client that acting-out behavior will result in rejection. The client may not recall what happened yesterday and may not know why today's behavior is better.

An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using? An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using? Projection Introjection Somatization Rationalization

1. Projection **The client is assigning to others those feelings and emotions that are unacceptable to him- or herself. Introjection is treating something outside the self as if it is inside the self. Somatization is the unconscious transformation of anxiety into a physical symptom that has no organic cause. Rationalization is the use of a socially acceptable logical explanation to justify personally unacceptable material.

What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client? What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client? Contradicting the client's persecutory delusions Accepting the client's statements as the client's beliefs Medicating the client when these thoughts are expressed Redirecting the client whenever a negative topic is mentioned

Accepting the client's statements as the client's beliefs -The nurse must accept the client's statement and beliefs as real to the client to develop trust and move toward a therapeutic relationship. Clients cannot be argued out of delusions. These feelings and thoughts are constant; medicating the client whenever they are expressed could result in an overdose. Redirecting the client's conversation whenever negative topics are brought up may cut off conversation and the development of trust.

A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing? A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing? Fixed delusion Magical thought Pathological regression Command hallucination

Command hallucination Rationale Command hallucinations are auditory hallucinations that give verbal messages to do harm either to the self or others; giving an identity to the hallucinated voice increases the risk of compliance. A delusion is a false belief held to be true even with evidence to the contrary. In magical thinking, the individual believes that thinking about something can make it happen. Magical thinking is common in young children. The data do not indicate the client has regressed to a prior level of development.

Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization? Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization? Board game Project involving drawing Small aerobic exercise group Card game with three other clients

Project involving drawing Rationale An art-type project that may be worked on successfully at one's own pace is appropriate for a depressed client. Board games and card games with three other clients require too much concentration and may increase the client's feelings of despair. This client is probably experiencing psychomotor retardation, and at this time an aerobic exercise group would not be appropriate.

A client who is a polysubstance abuser is mandated to seek drug and alcohol counseling. What is an appropriate initial outcome criterion for this client? A client who is a polysubstance abuser is mandated to seek drug and alcohol counseling. What is an appropriate initial outcome criterion for this client? Verbalizes that a substance abuse problem exists Discusses the effect of drug use on self and others Explores the use of substances and problematic behaviors Expresses negative feelings about the current life situation

Verbalizes that a substance abuse problem exists Rationale The client must first acknowledge that a substance abuse problem exists and is creating chaos; verbalizing that a problem exists indicates that the client is not in denial and is taking the first step toward change. Once a problem is identified, the numerous ways in which drug use has controlled the client's life and the resulting lifestyle problems can be explored and the nurse can help the client express and process negative feelings.

A client being admitted for alcoholism reports having had alcoholic blackouts. The nurse knows that an alcoholic blackout is best described as: A client being admitted for alcoholism reports having had alcoholic blackouts. The nurse knows that an alcoholic blackout is best described as: A fugue state resembling absence seizures Fainting spells followed by loss of memory Loss of consciousness lasting less than 10 minutes Absence of memory in relation to drinking episodes

Absence of memory in relation to drinking episodes Rationale Although the exact cause is unclear, alcoholic blackouts appear to result from responses of central nervous system cells to the substance. The individual does not have any type of seizure during the blackout. Fainting is not associated with the blackout. The individual loses memory but not consciousness.

The nurse is caring for a client with Alzheimer's disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, the nurse will instruct staff to monitor the client: The nurse is caring for a client with Alzheimer's disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, the nurse will instruct staff to monitor the client: At meals to help prevent choking For the presence of mouth ulcers To prevent injury caused by hot foods For attempts at eating inedible objects

For attempts at eating inedible objects -Hyperorality is the compulsive need to taste and chew inedible objects.

A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation? A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation? Ideas of grandeur Need to get attention Marked loss of memory Difficulty accepting the truth

Marked loss of memory -Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered.

A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test? A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test?

"Have you ever felt bad or guilty about your drinking?" -The CAGE screening test for alcoholism contains four questions, corresponding to the letters CAGE: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (as an "Eye-opener") to steady your nerves or get rid of a hangover? "How often did you have a drink containing alcohol in the past year?" is one of the 10 questions on the Alcohol Use Disorders Identification Test (AUDIT). "Do you feel that you are a normal drinker" and "Are you always able to stop drinking when you want to" are two of the 26 questions on the Michigan Alcohol Screening Test (MAST).

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? "I didn't hear anyone talking; come with me to your room." "What you heard was in your head; it was your imagination." "Come to the dayroom and watch television; you'll feel better." "God wouldn't tell you to lie there in the hall. God wants you to behave reasonably."

"I didn't hear anyone talking; come with me to your room." Rationale The nurse is focusing on reality and trying to distract and refocus the client's attention. "What you heard was in your head; it was your imagination" is too blunt and belittling; this approach rarely is effective. "Come to the dayroom and watch television; you'll feel better" is false reassurance; the nurse does not know that the client will feel better. "God wouldn't tell you to lie in the hall; God wants you to behave reasonably" may be interpreted as belittling or an attempt to convince the client that the behavior is irrational, which is usually ineffective.

A client on the psychiatric unit tells the nurse, "The voices have told me that I'm in danger. They say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse to this statement? A client on the psychiatric unit tells the nurse, "The voices have told me that I'm in danger. They say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse to this statement? "Don't worry. You're safe here. Are you afraid that I'll let someone hurt you?" "I know that these voices are real to you, but I want you to know that I don't hear them." "Tell me more about the voices. Are they male or female? How many voices do you hear?" "You need to leave this room and get your mind occupied so the voices don't bother you anymore."

"I know that these voices are real to you, but I want you to know that I don't hear them." Rationale "I know that these voices are real to you, but I want you to know that I don't hear them" demonstrates recognition and acceptance of the client's feelings and also points out reality. "Don't worry. You're safe here. Are you afraid that I will let someone hurt you?" provides false reassurance; the client has no reason to trust that the nurse can provide protection. Focusing on the content of the delusion will reinforce the delusion. Encouraging the client to focus on hallucinations tends to strengthen and confirm them. "You need to leave this room and get your mind occupied so the voices don't bother you anymore" denies the client's feelings and may increase anxiety.

A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse's initial reply? A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse's initial reply? "No, I don't see any bugs." "I'll get rid of them for you." "I'll stay here until you're calmer." "Those bugs are a part of your sickness."

"No, I don't see any bugs." Rationale Telling the client that there are no bugs presents reality and answers the client's question. Offering to get rid of the bugs is entering into the misperception of reality. Offering to stay with the client and telling the client that the bugs are part of her sickness both provide comfort and may reduce anxiety but should each follow the priority intervention of pointing out reality.

An adolescent female with an antisocial personality disorder plans to live with her parents after discharge. The parents request advice on how to respond to their daughter's unruly behavior. What is the most therapeutic response by the nurse? An adolescent female with an antisocial personality disorder plans to live with her parents after discharge. The parents request advice on how to respond to their daughter's unruly behavior. What is the most therapeutic response by the nurse? "Discuss her behavior with her and encourage her to develop self-control." "Avoid setting expectations for her behavior and react to each situation as it arises." "Help her find new friends and encourage her to get a job and assume responsibility for herself." "Set clear limits, explain the consequences if she disregards them, and firmly and consistently apply them."

"Set clear limits, explain the consequences if she disregards them, and firmly and consistently apply them." Rationale Setting clear limits, explaining the consequences of disregarding them, and firmly and consistently applying them are the most therapeutic parental actions; the client must be made accountable for behavior and must know that manipulation and acting-out will not be tolerated. The response "Discuss her behavior with her and encourage her to develop self-control" is probably a continuation of the parents' previous response to the client and is of little value. The response "Avoid setting expectations for her behavior and react to each situation as it arises" may cause the client to continue to act out to test the limit of the parents' endurance. The activities in the response "Help her find new friends and encourage her to get a job and assume responsibility for herself" are outside the parents' control.

An older client is hospitalized with the diagnosis of dementia of the Alzheimer type. The son tearfully tells the nurse, "I should never have allowed my father to live alone like he wanted to do, but he hasn't been this bad! I'm to blame! He didn't even recognize me right off the bat." What response by the nurse is most therapeutic? "I don't think that anybody can blame you. You did what he wanted. Your being here tells us that you care." "I realize that you're upset now. You can visit again when he is more responsive. I'm sure you'll see a change." "Why do you think your father's condition has deteriorated? His forgetfulness is temporary. You'll help if you don't cry." "This must be a difficult time for both of you. Please share some of your other observations with us—that will help us plan his care."

"This must be a difficult time for both of you. Please share some of your other observations with us—that will help us plan his care." Rationale Noting that this must be a difficult time for both father and son and asking the son to share some of his other observations to help the nursing staff plan the father's care focuses on feelings and promotes verbalization, which may ease anxiety and feelings of guilt. Also, it may help the son feel useful. Saying that no one could blame the son because he did what the father wanted and telling the son that his presence indicates caring is a generalized personal opinion; the nurse at this time does not know about the family's relationships. Telling the son that the father will certainly show a change in his behavior provides false reassurance. Asking the son why he thinks that his father's condition has deteriorated is confrontational and may precipitate a defensive response. Moreover, dementia of the Alzheimer type is not temporary and crying should not be discouraged because it helps relieve tension.

A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit of the local community hospital. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After evaluating the client, what should the nurse ask? A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit of the local community hospital. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After evaluating the client, what should the nurse ask? "Exactly when did the weakness begin?" "Is this similar to what you usually experience?" "Would you like to leave the group for a while?" "What emotion were you feeling before you felt the weakness?"

"What emotion were you feeling before you felt the weakness?" Rationale Asking what emotion the client was feeling before he felt the weakness focuses the client on the relationship between emotion and physical symptoms in a nonthreatening, accepting manner. The nurse knows when the weakness began, so it is unnecessary to ask. Asking whether this experience is similar what the client usually experiences does not identify what the person was feeling when the weakness happened. Asking the client whether he would you like to leave the group for a while will provide a secondary gain; it implies sympathy and allows the client to avoid an undesired activity.

A client who had a panic attack yesterday says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." The most therapeutic response by the nurse is: A client who had a panic attack yesterday says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." The most therapeutic response by the nurse is: "It's best that you try to talk about it." "Why don't you want to talk about it now?" "What were you doing yesterday when you first noticed the feeling?" "I understand that you're upset, but don't be concerned, because that feeling probably won't come back."

"What were you doing yesterday when you first noticed the feeling?" Rationale The response "What were you doing yesterday when you first noticed the feeling?" helps the client focus on the situation that precipitated the frightening feelings but not the attack itself. The response "It's best that you try to talk about it" will not help the client focus on his feelings. Asking, "Why don't you want to talk about it now?" will not help the client focus on feelings; also, "why" questions often make people feel defensive. The response "I understand that you're upset, but don't be concerned, because that feeling probably won't come back" is false reassurance; the nurse cannot guarantee that the feelings will not come back.

A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse? A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse? "OK; we don't have to talk about it." "Why don't you want to talk about it?" "What were you doing yesterday when you first noticed the feeling?" "I understand, but don't be concerned; that feeling probably won't come back."

"What were you doing yesterday when you first noticed the feeling?" Rationale The response "What were you doing yesterday when you first noticed the feeling?" helps the client focus on a situation that has precipitated frightening feelings. "OK; we don't have to talk about it" avoids an opportunity for the nurse to help the client explore feelings. The client may not be able to answer the question "Why don't you want to talk about it?" The focus should be on feelings. The response "I understand, but don't be concerned; that feeling probably won't come back" is false reassurance; the nurse cannot guarantee that the feelings will not come back.

A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse? A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse? "Tell me why you did this." "You must have been upset to try to take your life." "Of course you're good; we'll take excellent care of you." "You've been through a rough time; let me take care of you."

"You must have been upset to try to take your life." Rationale Identifying and showing understanding of the client's feelings by giving feedback helps establish a therapeutic relationship and promotes exploration of feelings. Asking why the client attempted suicide is too direct; it does not allow the client time to reflect and explore feelings. Telling the client he or she is good and promising to take care of him or her negates the client's feelings and cuts off any further communication of feelings. Telling the client to let the nurse take care of him or her encourages dependence; it does not permit exploration of feelings.

A depressed client is concerned about many fears that are upsetting and frightening and expresses a feeling of having committed the "unpardonable sin." What is the most therapeutic response by the nurse? A depressed client is concerned about many fears that are upsetting and frightening and expresses a feeling of having committed the "unpardonable sin." What is the most therapeutic response by the nurse? "Your family loves you very much." "You do understand that you really aren't a bad person, right?" "You know that these feelings are in your imagination and aren't true, right?" "Your thoughts are just a part of your illness, and they'll change as you get better."

"Your thoughts are just a part of your illness, and they'll change as you get better." Rationale Telling the client that these thoughts are part of your illness and that they will change as the client gets better points out reality while accepting that the client believes that the feelings and thoughts are real. "Your family loves you very much" is false reassurance; there are no data about the client's family. The client does not know that he or she isn't a bad person; in fact, the client believes the opposite to be true. "You know that these feelings are in your imagination and aren't true" is reality, but it is not a supportive response.

A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil (Aricept) 10 mg/day for 3 months. The client's partner calls the clinic and reports, "He's gotten more restless and agitated, and now he's nauseated." What should the nurse advise the partner to do? A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil (Aricept) 10 mg/day for 3 months. The client's partner calls the clinic and reports, "He's gotten more restless and agitated, and now he's nauseated." What should the nurse advise the partner to do? Give the medication with food Administer the medication to the partner at bedtime Omit one dose today and start with a lower dose tomorrow Bring the partner to the clinic for testing and a physical examination

. Bring the partner to the clinic for testing and a physical examination Rationale Many people with dementia experience physical problems such as urinary tract infections but cannot adequately verbalize what is happening. They may just become more restless and agitated. Because the client has been taking this dose for 3 months, the problems are probably not being caused by the medication. The client should be brought in for an evaluation. Taking the medication with meals is recommended to decrease gastrointestinal side effects, but this client is experiencing more than gastrointestinal effects. Donepezil (Aricept) can cause insomnia. The client is already restless and agitated. Taking the medication at bedtime will not help. The nurse should not advise a modification of the dosage without consulting the health care provider.

A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? (Select all that apply.) A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? (Select all that apply.) Tremors Anorexia Agitation Delusions Confusion

1 Tremors 2 Anorexia -Hand tremors, related to dysfunction of the nervous system, are an early sign of withdrawal from alcohol; alcohol depresses the central nervous system, interferes with nerve conduction, and results in peripheral neuropathy. Signs and symptoms of alcohol withdrawal begin within 12 hours of cessation or decrease in alcohol consumption, peak in 48 to 72 hours, and usually begin to ease after 4 or 5 days. Anorexia, nausea, and vomiting are early signs of withdrawal from alcohol; alcohol affects the gastrointestinal system and can cause gastritis, pancreatitis, hepatitis, and cirrhosis. Psychomotor agitation is a late, not an early, sign of alcohol withdrawal. Transient visual, auditory, and tactile hallucinations, rather than delusions, are associated with alcohol withdrawal. Confusion, disorientation, and impaired cognition are not early signs of alcohol withdrawal; alcohol withdrawal delirium occurs in less than 10% of those who experience the alcohol withdrawal syndrome.

People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? (Select all that apply.) People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? (Select all that apply.) Guilt Denial Altruism Confusion Helplessness

2 Denial 4 Confusion 5 Helplessness -Rationale: Shock and disbelief are the initial responses to a traumatic experience; a situational crisis usually is unexpected, and its impact causes disequilibrium. Disequilibrium results in confusion, disorganization, and difficulty making decisions. When a person is unable to cope, helplessness and regression often emerge; a crisis occurs when there is a painful, frightening event that is so overwhelming an individual's usual coping mechanisms are inadequate.

A daycare environment is recommended for a client with incapacitating behaviors resulting from an obsessive-compulsive personality disorder. The client's partner asks the nurse why this approach is necessary. What is the best response by the nurse? A daycare environment is recommended for a client with incapacitating behaviors resulting from an obsessive-compulsive personality disorder. The client's partner asks the nurse why this approach is necessary. What is the best response by the nurse? "This environment limits time to carry out the rituals." "A neutral atmosphere facilitates the working through of conflicts." "A location that requires no decision-making will resolve feelings of anxiety." "The daycare setting allows the staff to exert control over unacceptable behaviors."

A neutral atmosphere facilitates the working through of conflicts." -These clients can better work through their underlying problems when the environment is structured, demands are reduced, and the routine is simple

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? Telling the other clients to disregard what the client is saying Ignoring the client's disruptive behavior and waiting for it to subside Restricting the client's contact with other clients until the disruptive behavior ceases Accepting that the client is unable to control this behavior and setting appropriate limits

Accepting that the client is unable to control this behavior and setting appropriate limits Rationale Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.

Which activity is the least therapeutic for a severely depressed client? Simple short-term activity Activity selected by the client Monotonous, repetitive activity Specific activity to be followed

Activity selected by the client Rationale It is unreasonable to expect a severely depressed client to select an activity. Severely depressed clients are not motivated to take action or to plan ahead. They are unable to direct their energy toward the environment. If they do select an activity, it may be too difficult for them to complete. Simple short-term activities are helpful for a severely depressed client whose attention span is limited. Monotonous, repetitive activity is helpful to a severely depressed client because it requires little thought and provides gratification and satisfaction. A specific activity is helpful for a person who is experiencing depression or who is cognitively impaired.

On the third day of hospitalization, a client with a history of heavy drinking begins experiencing alcohol withdrawal delirium. What is the most appropriate response by the nurse when the client begins experiencing hallucinations? On the third day of hospitalization, a client with a history of heavy drinking begins experiencing alcohol withdrawal delirium. What is the most appropriate response by the nurse when the client begins experiencing hallucinations? Withholding intervention, because the client may be having vivid dreams Asking the client to describe the hallucinations and explaining that they are not real Administering the prescribed medication to the client to subdue the agitated behavior Pretending to visualize the imaginary things the client is describing to foster acceptance

Administering the prescribed medication to the client to subdue the agitated behavior -The nurse must administer the prescribed medication to the client to subdue the agitated behavior in this life-threatening situation. The client's central nervous system (CNS) is overstimulated, and seizures and death can occur. CNS-depressant medications, usually benzodiazepines, are needed to blunt the withdrawal effects.

A nurse is caring for a client with dementia. Which clinical manifestations are expected? (Select all that apply.) A nurse is caring for a client with dementia. Which clinical manifestations are expected? (Select all that apply.) Agitation Pessimism Short attention span Disordered reasoning Impaired motor activities

Agitation Short attention span Disordered reasoning Impaired motor activities Rationale: The behavior of clients with dementia tends to be inappropriate, restless, and agitated. Cognitive abilities are impaired, as evidenced by a short attention span, limited ability to focus, and limited judgment and insight. Reasoning is disordered, speech may be incoherent, and memory, particularly short-term memory, is impaired. Impaired motor activity (apraxia) and impaired coordination (ataxia) are associated with dementia. Pessimism is more characteristic of depression, not dementia. The two often occur together and should be identified and treated appropriately.

A middle-age female client who has lost 20 lb over the last 2 months cries easily, sleeps poorly, and refuses to participate in any family or social activities that she previously enjoyed. What is the most important nursing intervention? A middle-age female client who has lost 20 lb over the last 2 months cries easily, sleeps poorly, and refuses to participate in any family or social activities that she previously enjoyed. What is the most important nursing intervention? Providing the client with a high-calorie, high-protein diet Reducing the client's crying episodes by setting firm, consistent limits Assuring the client that she will regain her usual function in a short time Allowing the client to externalize her feelings, especially anger, in a safe manner

Allowing the client to externalize her feelings, especially anger, in a safe manner Rationale When a client exhibits adaptations related to depression, the greatest danger is self-inflicted injury when feelings, especially anger, are internalized. There are not enough data to show that the weight loss is the result of malnutrition. The client is unable to regulate her crying at this time. Assuring the client that she will regain her usual function in a short time is false reassurance and is not supportive of the client's feelings.

A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel: A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel: Angry Dependent Inadequate Ambivalent

Angry Rationale A person with a condescending, superior attitude frequently evokes feelings of anger in others and will increase their anxiety. It is unlikely that a condescending, superior attitude will produce feelings of dependency, inadequacy, or ambivalence in others.

A client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. Which finding should the nurse consider consistent with this diagnosis? A client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. Which finding should the nurse consider consistent with this diagnosis? Feeling depressed Appearing composed Demonstrating free-floating anxiety Exhibiting tension when discussing symptoms

Appearing composed Rationale The client with a conversion disorder literally converts the anxiety to the symptom. Once the symptom develops, it serves as a defense against the anxiety and the client is diagnostically almost anxiety free. In a conversion disorder, the reactions the nurse should expect to encounter are not in proportion to the disability; therefore the affected client is usually not depressed. The conflict is resolved by the paralysis of the legs; therefore the anxiety is under control. These clients usually are calm and composed, not tense, when discussing symptoms.

A nurse is caring for several clients who are going through withdrawal from alcohol. The primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they: A nurse is caring for several clients who are going through withdrawal from alcohol. The primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they: Are dependent on it Lack the motivation to stop Have no other coping mechanism Enjoy the associated socialization

Are dependent on it Rationale Alcohol causes both physical and psychological dependence; the individual needs and depends on the alcohol to function. The theory that alcoholics have no other coping mechanism is a myth that often is associated with alcoholism; the individual needs to learn how to use other coping mechanisms more consistently and effectively. People with alcoholism commonly drink alone or feel alone in a crowd.

An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get the urge to do it, too." What is the most appropriate response by the nurse? An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get the urge to do it, too." What is the most appropriate response by the nurse? Asking the client, "Have you ever acted on these thoughts?" Explaining that these thoughts are unacceptable and that intensive therapy is needed. Asking the client, "Are you able to control your thoughts about sexual relations with children?" Informing the appropriate child protective services about the client and the thoughts that the client has reported

Asking the client, "Have you ever acted on these thoughts?" Rationale If a client reveals a predilection for pedophilia, it is most important to determine whether the client has ever acted on these thoughts, because the best predictor of future behavior is past behavior. No human thoughts are unacceptable; therapy is indicated if they are ego-dystonic. Humans may have bizarre sexual fantasies, but it is their behavior, not their thoughts, by which they will be judged. Informing the appropriate child protective services about the client and the thoughts that the client has reported is premature; the nurse has not obtained information about whether the client has acted on these thoughts.

A nurse is assigned to care for a college student who has been talking to unseen people and refusing to get out of bed, go to class, or participate in daily grooming activities. What is the nurse's initial effort toward helping this client? A nurse is assigned to care for a college student who has been talking to unseen people and refusing to get out of bed, go to class, or participate in daily grooming activities. What is the nurse's initial effort toward helping this client? Providing frequent rest periods Reducing environmental stimuli Facilitating the client's social relationships with a peer group Attempting to establish a meaningful relationship with the client

Attempting to establish a meaningful relationship with the client Rationale The first step in a plan of care should be the establishment of a meaningful relationship because it is through this relationship that the client can be helped. This client is not getting out of bed; rest periods are not needed. The client has already reduced environmental stimuli by staying in bed; further reduction is not needed. Establishing social relationships is a long-term goal.

An adolescent is admitted to the psychiatric service in stable physical condition with the diagnosis of anorexia nervosa. The adolescent has lost 20 lb in 6 weeks and is very thin but is excessively concerned about being overweight. What is the most important initial nursing intervention? An adolescent is admitted to the psychiatric service in stable physical condition with the diagnosis of anorexia nervosa. The adolescent has lost 20 lb in 6 weeks and is very thin but is excessively concerned about being overweight. What is the most important initial nursing intervention? Complimenting the physical appearance of the adolescent Explaining the value of adequate nutrition to the adolescent Exploring the reasons that the adolescent does not want to eat Attempting to establish a trusting relationship with the adolescent

Attempting to establish a trusting relationship with the adolescent Rationale The problem is psychological. Therefore the nurse's initial approach should be directed toward establishing trust. The client is convinced that he or she is overweight; complimenting the client will not change his or her self-perception. The client is not ready for nutrition information. Exploring the reasons that the adolescent does not want to eat may be appropriate after trust has been established.

A nurse is caring for a client with generalized anxiety disorder. Which factor should be evaluated to determine the client's present status? A nurse is caring for a client with generalized anxiety disorder. Which factor should be evaluated to determine the client's present status? Memory Behavior Judgment Responsiveness

Behavior Rationale The client's current behavior is the best indicator of the client's current level of function; all behavior has meaning. Memory, judgment, and responsiveness are all important and should be evaluated, but none is the best indicator of the client's current level of function.

A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors? Bipolar disorder, manic phase Antisocial personality disorder Obsessive-compulsive disorder Chronic undifferentiated schizophrenia

Bipolar disorder, manic phase This kind of hyperactive behavior is typical of the manic flight into reality associated with mood disorders. The behaviors are more indicative of a mood disorder than a personality disorder. Ritualistic, not manic, behavior is indicative of obsessive-compulsive disorder. A flat affect and apathy are more indicative of a schizophrenic disorder.

An adolescent with a major depressive disorder is prescribed venlafaxine (Effexor). What signs or symptoms related to the medication should the nurse communicate immediately to the prescribing provider? (Select all that apply.) An adolescent with a major depressive disorder is prescribed venlafaxine (Effexor). What signs or symptoms related to the medication should the nurse communicate immediately to the prescribing provider? (Select all that apply.) Blurred vision Suicidal ideation Difficult urination Tardive dyskinesia Transient hypoglycemia

Blurred vision Suicidal ideation Difficult urination Rationale Abnormal vision (e.g., blurred or double vision) is a side effect of venlafaxine (Effexor). Central nervous system effects such as emotional lability, vertigo, anxiety, insomnia, and suicidal ideation in children and adolescents are side effects of venlafaxine. Difficult or painful urination is a serious side effect of venlafaxine; impairment of urine flow can lead to urinary tract infection and renal failure. Extrapyramidal side effects such as tardive dyskinesia do not occur with venlafaxine. Transient hypoglycemia is not a side effect of venlafaxine.

A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence? A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence? Eases pain Blurs reality Clears the sensorium Decreases motor activity

Blurs reality Rationale The addict tries to avoid stress and reality. The drug produces a blurring of these feelings to the point that the addict becomes dependent on it. The psychological effect is usually more important than the ability to ease pain. Large doses of opioids, not cocaine, can cause a dreamlike state. Cocaine can increase, not decrease, motor activity.

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? (Select all that apply.) The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? (Select all that apply.) Bouts of crying Self-destructive acts Presence of delusions Feelings of worthlessness Intense interpersonal relationships

Bouts of crying Self-destructive acts Feelings of worthlessness

A male client with the diagnosis of pedophilia is admitted to the psychiatric hospital because of repeated episodes of exhibitionism. In the recreation room the client exposes himself to a nurse and begins to masturbate. How should the nurse respond? A male client with the diagnosis of pedophilia is admitted to the psychiatric hospital because of repeated episodes of exhibitionism. In the recreation room the client exposes himself to a nurse and begins to masturbate. How should the nurse respond? By turning away from the client and ignoring the behavior By telling the client that the behavior is unacceptable and to stop By removing the client from the recreation room and escorting him to his own room By recognizing that the behavior is part of his illness and obtaining a prescription for a libido-lowering medication

By telling the client that the behavior is unacceptable and to stop -Exposing the genitals and masturbating in a public place are unacceptable behaviors. Unacceptable behavior should be pointed out to the client and the client should be instructed to stop.

A client has been receiving oxycodone (OxyContin) for moderate pain associated with multiple injuries sustained in a motor vehicle collision. The client has returned three times for refills of the prescription. What behavior, in addition to the client's slurred speech, leads the nurse to suspect opioid intoxication? A client has been receiving oxycodone (OxyContin) for moderate pain associated with multiple injuries sustained in a motor vehicle collision. The client has returned three times for refills of the prescription. What behavior, in addition to the client's slurred speech, leads the nurse to suspect opioid intoxication? Mood lability Hypervigilance Constricted pupils Increased respirations

Constricted pupils -Pupil constriction is a physical response to opioid intoxication; the pupils will dilate with opioid overdose. Opioids cause apathy or a depressed, sad mood (dysphoria); lability of mood is associated with the use of anabolic-androgenic steroids. Opioids cause drowsiness and psychomotor retardation; alertness is associated with the use of stimulants such as caffeine and amphetamines. Opioids depress the respiratory center of the brain, causing slow, shallow respirations; increases in temperature, pulse, respirations, and blood pressure are associated with cocaine use.

Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing? Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing? Illusion Delusion Confabulation Hallucination

Delusion Rationale A delusion is a fixed false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client's attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.

A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing? Flight of ideas Idea of reference Delusion of grandeur Auditory hallucination

Delusion of grandeur A delusion of grandeur is a fixed false belief that the person is a powerful, important person. A flight of ideas is an increase in the speed of thinking causing the person to shift from one idea to another without completing the previous idea; it is often expressed with pressured speech. An idea of reference is an incorrect interpretation of an external event as having a special meaning to the person. An auditory hallucination is experienced when a person hears voices without external stimuli.

A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing? Hallucination Error in judgment Delusion of persecution Self-accusatory delusion

Delusion of persecution A A delusion of persecution is a fixed and firm belief or a feeling of being harassed, in danger, or at the mercy of others. Hallucinations are perceived experiences that occur in the absence of actual sensory stimulation. An error in judgment is poor decision-making, not a distortion of reality like a delusion. In a self-accusatory delusion the person accepts blame for an act that never was committed.

In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting: In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting: Ideas of reference Loose associations Delusional thinking Tactile hallucinations

Delusional thinking Rationale Delusions are false fixed beliefs that have a minimal basis in reality. This is a somatic delusion. Ideas of reference are false beliefs that every statement or action of others relates to the individual. Loose associations are verbalizations that sound disjointed to the listener. Tactile hallucinations are false sensory perceptions of touch without external stimuli.

A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, the nurse determines that the client is experiencing: A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, the nurse determines that the client is experiencing: Illusions Hallucinations Delusional thoughts Neologistic thinking

Delusional thoughts Rationale The client's statement reveals the cognitive disturbance called a delusion, which is a fixed set of false beliefs that cannot be corrected by reason. An illusion is a misperception of an actual environmental stimulus. A hallucination is a sensory experience, unrelated to external stimuli. Neologisms are made-up words understood only by the speaker.

A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual? A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual? It demonstrates respect for the client's autonomy. This behavior is viewed as a result of anger turned inward. Denying this activity may precipitate an increased level of anxiety. Successful performance of independent activities enhances self-esteem.

Denying this activity may precipitate an increased level of anxiety. Rationale The repeated thought or act defends the client against severe anxiety; the client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level. Compulsive behaviors are not autonomous choices. The client is compelled to perform the activity to reduce anxiety. Anxiety reduction, not anger, is the motivation for performing the ritual. Rituals are not activities that enhance self-esteem; they control anxiety. The client may be ashamed of the rituals that cannot be stopped.

A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of: A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of: Apathy versus anger Trust versus mistrust Intimacy versus isolation Dependence versus independence

Dependence versus independence Rationale A conflict exists between wanting to be taken care of and wanting to be self-reliant; ambivalence fosters lowered self-esteem. Apathy versus anger does not relate to the behavior described; people usually do not alternate these emotions, which are at opposite ends of the spectrum. Trust versus mistrust is the developmental conflict of the infant, according to Erikson; it is not related to the behavior described. Intimacy versus isolation is the developmental conflict of the young adult, according to Erikson; it is not related to the behavior described.

A 6-year-old child recently started school but has been refusing to go for the past 3 weeks. The nurse determines that an appropriate intervention for this child is to: Explain that school is a place to have fun Delay the return to school for several months Enroll the child in a special education program Develop a behavior modification program with the child

Develop a behavior modification program with the child A behavior modification program tailored for and developed with the individual child is the most appropriate approach at this time. School may or may not be a place to have fun. The child may not like school and may not think that it is fun, but having fun is not the purpose of school. Delaying the child's return to school for several months serves no purpose and may be viewed by the child as a reward for the behavior. There are no data to indicate that the child is in need of special education.

A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? Chronic confusion Disordered thinking Rigid personal boundaries Violence directed toward others

Disordered thinking Rationale The schizophrenic individual has neurobiological changes that cause disorders in thought process and perceiving reality. Chronic confusion and disorientation are not usually associated with this disorder. Illogical thinking and impaired judgment are associated with schizophrenia. Individuals with the diagnosis of schizophrenia often have personal boundary difficulties. They lack a sense of where their bodies end in relation to where others begin. Loss of ego boundaries can result in depersonalization and derealization. Most clients with schizophrenic disorders are not violent.

When a client is expressing severe anxiety by sobbing in the fetal position on her bed, the nurse's priority is: When a client is expressing severe anxiety by sobbing in the fetal position on her bed, the nurse's priority is: Ensuring a safe therapeutic milieu Monitoring and documenting vital signs Eliminating the cause of the client's anxiety Ensuring that the client's physical needs are met

Ensuring a safe therapeutic milieu Rationale Client safety is the nurse's first priority, and because the client has not experienced any physical injuries and is not at risk, attention should be directed toward psychiatric risk, in this case crisis control. The severely stressed individual is likely to experience increased vital signs and will continue to have physiological needs such as food and water; however, these issues do not take the priority over a psychiatric crisis. The client will not be able to concentrate on therapy related to identifying the source of the anxiety until the crisis has been managed.

What is the most appropriate nursing intervention when a client is seen openly masturbating in the recreation room? What is the most appropriate nursing intervention when a client is seen openly masturbating in the recreation room? Restraining the client's hands Putting the client in seclusion Escorting the client from the room Teaching the client acceptable behavior

Escorting the client from the room Rationale Escorting the client from the room accepts the client but rejects the behavior. The nurse should set limits on this behavior when it is not performed in a private area. Restraining the client's hands is unrealistic and violates the client's rights. Putting the client in seclusion is a punishment rather than a setting of limits. The client may be too anxious at this time to understand a conversation about acceptable and unacceptable behavior. The nurse has a responsibility to the other clients to limit the behavior.

A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feeling stop." What clinical manifestation is evident? A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feeling stop." What clinical manifestation is evident? Feelings of panic Suicidal tendencies Narcissistic ideation Demanding personality

Feelings of panic Rationale The client can no longer control or tolerate these overwhelming feelings and is seeking help. The client has not indicated plans for self-harm. Narcissistic ideation is not typical of a narcissistic personality. The client's behavior does not indicate a demanding personality.

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates that she is hearing voices. When a nurse begins to walk toward her, the client pulls out a large knife. What is the best approach by the nurse? A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates that she is hearing voices. When a nurse begins to walk toward her, the client pulls out a large knife. What is the best approach by the nurse? Firm Passive Empathetic Confrontational

Firm Rationale A firm approach prevents anxiety transference and provides structure and control for a client who is out of control. A passive approach for a client who may be out of control does not provide structure, which may increase the client's anxiety. Although the nurse should always base a therapeutic response on empathy, an obviously empathetic response may indicate to the client that the behavior is acceptable. A confrontational approach in this situation may escalate the client's agitation and precipitate further acting out.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate: During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate: Flight of ideas Ritualistic behaviors Associative looseness Auditory hallucinations

Flight of ideas Rationale Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive? What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive? Foster a trusting relationship Administer medications on time Involve the client in a group with peers Remove the client from the family home

Foster a trusting relationship Rationale An interpersonal relationship based on trust must be established before a client can be helped. Administering medications on time is an important part of the treatment and care, but it is of lesser importance than a trusting relationship. Socialization comes at a later point in therapy. There is nothing to indicate a need to remove the client from the home.

An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention? An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention? Instructing the client to be quiet Allowing the client to act out until fatigue sets in Guiding the client from the room by gently holding the client's arm Giving the client one simple direction at a time in a firm low-pitched voice

Giving the client one simple direction at a time in a firm low-pitched voice Rationale Clients who are out of control are seeking control and frequently respond to simple directions stated in a firm voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client's arm is done only after an attempt at calming the client has failed.

A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing? Guilt Paranoia Euphoria Satisfaction

Guilt Rationale A sense of being out of control accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one's self. Paranoia is associated with paranoid schizophrenia, not with bulimia nervosa. After bingeing, a person with bulimia nervosa usually feels depressed rather than euphoric.

What is an appropriate way for a nurse to help a client ease anxiety? What is an appropriate way for a nurse to help a client ease anxiety? Avoid unpleasant events Prolong exposure to fearful situations Introduce an element of pleasure into fearful situations Help the client acquire skills with which to face stressful events

Help the client acquire skills with which to face stressful events Rationale Learning a variety of coping mechanisms helps reduce anxiety in stressful situations. A person must learn to cope with unpleasant events; they cannot be avoided. Prolonged exposure may increase anxiety to possibly uncontrollable levels. Fearful situations can never be viewed as pleasurable.

What should a nurse do when caring for a client whose behavior is characterized by pathological suspicion? What should a nurse do when caring for a client whose behavior is characterized by pathological suspicion? Protect the client from environmental stress Help the client feel accepted by the staff on the unit Ask the client to explain the reasons for the feelings Help the client realize that the suspicions are unrealistic

Help the client feel accepted by the staff on the unit Rationale Delusions are protective and can be abandoned only when the individual feels secure and adequate. Helping the client feel accepted by the staff is the only response directed at building the client's security and reducing anxiety. Protecting the client from environmental stress is almost impossible. A client cannot be argued out of a delusion. The client is unable to explain the reason for the feelings.

A nurse uses behavior modification to foster toilet-training efforts in a cognitively impaired child. What reward should the nurse provide to reinforce appropriate use of the toilet? A nurse uses behavior modification to foster toilet-training efforts in a cognitively impaired child. What reward should the nurse provide to reinforce appropriate use of the toilet? Candy bar Piece of fruit Hug with praise Choice of rewards

Hug with praise Rationale Secondary reinforcers involve social approval; a hug meets this requirement. Food is a primary reinforcer and should not be associated with behavior modification. The child may not be capable of choosing an appropriate secondary reinforcer. TABLE 26-3 TYPES OF REINFORCEMENT TYPE DEFINITION EXAMPLE Positive A pleasant or desirable behavior occurs and a positive reinforcer or consequence is added to increase the frequency of the response. A teacher smiling at a student during class when the student gives a correct response to a question Negative A behavior is used to stop or avoid a stimulus or condition that is undesirable. Testing the temperature of the water before stepping into the shower so as to not be burned Punishment A negative consequence is given in response to an undesirable behavior to weaken the frequency. Giving a child a time out or removing points for hitting another child Extinction The connection between a behavior and a response is broken by removing the reinforcer. Ignoring or walking away when a child engages in a temper tantrum

A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The statement that best describes how clients with obsessive-compulsive behavior view this disorder is: "I know there's no reason to do these things, but I can't help myself." "I don't know why everyone's upset with me—I'm doing nothing wrong." "The things I do take a little time, but they make me a productive person." "The devil makes me do it—it's not my fault that I constantly act this way."

I know there's no reason to do these things, but I can't help myself." Rationale Intellectually the person knows that the compulsive acts are senseless but is unable to stop doing them because they control anxiety. "I don't know why everyone is upset with me—I'm doing nothing wrong" is an example of denial. Most people with compulsive behaviors are not in denial. "The things I do take a little time, but they make me a productive person" is rationalization; obsessive-compulsive behavior is usually counterproductive and time consuming and interferes with function. "The devil makes me do it—it's not my fault that I constantly act this way" is an example of delusional thinking.

When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic? When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic? "Everyone is important." "Do you feel that you're not important?" "Why do you feel that you're not important?" "I want to talk with you because you are important to me."

I want to talk with you because you are important to me." -The response "I want to talk with you because you are important to me" is an expression of the nurse's positive thoughts about the client and lets the client know that the nurse is concerned.

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? Inept Eccentric Impulsive Dependent

Impulsive Rationale Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Inept behavior, by itself, is not typical of clients with any specific personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is more typical of the client with a dependent personality disorder.

A college student is brought to the mental health clinic by his parents. The diagnosis is borderline personality disorder. Which factors in the client's history support this diagnosis? (Select all that apply.) A college student is brought to the mental health clinic by his parents. The diagnosis is borderline personality disorder. Which factors in the client's history support this diagnosis? (Select all that apply.) Impulsiveness Lability of mood Ritualistic behavior Psychomotor retardation Self-destructive behavior

Impulsiveness 2. Lability of mood 5. Self-destructive behavior

A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? (Select all that apply.) A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? (Select all that apply.) Impulsivity Panic attacks Unemployment Religious beliefs Substance abuse Sense of responsibility to family

Impulsivity Panic attacks Unemployment Substance abuse Rationale Impulsivity, panic attacks, unemployment, and substance abuse have all been linked with an increased risk for suicide. A sense of responsibility to family and religious beliefs are considered protective factors that may lessen the risk of suicide.

Which suicide method is the least lethal? Which suicide method is the least lethal? Hanging Ingesting pills Jumping from a tall bridge Poisoning with carbon monoxide

Ingesting pills Rationale Ingesting pills is considered the least lethal of these suicide methods because it is considered slower. Hanging, jumping, and carbon monoxide poisoning are all quicker and therefore more lethal methods.

A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity? A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity? Find solitary pursuits that the client can enjoy Speak to the client about the importance of entering into activities Ask the health care provider to speak to the client about participating Invite another client to take part in a joint activity with the nurse and the client

Invite another client to take part in a joint activity with the nurse and the client. Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the health care provider to speak to the client about participating transfers the nurse's responsibility to the health care provider.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? Feels undeserving of the food Is too busy to take the time to eat Wishes to avoid others in the dining room Believes that there is no need for food at this time

Is too busy to take the time to eat Rationale Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk? A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk? "It's time for you to go for a walk now." "Do you want to take your scheduled walk now?" "When would you like to go for your walk today?" "You're supposed to be going for your walk now."

It's time for you to go for a walk now." Rationale Telling the client that it is time to take a walk is concise and does not require decision-making; it is therefore less likely to increase anxiety. "Do you want to take your scheduled walk now?" asks the client to make a decision when a refusal is unacceptable. Requiring the client to make a decision when acutely ill may increase anxiety; also, it permits the unacceptable answer of "never." "You're supposed to be going for your walk now" is somewhat accusatory; it may increase anxiety by placing responsibility on the client.

An agitated, acting-out, delusional client is receiving large doses of haloperidol (Haldol), and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations should alert the nurse to stop the drug immediately? (Select all that apply.) An agitated, acting-out, delusional client is receiving large doses of haloperidol (Haldol), and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations should alert the nurse to stop the drug immediately? (Select all that apply.) Jaundice Dizziness Tachycardia Lethargic behavior Extrapyramidal symptoms

Jaundice Tachycardia Rationale Jaundice signifies liver function interference and requires that the medication be stopped. Tachycardia, QT-interval prolongation, and cardiac arrest are life-threatening cardiovascular effects of haloperidol (Haldol). Dizziness due to orthostatic hypotension usually subsides after several weeks of treatment. Lethargy and drowsiness usually subside after several weeks of treatment. Extrapyramidal symptoms usually require that the dose be reduced or can be treated with other medications; if symptoms do not subside, then the drug is stopped.

An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately? An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately? Probate judge Client's family Client's psychiatrist Law enforcement officer

Law enforcement officer Rationale Legally it is the responsibility of the staff to notify law enforcement officers so the client can be apprehended. A judge may be involved later in a nonemergency situation. Although the client's family and psychiatrist will be notified eventually, neither is the priority.

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? Shutting the client's door during the night Applying a vest restraint when the client is in bed Leaving a dim light on in the client's room at night Administering the client's prescribed as-needed sedative medication

Leaving a dim light on in the client's room at night Rationale A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults because they may cause further confusion and agitation.

A client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol (Haldol) tablets orally to reduce agitation and preoccupation with auditory hallucinations. There has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started. What should the nurse's priority intervention be? A client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol (Haldol) tablets orally to reduce agitation and preoccupation with auditory hallucinations. There has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started. What should the nurse's priority intervention be? Asking the health care provider to change the medication Making certain that the client is swallowing the medication Concluding that a therapeutic level of the drug has not been achieved Securing a prescription for as-needed sedation until the client calms down

Making certain that the client is swallowing the medication Rationale Because the medication is being taken orally, the client may be pocketing the tablet in the buccal cavity and discarding it later; the nurse must check to ensure that the administered medication is swallowed. Asking the health care provider to change the medication, may not be a response failure. If the client is swallowing the medication, this may be necessary; the nurse first should ensure that the medication is swallowed. This medication reaches a peak of action in 3 to 5 hours.

A client with a history of substance abuse is brought to the emergency department. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing? A client with a history of substance abuse is brought to the emergency department. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing? Alcohol Fentanyl Oxycodone Methamphetamine

Methamphetamine Rationale Methamphetamine is a stimulant that increases the heart rate and blood pressure. It can cause hyperthermia, convulsions, and death. Alcohol is a central nervous system (CNS) depressant. Overdose of alcohol leads to a decreased level of consciousness and respiratory depression. Fentanyl and oxycodone are opioid and CNS depressants. Overdose leads to hypotension, a decreased level of consciousness, and respiratory depression.

A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? Mild Panic Severe Moderate

Mild Rationale A person with mild anxiety has a broad perceptual field and increased problem-solving abilities. A moderately anxious person shuts out peripheral events and focuses on central concerns but has a decreased ability to problem solve. Panic is characterized by a completely disruptive perceptual field. With severe anxiety, the perceptual field is reduced, as is the ability to focus on details.

What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol? What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol? Motivational readiness Availability of community resources Accepting attitude in the client's family Qualitative level of the client's physical state

Motivational readiness Rationale Intrinsic motivation, stimulated from within the learner, is essential if rehabilitation is to be successful. Often clients are most emotionally ready for help when they have "hit bottom." Only then are they ready to face reality and put forth the necessary energy and effort to change behavior. The availability of community resources and the qualitative level of the client's physical state are important factors, but neither is the most important one. An accepting attitude on the part of the client's family is an important factor and a helpful one, but not the most important one.

Which client statement supports the diagnosis of somatic delusions? "I wear this coat all the time to keep them from x-raying my organs" "The president of France and I will be announcing our engagement soon." "My heart stopped beating 3 days ago, and now my lungs are rotting away." "The government has assigned a team of assassins to kill me because I know too much."

My heart stopped beating 3 days ago, and now my lungs are rotting away." Rationale A somatic delusion is a belief that the body is changing or behaving in an unusual way (e.g., the client's heart stopping and the lungs rotting away). Erotomanic delusions are focused on the belief that another person (usually famous or otherwise unattainable) is romantically interested in the client. Control delusions center on the belief that others are attempting to control or affect the person in some manner. Persecutory delusions involve beliefs that one is being singled out for harm.

On the fifth day of hospitalization the nurse notes that a depressed client remains lying on her bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat? On the fifth day of hospitalization the nurse notes that a depressed client remains lying on her bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat? Have a lunch tray sent to the client's room Offer to accompany the client to the dining room Explain that all clients are expected to go to the dining room for meals Provide information about the importance of eating to maintain health

Offer to accompany the client to the dining room Rationale The client will be most likely to eat if accompanied and encouraged by an individual with whom a trusting relationship has been established. Having a lunch tray sent to the client's room will not encourage the client to eat and will promote isolation. Explaining that all clients are expected to go to the dining room for meals will be ineffective at this time; the client is too introspective to care. The client is not interested in maintaining health and is not ready for any teaching.

At a staff meeting, the question of a staff nurse's returning to work after completing a drug rehabilitation program is discussed. What is the most therapeutic way for the staff to handle the nurse's return? At a staff meeting, the question of a staff nurse's returning to work after completing a drug rehabilitation program is discussed. What is the most therapeutic way for the staff to handle the nurse's return? Offering the nurse support in a straightforward manner Avoiding mention of the problem unless the nurse brings it up Having another staff member keep the nurse under close observation Ensuring that the nurse is assigned to administer only noncontrolled medications

Offering the nurse support in a straightforward manner Rationale Offering the nurse support in a straightforward manner allows the individual to include the staff in her support system and removes an opportunity to deny the problem. Avoiding mentioning the problem unless the nurse brings it up supports and permits denial; both the individual and the staff know that a problem exists. Having another staff member keep the nurse under close observation is a nonprofessional approach that is nontherapeutic. Although refraining from handling controlled medications may be part of a return-to-work contract, it is not necessarily therapeutic; it simply reduces legal risks.

A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the health care provider makes the diagnosis of Munchausen syndrome by proxy. What is the most therapeutic approach by the nurse to the involved parent? A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the health care provider makes the diagnosis of Munchausen syndrome by proxy. What is the most therapeutic approach by the nurse to the involved parent? Confrontation Open communication Health teaching about child-rearing Validation of the child's physical status

Open communication Rationale Maintaining open communication is important for any therapeutic nurse-client relationship. Confrontation will put the parent on the defensive and close off communication. Health teaching at this time is premature; the parent is not ready for this approach. Validation of the child's physical status focuses on the physical symptoms, which will reinforce the parent's behavior.

A nurse is caring for a client during the manic phase of bipolar disorder. What should the nurse do to best help meet the nutritional needs of this client? A nurse is caring for a client during the manic phase of bipolar disorder. What should the nurse do to best help meet the nutritional needs of this client? Provide a tray in the client's room Assure the client that the food is deserved Point out that the energy the client is burning up must be replaced Order foods that the client can hold in the hand to eat while moving around

Order foods that the client can hold in the hand to eat while moving around Rationale The hyperactive client should be given handheld foods that do not require sitting down to eat. The client most likely will ignore the tray. Unworthy feelings may be part of a depressive, not manic, episode. It is unlikely that the client will understand or care about the need to replenish lost energy.

A nurse concludes that a client has successfully achieved the long-term goal of mobilizing effective coping responses when the client states that when he feels himself getting anxious he will: A nurse concludes that a client has successfully achieved the long-term goal of mobilizing effective coping responses when the client states that when he feels himself getting anxious he will: Perform a relaxation exercise Get involved in some type of quiet activity Avoid the situation that precipitated the anxiety Examine carefully what precipitated the anxiety

Perform a relaxation exercise Rationale Relaxation techniques refocus energy and eventually ease physical and emotional stress. Getting involved in some type of quiet activity is not always possible; forced quiet activity may increase stress and anger rather than reduce it. Avoiding the situation that precipitated the anxiety is not always possible; stress can develop from a variety of feelings stimulated by many situations. What precipitated feelings of anxiety is not easy to identify; it is better to learn to deal with feelings once they develop.

A client who is being treated for schizophrenia, paranoid type, arrives at the clinic demonstrating a shuffling gait and tilting his head toward one shoulder. What should the nurse conclude about these clinical manifestations? A client who is being treated for schizophrenia, paranoid type, arrives at the clinic demonstrating a shuffling gait and tilting his head toward one shoulder. What should the nurse conclude about these clinical manifestations? Expected characteristics of this illness Consistent with an acute exacerbation of the illness Possible side effects of the antipsychotic medication Life-threatening and requiring immediate intervention

Possible side effects of the antipsychotic medication Rationale Shuffling gait and torticollis are symptoms of pseudoparkinsonism that are caused by antipsychotic medications, particularly the typical antipsychotics. Expected characteristics of schizophrenia, paranoid type, include delusions, hallucinations, suspiciousness, anger, hostility, and paranoia. Although these physical manifestations require intervention, they are not life threatening. An acute exacerbation of the illness reflects an increased intensity of the expected characteristics associated with paranoid schizophrenia, which include pressured speech, suicidal ideation, and aggressive, agitated behavior.

The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do? The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do? Hang a list of medications with the times at which the spouse should take them Prefill a weekly drug box with the medications for the spouse to self-administer Remind the spouse in the morning which medications must be taken during the day Provide the spouse with the medications at the appropriate times they should be taken

Prefill a weekly drug box with the medications for the spouse to self-administer -Clients with early dementia of the Alzheimer type usually have some short-term memory loss. A prefilled box of medications eliminates the need to determine what drugs need to be taken. Also, it provides the spouse with objective proof that the medications have or have not been taken.

A male client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention? A male client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention? Encouraging interactions with others Presenting a united, consistent staff approach Assuming a nurturing, forgiving tone in disputes Using seclusion when manipulative behaviors are exhibited

Presenting a united, consistent staff approach Rationale Clients with an antisocial personality disorder need a consistent, united staff approach because they are experts in manipulation and exploitation; they may ignore rules and divide staff members. These clients do not need to be encouraged to interact with other people because they are forward in their approach to others. A nurturing, forgiving tone will foster and worsen manipulation, not decrease it. Seclusion is an overreaction to manipulative behaviors; it implies punishment, which is not productive. Seclusion is used only when the client may injure himself or others.

Hospitalization or day-treatment centers are often indicated for the treatment of a client with obsessive-compulsive disorder because these settings: Hospitalization or day-treatment centers are often indicated for the treatment of a client with obsessive-compulsive disorder because these settings: Prevent the client from completing rituals Allow the staff to exert control over the client's activities Resolve the client's anxiety because decision making is minimal Provide the neutral environment the client needs to work through conflicts

Provide the neutral environment the client needs to work through conflicts Rationale Clients with obsessive-compulsive disorder can work through their underlying conflicts more easily or productively when demands are reduced and the routine is simple. Preventing such a client from carrying out rituals can precipitate a panic reaction. The intent of therapy should be to help the client gain control, not to enable others to do the controlling. Because anxiety stems from unconscious conflicts, a controlled environment alone is not enough to produce resolution.

A man is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After taking the medication for 1 month the client comes to the clinic and says, "I feel stiff, my hands shake, and I started drooling. The picture illustrates the client's physical status observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude has developed? Dystonia Akathisia Tardive dyskinesia Pseudoparkinsonism

Pseudoparkinsonism Rationale Pseudoparkinsonism has adaptations similar to those of Parkinson disease (e.g., shuffling gait, tremors, rigidity, bradykinesia). Pseudoparkinsonism, an extrapyramidal side effect of typical antipsychotics, can occur any time after initiation of therapy. Dystonia is muscle spasms of the face, tongue, head, neck, jaw, and back, usually causing exaggerated posturing of the head. Akathisia is exhibited by motor restlessness. Tardive dyskinesia is exhibited by facial, ocular, oral/buccal, lingual/masticatory, and systemic movements.

A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify? A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify? Sublimation Suppression Compensation Rationalization

Rationalization Rationale The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.

A 54-year-old client has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After being found walking down a street, disoriented and semi-naked, the client is admitted to the hospital, and a diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety. What is the best approach for the nurse to take? A 54-year-old client has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After being found walking down a street, disoriented and semi-naked, the client is admitted to the hospital, and a diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety. What is the best approach for the nurse to take? Exploring the reasons for the client's concerns Reassuring the client with the frequent presence of staff Initiating the program of planned interaction and activity Explaining the purpose of the unit and why admission was necessary

Reassuring the client with the frequent presence of staff -The client needs constant reassurance because forgetfulness blocks previous explanations; frequent presence of staff serves as a continual reminder.

What is the best nursing intervention when the language of a client in the manic phase of a bipolar disorder becomes vulgar and profane? What is the best nursing intervention when the language of a client in the manic phase of a bipolar disorder becomes vulgar and profane? Stating, "We don't like that kind of talk around here." Ignoring it because the client is using it to gain attention Recognizing that the behavior is part of the illness but setting limits on it Responding, "We'll talk with you when you can speak in an acceptable way."

Recognizing that the behavior is part of the illness but setting limits on it Rationale Recognizing the language as part of the illness makes it easier to tolerate, but limits must be set for the benefit of the staff and other clients. Setting limits also shows the client that the nurse cares enough to stop the behavior. "We don't like that kind of talk around here" shows little understanding or tolerance of the illness. Ignoring the behavior is a form of rejection; the client is not using the behavior for attention. "We'll talk with you when you can speak in an acceptable way" demonstrates rejection of the client and little understanding of the illness.

It is determined that a staff nurse has a drug abuse problem. As an initial intervention the staff nurse should be: It is determined that a staff nurse has a drug abuse problem. As an initial intervention the staff nurse should be: Counseled by the staff psychiatrist Dismissed from the job immediately Referred to the employee assistance program Forced to promise to abstain from drugs in the future

Referred to the employee assistance program Rationale Referring to the employee assistance program is a nonpunitive approach that attempts to help the nurse as an individual and as a professional. Counseling by the staff psychiatrist may be necessary for long-term therapy but is not the initial approach. Dismissing the nurse from the job immediately is a punitive nontherapeutic response that offers no chance of rehabilitation. The client has an addiction problem; promises will not keep the client from abusing drugs.

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. The nurse knows that the defense mechanism being utilized by this woman is: A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. The nurse knows that the defense mechanism being utilized by this woman is: Projection Regression Repression Displacement

Repression Rationale Repression occurs when an individual unconsciously excludes distressing emotions, thoughts, or experiences from his or her awareness. It is a mechanism to help a person deal with the shock of stressful emotional experiences. A repressed memory is "forgotten" and cannot be deliberately brought to awareness. Projection occurs when an individual attributes his or her own unacceptable feelings and thoughts to others, allowing the individual to blame others for personal shortcomings. Regression occurs when an individual reverts to an earlier stage of development involving less mature behavior and responsibility as a way of coping with a stressful situation; it often results in more dependent behavior. Displacement occurs when an individual releases pent-up feelings on people perceived to be less dangerous than those who initially aroused the emotion. For example, after receiving a speeding ticket from the police a man yells at his wife when she asks him how his day went.

The nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? (Select all that apply.) The nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? (Select all that apply.) Ritualistic behaviors Desire to improve her self-image Supportive mother-daughter relationship Low achievement in school and little concern for grades Satisfaction with and a desire to maintain her current weight

Ritualistic behaviors Desire to improve her self-image Rationale Clients with anorexia nervosa frequently have a history of ritualistic behaviors, rigidity, and meticulousness, reflecting a need for control. Clients with anorexia nervosa have a disturbed self-image and always see themselves as fat and needing further weight loss. The relationship between mother and daughter is often not supportive but instead conflicted. Usually there is high achievement and great concern about grades. Usually there is dissatisfaction with weight and a desire to lose weight.

An autistic toddler is sitting in a corner, rocking and spinning a top. How can the nurse be most therapeutic when approaching this toddler? An autistic toddler is sitting in a corner, rocking and spinning a top. How can the nurse be most therapeutic when approaching this toddler? Holding the toddler to provide a sense of security Stroking the toddler's arm gently to gain the child's attention Waiting for the toddler to make the initial contact before moving close Sitting with the toddler while watching the spinning top to provide a nonintrusive presence

Sitting with the toddler while watching the spinning top to provide a nonintrusive presence Rationale Autistic children relate best with objects, which can be used as a bridge in interpersonal relationships; this begins at the child's level. Autistic children often become agitated when movement is restricted and personal space is invaded. Autistic children usually have difficulty tolerating being touched. They will not initiate contact or interactions.

A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be? A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be? Staying physically close to the client Gently asking what is bothering the client Telling the client to try to relax by sitting quietly Getting the client involved in a nonthreatening activity

Staying physically close to the client Rationale By staying physically close, the nurse conveys the message that someone cares enough to be there and that the client is a person worthy of care. The client is incapable of telling anyone what the problem is. Sitting still will increase the tension the client is experiencing. Involving the client in a nonthreatening activity is not an initial nursing intervention.

A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should: A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should: Demand that the client stop the behavior immediately Tell the client firmly that the behavior is unacceptable Ask the client to identify what is precipitating the behavior Increase the client's medication or get a prescription for another drug

Tell the client firmly that the behavior is unacceptable Rationale A firm voice is most effective; the statement tells the client that it is the behavior, not the client, that is upsetting to others. Demanding that the client stop the current behavior is a useless action; the client is out of control and needs external control. The client does not know what is precipitating the behavior, and asking the client will be frustrating for him. The dosage of the client's medication should be increased or a prescription for another drug should be obtained if the client does not respond to firm limit-setting.

An adolescent with anorexia nervosa frequently telephones home just before mealtimes. The client uses the phone calls to avoid eating. What client behavior supports the nurse's conclusion that the nursing plan to set limits on this avoidance behavior has been effective? An adolescent with anorexia nervosa frequently telephones home just before mealtimes. The client uses the phone calls to avoid eating. What client behavior supports the nurse's conclusion that the nursing plan to set limits on this avoidance behavior has been effective? The client begins to clip recipes from magazines The client arrives on time for meals without being told The client organizes an aerobic exercise group for other clients The client contacts the family frequently by telephone between meals

The client arrives on time for meals without being told Rationale Arriving on time for meals without being told demonstrates a change in behavior, as well as a positive approach to meals. The problem is not a lack of interest in food but a deliberate failure to ingest food. Organizing an aerobic exercise group for other clients is typical of a client with anorexia nervosa. Contacting the family frequently by telephone between meals is unrelated to the behavior that needs to be changed.

A teenager with anorexia nervosa is admitted to the adolescent unit of a mental health facility and signs a contract calling for her to gain weight or lose privileges. There is no weight gain after a week. What should the nurse explain to the client? A teenager with anorexia nervosa is admitted to the adolescent unit of a mental health facility and signs a contract calling for her to gain weight or lose privileges. There is no weight gain after a week. What should the nurse explain to the client? The prearranged consequences will go into effect. Death from starvation could occur if the client does not eat. Stricter goals will be instituted if the initial goals are not met. It may be necessary to become involved with meal preparation.

The prearranged consequences will go into effect. Rationale The imposition of the prearranged consequences reinforces the agreed-upon contract; a behavior modification program must follow through consistently on issues of cause and effect. Death from starvation is not therapeutic; it is threatening. Goals are not changed; prearranged consequences are instituted when goals are not met. Working with food will not stimulate the client's eating; this is not therapeutic or productive.

After 4 days on the inpatient psychiatric unit a client on suicidal precautions tells the nurse, "Hey, look! I was feeling pretty depressed for a while, but I'm certainly not going to kill myself." What is the nurse's best response to this statement? After 4 days on the inpatient psychiatric unit a client on suicidal precautions tells the nurse, "Hey, look! I was feeling pretty depressed for a while, but I'm certainly not going to kill myself." What is the nurse's best response to this statement? "You do seem to be feeling better." "We should talk some more about this." "We have to observe you until you're better." "I don't understand what you mean by killing yourself."

We should talk some more about this." Rationale The statement "We should talk some more about this" encourages the client to talk about feelings without the nurse setting the focus for the discussion. "You do seem to be feeling better" cuts off further communication of feelings; the client's statement may actually indicate a desire to act on the suicidal ideation. "We have to observe you until you're better" does not foster communication or a discussion of feelings. "I don't understand what you mean by killing yourself" will make the client wonder where the nurse has been for 4 days.

In what situation should a nurse anticipate that a client will experience a phobic reaction? In what situation should a nurse anticipate that a client will experience a phobic reaction? When seeking attention from others When thinking about the feared object When coming into contact with the feared object When being exposed to an unfamiliar environment

When coming into contact with the feared object Rationale With phobias, the individual transfers anxiety to a safer inanimate object or situation. Therefore the anxiety and resulting feelings will be precipitated only when the client is in direct contact with the object or situation. Phobias are severe anxiety reactions, not attention-seeking actions. It is not thinking about the feared object that causes anxiety; it is the possibility of having to come into contact with it. It is the presence of the phobic object or situation that triggers the anxiety, not the unfamiliarity of the environment.

mental health

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