Mental Health Study Guide #2

A heroin addicted client takes methadone and discontinued it without consulting a dcotor. The client says "I thought I didnt need it after 1 year, I had a job and was even saving money. I cant believe I ruined everything." Which would be the most theraputic response from the nurse? a. "It sounds as if everything you do is either all or nothing." b. "Talk to your counselor; maybe everything isn't ruined yet." c. "You will need to restart your recovery starting from the beginning." d. "We need to prepare you to recognize those things that trigger you to relapse."

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

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 4.Provide stimulation in the environment. 5.Provide reality orientation as appropriate. 6.Maintain NPO (nothing by mouth) status.

1, 2, 3, 5

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. ask the client why he started taking illegal drugs 2. ask the client about the amount of drug use and its effect 3. ask the client how long he thought that he could take drugs without someone finding out 4. not ask any questions for fear that the client is in denial and will throw the nurse out of the home

2. ask the client about the amount of drug use and its effect

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?"

The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. Call security. 2. Call the police. 3. Call the nursing supervisor. 4. Lock the co-worker in the medication room until help is obtained.

3. Call the nursing supervisor.

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, Another nurse said you dont do your job right. Collectively, these interactions can be assessed as: 1. Seductive 2. Detached 3. Manipulative 4. Guilt producing

3. Manipulative

Which is a primary behavior of a client diagnosed with antisocial personality disorder?

3. Will take personal items from other clients rooms.

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teachin g about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

A patient who fears serious heart disease was referred to the mental health center by a cardiologist after extensive diagnostic evaluation showed no physical illness. The patient says, "I have tightness in my chest and my heart misses beats. I'm frequently absent from work. I don't go out much because I need to rest." Which health problem is most likely? 1. Dysthymic disorder 2. Simple somatic symptom disorder 3. Antisocial disorder 4. Illness anxiety disorder

4. Illness anxiety disorder

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping

4. Inquiring about and examining the client's feelings for any that may block adaptive coping

A client diagnosed with a borderline personality disorder says to the nurse, "Sometimes I do things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the appropriate nursing response? 1."Next time, pick less dangerous and expensive ways to explode." 2."What can you do to stop your behavior when it gets to that point the next time?" 3."It's a good thing that you don't abuse substances, or you might be dead because of your recklessness." 4."It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

4."It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."

Select the priority nursing intervention when caring for a patient after an overdose of amphetamines. A) Monitor vital signs. B) Observe for depression. C) Awaken the patient every 15 minutes. D) Use warmers to maintain body temperature.

A) Monitor vital signs.

The nurse is caring for a client diagnosed with alzheimer's who is demonstrating characteristics agnosia. Which client behavior supports with cognitive deficiency?

D. When asked to pick up the cup, the client consistently fails identify the cup.

During the assessment what is the primary goal for a disoriented and confused patient with ptsd? Explaining the unit rules Making the client feel safe Orienting the client to the unit Stabilizing the client's psychiatric needs

Making the client feel safe.

The nurse is caring for a patient diagnosis with Alzheimers the nurse should anticipate that the client has changes in which component of the nervous system?

Neuronal dendrites

Normally, most people sleep at night. What is the physiological rationale?

The master biological clock responds to darkness with sleep

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which comment is most likely from this patient? a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion." b. "I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I think I'm getting seriously dehydrated." c. "Sexual intercourse is painful. I pretend as if I'm asleep so I can avoid it. I think it's starting to cause problems with my marriage." d. "I get choked very easily and have trouble swallowing when I eat. I think I might have cancer of the esophagus."

a. "Since my father died, I've been short of breath and had sharp pains that go down my left arm, but I think it's just indigestion."

The nurse provides health education for an adult experiencing sleep deprivation. Which instruction has the highest priority? a. "It's important to limit your driving to short periods. Sleep deprivation increases your risks for serious accidents." b. "Sleep deprivation is usually self-limiting. See your health care provider if it lasts more than a year." c. "Turn the radio on with a soft volume as you prepare for bed each evening. It will help you relax." d. "Three glasses of wine each evening help many patients who suffer from sleep deprivation."

a. "It's important to limit your driving to short periods. Sleep deprivation increases your risks for serious accidents."

Which question should the nurse ask to identify secondary gains associated with a somatic system disorder? a. "What are you unable to do now but were previously able to do?" b. "How many doctors have you seen in the last year?" c. "Who do you talk to when you're upset?" d. "Did you experience abuse as a child?"

a. "What are you unable to do now but were previously able to do?"

1. A patient diagnosed with alcohol use disorder asks, "How will Alcoholics Anonymous (AA) help me?" Select the nurse's best response. a. "The goal of AA is for members to learn controlled drinking with the support of a higher power." b. "An individual is supported by peers while striving for abstinence one day at a time." c. "You must make a commitment to permanently abstain from alcohol and other drugs." d. "You will be assigned a sponsor who will plan your treatment program."

b. "An individual is supported by peers while striving for abstinence one day at a time."

Clients with which diagnosis are prescribed interventions to manage anxiety? Select all that apply: a. Dementia b. Panic Disorder c. Multiple personality disorder d. PTSD e. OCD

b. Panic Disorder d. PTSD e. OCD

The nurse is preforming an assessment for a new admission on a mental health unit. During the interview, the nurse discovered that the client suffered a severe emotional truama 1 month earlier and is now experiencing paralysis of the right arm. What does the nurse do next? a. Refer the client to a psychiatrist. b. Encourage the client to move and use the arm. c. Assess the client for organic causes of the paralysis. d. Encourage the client to talk about his or her feelings.

c. Assess the client for organic causes of the paralysis.

Consider this comment to three different nurses by a patient diagnosed with an antisocial personality disorder, Another nurse said you dont do your job right. Collectively, these interactions can be assessed as:

manipulative

A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis? 1. Depression 2.Somatization disorder 3.Post-traumatic stress disorder 4.Obsessive-compulsive disorder

2.Somatization disorder

Which individual in the emergency department should be considered the highest risk for completing suicide? 1. An Asian girl was superior athletic and academic skills who has asthma 2. A 38 year old single African-American female church member with fibercystic breast disease 3. A 60 year old married Hispanic man with 12 grandchildren who has Type 2 Diabetes 4. A 79 year old single white male diagnosed with terminal cancer

4. A 79 year old single white male diagnosed with terminal cancer

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? 1. Provide a well-lit room without glare or shadows. Limit noise and stimulation. 2. Maintain soft lighting day and night. Keep a radio on low volume continuously. 3. Light the room brightly day and night. Awaken the patient hourly to assess mental status. 4. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

1. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 1."I'm afraid of spiders." 2."I keep reliving the robbery." 3."I see his face everywhere I go." 4."I don't want anything to eat now." 5."I might have died over a few dollars in my pocket." 6."I have to wash my hands over and over again many times."

2, 3, 5

A client is experiencing anxiety about being hospitalized. What therapeutic technique should the nurse use while interacting with this client? Select all that apply 1. Turn on the patient's favorite TV show 2. Ask the patient to identify how s/he feels 3. Help the patient identify the causative factors 4. Have casual posture 5. Tell a funny story

2. Ask the patient to identify how s/he feels 3. Help the patient identify the causative factors

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?1. increase socialization of the client with peers 2. avoid using a whisper voice in front of the client 3. begin to educate the client about social supports in the community 4. have the client sign a release of information to appropriate parties for assessment purposes

2. avoid using a whisper voice in front of the client

What statement should the nurse make to a client diagnosed with posttraumatic stress disorder who appears to be experiencing anxiety? 1."Try not to worry so much." 2."I can see that you are becoming upset." 3."Everything is going to be all right; just relax." 4."Why are you having trouble controlling your anxiety?"

2."I can see that you are becoming upset."

A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive

1. Avoidance

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

2."Tell me what makes you feel that you are ready."

On review of the client's record, the nurse notes that the mental health admission was voluntary. Based on this information, the nurse anticipates which client behavior? 1. Fearfulness regarding treatment measures. 2. Anger and aggressiveness directed toward others. 3. An understanding of the pathology and symptoms of the diagnosis. 4. A willingness to participate in the planning of the care and treatment plan.

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

A nurse set limits while interacting with a patient demonstrating behaviors associated with borderline personality disorder. The patient tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be assessed as: a. Denial b. Splitting c. Defensive d. Reaction formation

b. Splitting

A patient says, "I know I have a brain tumor despite the results of the MRI. The radiologist is wrong. People who have brain tumors vomit, and yesterday I vomited all day." Which response by the nurse fosters cognitive reframing? A. You do not have a brain tumor. The more you talk about it, the more it reinforces your belief B. Let's see if there are any other possible explanations for your vomiting C. You seem so worried. Let's talk about how you're feeling D. We need to talk about something else

B. Let's see if there are any other possible explanations for your vomiting

A patient experiencing primary insomnia asks the nurse, "I take a nap during the day. Doesn't that make up for a lost night's sleep?" Select the nurse's best reply. a. "Circadian drives give daytime naps a structure different from nighttime sleep." b. "The body clock operates on a 24-hour cycle, making nap effectiveness unpredictable." c. "It is a matter of habit and expectation. We expect to be more refreshed from a night's sleep." d. "Sleep restores homeostasis but works more efficiently when aided by melatonin secreted at night."

a. "Circadian drives give daytime naps a structure different from nighttime sleep."

A parent who is very concerned about a 3-year-old son says, "He likes to play with girls' toys. Do you think he is homosexual or mentally ill?" Which response by the nurse most professionally describes the current understanding of gender identity? a. "A child's interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood." b. "It's difficult to say for sure because the research is incomplete so far, but chances are that he will grow up to be a normal adult." c. "The research is incomplete, but many boys play with girls' toys and turn out normal as adults." d. "I am sure that whatever happens, he will be a loving son, and you will be a proud parent."

a. "A child's interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood."

A patient who experienced a myocardial infarction was transferred from critical care to a step-down unit. The patient then used the call bell every 15 minutes for minor requests and complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient's needs. When the nurse manager intervenes directly with this patient, which comment is most therapeutic? a. "I'm wondering if you are feeling anxious about your illness and being left alone." b. "The staff are concerned that your not satisfied that you are receiving." c. "Let's talk about why you use your call light so frequently." d. "You frustrate the staff by calling so much. Why are you doing that?"

a. "I'm wondering if you are feeling anxious about your illness and being left alone."

A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patient's sexual practices? a. "Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern?" b. "Sexual health can reflect a number of medical problems, so I'd like to ask if you have any sexual problems you think we should know about." c. "It's your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please?" d. "I would appreciate it if you could share your sexual history with me so I can share it with your health care provider. It might be helpful in planning your treatment."

a. "Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern?"

An elderly person presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

a. A list of all medications the person currently takes

A patient has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the patient to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the patient. c. Stimulate intellectual function by discussing new topics with the patient. d. Read one story from the newspaper to the patient every day.

a. Assist the patient to perform simple tasks by giving step-by-step directions.

An adolescent was arrested for prostitution and assault on a parent. The adolescent says, "I hate my parents. They focus all attention on my brother, who's perfect in their eyes." Which type of therapy might promote the greatest change in the adolescent's behavior? a. Family therapy b.Bibliotherapy c. Play therapy d. Art therapy

a. Family therapy

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

a. Monitor closely for harm to self or others.

A patient diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this patient? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the patient hourly to assess mental status. d. Keep the patient by the nurse's desk while awake. Provide rest periods in a room with a television on.

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation.

A nurse is performing an assessment for a 59-year-old man who has hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment? a. Sexual dysfunction may result from use of prescription medications for management of hypertension. b. Such questions are an indirect way of learning about the patient's medication adherence. c. These questions ease the transition to questions about sexual practices in general. d. Sexual dysfunction can cause stress and contribute to increased blood pressure.

a. Sexual dysfunction may result from use of prescription medications for management of hypertension.

A 16-year-old diagnosed with a conduct disorder has been in a residential program for 3 months. Which outcome should occur before discharge? a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences. b. The adolescent identifies friends in the home community who are a positive influence. c. Temporary placement is arranged with a foster family until the parents complete a parenting skills class. d. The adolescent experiences no anger and frustration for 1 week.

a. The adolescent and parents create and agree to a behavioral contract with rules, rewards, and consequences.

An older client with delirium because agitated and confused at night. Which intervention is best to minimize risk for injury? a. Turn off the television and radio, and use a night-light. b. Keep soft lighting and the television on during the night. c. Change the client's room to one nearer the nurses' station. d. Play soft instrumental music all night, and do not turn down the lights.

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

The nurse is preforming an assessment on a patient. Which piece of data gathered during the assessment indicated a manifestation associated with dementia? a. Use of confabulation b. Improvement in sleeping c. Absence of sundown syndrome d. Presence of personal hygienic care

a. Use of confabulation

An adult seeks treatment for urges involving sexual contact with children. The adult has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in treatment? The adult: a. consistently avoids schools and shops at malls only during school hours. b. indicates sexual drive and enjoyment from sex have decreased. c. reports an active and satisfying sex life with an adult partner. d. volunteers to become a scout troop leader.

a. consistently avoids schools and shops at malls only during school hours.

A patient with blindness related to conversion disorder tells a nurse, "I'm really popular here in the hospital. All the doctors and nurses stop by to check on me. Other patients are really interested in my blindness, too. Too bad people outside the hospital don't find me so interesting." Which nursing diagnosis is most relevant? a. Social isolation b. Chronic low self-esteem c. Interrupted family processes d. Ineffective health maintenance

b. Chronic low self-esteem

A nurse cares for these four patients. Which patient has the highest risk for problems with sleep physiology? a. Retiree who volunteers twice a week at Habitat for Humanity b. Corporate accountant who travels frequently c. Parent with three teenagers d. Lawn care worker

b. Corporate accountant who travels frequently

What is the most challenging nursing intervention with patients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

b. Maintaining consistent limits

A patient reports, "Nearly every night I awaken feeling frightened after a bad dream. The dream usually involves being hunted by people trying to hurt me. It usually happens between 4 and 5 AM." The nurse assesses this disorder as most consistent with criteria for which problem? a. Sleep deprivation b. Nightmare disorder c. Night terror disorder d. REM sleep behavior disorder

b. Nightmare disorder

Which nursing intervention has the highest priority as a patient diagnosed with anorexia nervosa begins to gain weight? a. Assess for depression and anxiety. b. Observe for adverse effects of refeeding. c. Communicate empathy for the patient's feelings. d. Help the patient balance energy expenditures with caloric intake.

b. Observe for adverse effects of refeeding.

Which assessment data would help the health care team distinguish symptoms of conversion (functional neurological) disorder from symptoms of illness anxiety disorder (hypochondriasis)? a. Voluntary control of symptoms b. Patient's style of presentation c. Results of diagnostic testing d. The role of secondary gains

b. Patient's style of presentation

A nurse counsels the family of a patient diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend to enhance safety? a. Apply a medical alert bracelet to the patient. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

b. Place locks at the tops of doors.

The nurse in the ED is caring for a young female client for sexual assualt. The client is withdrawn, tremulous, and bewildered at times. How should the nurse interpret this response? a. Signs of depression b. Reactions to a devastating event c. Evidence that the client is a high suicide risk d. Indicative of the need for hospital admission

b. Reactions to a devastating event

A nurse cares for a patient diagnosed with an opioid overdose. Which focused assessment has the highest priority? a. Cardiovascular b. Respiratory c. Neurologic d. Hepatic

b. Respiratory

A child known as the neighborhood bully says, "Nobody can tell me what to do." After receiving a poor grade on a science project, this child secretly loaded a virus on the teacher's computer. These behaviors support a diagnosis of: a. conduct disorder. b. oppositional defiant disorder. c. intermittent explosive disorder. d. attention deficit hyperactivity disorder.

b. oppositional defiant disorder.

A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should:

b. provide care in a matter-of-fact manner.

What is the most challenging nursing intervention with patient diagnosed with personality disorders who use manipulation? a.Supporting behavioral change b.Maintaining consistent limits c.Monitoring suicide attempts d.Using aversive therapy

b.Maintaining consistent limits

A young adult says to the nurse, "I go to sleep without any problem, but I often wake up during the night because it feels like there are rubber bands in my legs." Which assessment question should the nurse ask to assess for restless legs syndrome (RLS)? a. "What type of birth control do you use?" b. "How much caffeine do you use every day?" c. "How much exercise do you get in a typical day?" d. "Does anyone else in your family have this problem?"

c. "How much exercise do you get in a typical day?"

Which statement made by a patient diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think your the best nurse on the unit." b. "I'm never going to high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I call her today and she didn't answer."

c. "I felt empty and wanted to hurt myself, so I called you."

A nurse assesses a patient who reports a 3-week history of depression and periods of uncontrolled crying. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealedsuicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

c. "I have a plan that will fix everything."

An adolescent was recently diagnosed with oppositional defiant disorder. The parents say to the nurse, "Isn't there some medication that will help with this problem?" Select the nurse's best response. a. "There are no medications to treat with problem. This diagnosis is behavioral and nature. b. "It's a common misconception that there is medication available to treat every health problem." c. "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use." d. " There are many mediation that you can use to help your child aggression and destructiveness. The healthcare provider can discuss this with you."

c. "Medication is usually not prescribed for this problem. Let's discuss some behavioral strategies you can use."

An alcohol troubled clientt said "the 12 steps of AA really upset me I had to go for a drink after 1 hour with those people." Which comment by the nurse would be theraputic? a. "You think AA is for fanatics?" b. "It sounds as if you look for any reason to drink!" c. "Not any 1 strategy for remaining sober is best for everyone." d. "I agree. AA is definitely not for you if you find it is a trigger to drink."

c. "Not any 1 strategy for remaining sober is best for everyone."

A client is admitted with acute blindness following a hit and run. Diagnositic testing does not identify why this client cannot see and a mental health consult was prescribed. The nurse plans care based on which condition? a. Psychosis b. Repression c. Conversion disorder d. Dissociative disorder

c. Conversion disorder

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

c. Is pacing while describing the situation using a rapid speech pattern

As a nurse is preparing to administer medications to a person with boarderline personality disorder. The patient says "Leave it on the table until I finish combing my hair." What is the nurses best response? a.Reinforce this assertive action by the patient and leave it on the table as requested. b. Response to the patient "I'm worried you may not take it I will come back later." c. Say to the patient " I must watch you take the medication, take it now." d. Ask the patient "Why don't you want to take your medication."

c. Say to the patient " I must watch you take the medication, take it now."

A patient admitted for injuries sustained while intoxicated has been hospitalized for 48 hours. The patient is now shaky, irritable, anxious, diaphoretic, and reports nightmares. The pulse rate is 130 beats/min. The patient shouts, "Bugs are crawling on my bed. I've got to get out of here." Select the most accurate assessment of this situation. The patient: a. is attempting to obtain attention by manipulating staff. b. may have sustained a head injury before admission. c. has symptoms of alcohol-withdrawal delirium. d. is having an acute psychosis.

c. has symptoms of alcohol-withdrawal delirium

The spouse of an alcoholic client is attending a support group. The spouse says "Its fine if everyone wants to call me an enabler, but he would lose his job if I didn't call him in sick. Where would we be then?" Which statement by the nurse would be theraputic? a. "Does anyone in the group want to respond to that?" b. "So you only call him in sick because you are worried about money?" c. "Hasn't the group discussed this before? What conclusion did you all come to?" d. "It is a difficult situation, but do you agree that enabling creates codependency?"

d. "It is a difficult situation, but do you agree that enabling creates codependency?"

A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list for all of your problems and make a list of all of your problems and think of solutions for each one." b. "I am happy you are taking control of your problems and trying to find solutions" c. " When you have bad feelings try to think of the positive experiences from your life." d. "Let's consider which problems are very important and which are less important."

d. "Let's consider which problems are very important and which are less important."

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

d. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

A woman says, "I can't take it anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identify measure useful to help improve the couples communication. b. The patients feelings about a possibly having a mastectomy. c. Whether the husband is engaged is the affair d. Clarify what the patient means about "I can't take it anymore."

d. Clarify what the patient means about "I can't take it anymore."

A 15-year-old ran away from home six times and was arrested for shoplifting. The parents told the court, "We can't manage our teenager." The adolescent is physically abusive to the mother and defiant with the father. Which diagnosis is supported by this adolescent's behavior? a. Attention deficit hyperactivity disorder (ADHD) b. Posttraumatic stress disorder (PTSD) c. Intermittent explosive disorder d. Conduct disorder

d. Conduct disorder

A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially? a. Tell the client that leaving would likely result in an involuntary commitment b. Attempt to persuade the client to stay "for only a few more days." c. Call the client's family to arrange for transportation. d. Contact the client's primary health care provider (PHCP).

d. Contact the client's primary health care provider (PHCP).

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

d. During the admission interview, the client can't remember why the ECT treatment was originally prescribed.

A patient with fears of serious heart disease is refered by a cardiologist for a mental health assessment, diagnositic studies show no physical illness. Client states their chest is tight, heart misses beats, I don't go out much. Which disorder is most likely? a. Dysthymic disorder b. Somatic symptom disorder c. Antisocial personality disorder d. Illness anxiety disorder (hypochondriasis)

d. Illness anxiety disorder (hypochondriasis)

What is the appropirate nursing intervention for a client with ptsd who begins to pace and figdet? a.Escort the client to a private, low-stimulus room. b. Engage the client in a nonthreatening conversation. c. Allow the client to pace unless the behavior becomes aggressive. d. Share the observation with the client so the behavior can be recognized.

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

Which assessment finding for a patient diagnosed with an eating disorder meets a criterion for hospitalization? a. Urine output: 40 ml/hr b. Pulse rate: 58 beats/min c. Serum potassium: 3.4 mEq/L d. Systolic blood pressure: 62 mm Hg

d. Systolic blood pressure: 62 mm Hg

A nurse is caring for a client is respiratory distress related to an anxiety attack, pH 7.5, PAO2 72 Bicarb 28. What conclusion can the nurse make? a. The client has acidotic blood. b. The client is fluid volume overloaded. c. The client is probably overreacting. d. The client is probably hyperventilating.

d. The client is probably hyperventilating.

Which goal for treatment of alcoholism should the nurse address first? a.Learn about addiction and recovery. b.Develop alternate coping strategies. c.Develop a peer support system. d.Achieve physiologic stability.

d.Achieve physiologic stability.