Mental HESI
The psychiatric clinical nurse specialist decides to use cognitive behavioral therapy (CBT) techniques as she works with a bulimic client. Which statement by the nurse is an example of the application of cognitive behavioral therapy principles? "Being thin does not seem to solve your problems; you are thin now and still unhappy." "What are your feelings about not eating the food that you prepare for others?" "You seem to feel much better about yourself when you eat something." "Is it difficult to talk about your feelings and private matters with someone you've just met?"
"Being thin does not seem to solve your problems; you are thin now and still unhappy." Rationale Cognitive behavioral therapy (CBT) is the most effective treatment for bulimia. CBT helps the client restructure faulty perceptions and develop accepting attitudes towards themselves and their bodies. This process works by identifying the negative and irrational patterns of thought and then challenging the client based on rational evidence and thoughts. Applying these principles, the nurse challenges the irrational thinking by stating the obvious, that the client continues to be unhappy in spite of being thin.
The spouse of a client who was admitted to an alcohol detox center is attending an AL-ANON meeting. The spouse asks the group leader if their children could inherit the tendency for alcohol addiction. Which is a correct response by the group leader? "Children of alcoholics are three times more likely to inherit the disease than children of non-alcoholic parents." "Current studies are being conducted to investigate heredity as a factor, but unfortunately there has been no progress." "There are no genetics involved; alcohol abuse and addictions are learned behaviors." "Genetics have a minor effect, but if you educate your children about the dangers of drinking, they should be OK."
"Children of alcoholics are three times more likely to inherit the disease than children of non-alcoholic parents."
The school nurse is conducting an assessment on a 16-year-old female high school athlete who appears underweight to determine if a client has anorexia nervosa. Which statement by the client is indicative of this eating disorder? "I don't have periods as much as I used to, and I am glad." "When I graduate, I am going to culinary school." "I discovered that I am allergic to gluten, so I have to be careful about what I eat." "My mother thinks that I am too fat and always tries to get me to diet."
"I don't have periods as much as I used to, and I am glad." Rationale Amenorrhea can be a sign of an eating disorder resulting in extremely low body weight. This absence of a menstrual cycle may be the overall impact of excessive intense exercise and increased levels of stress to be perfect, resulting in the extreme weight loss causing the amenorrhea. .
A universal outcome for victims of rape is grief resolution. Which statement by the victim indicates that progress toward this outcome has been made? "I have begun to stop blaming myself for being raped." "If I had not worn that skirt to the party, the rape would not have happened." "I need to make sure that I do not go out alone anymore." "I feel ashamed that I could not defend myself against my attacker."
"I have begun to stop blaming myself for being raped." Rationale Rape victims must work through grief caused by various losses perceived as associated with rape. Overcoming self-blame represents progress toward grief resolution.
The nurse is providing counseling to a client about recovery from alcoholism. Which client statement indicates that learning has occurred? "Once I have detoxed, my recovery is complete." "I realize that recovery is a lifelong process that occurs in steps." "I understand that the goal of the program is to decrease my drinking." "I will only drink beer because hard liquor has a higher alcohol content."
"I realize that recovery is a lifelong process that occurs in steps." Rationale Recovery from addiction involves behavioral, cognitive, and dynamic factors. Support groups provide the structure needed to maintain sobriety, but it is crucial that clients understand that recovery is a lifelong process that occurs gradually.
The nurse is providing discharge education for a client prescribed a tricyclic antidepressant. Which statement by the client indicates the need for additional teaching? "It is best for me to take the full dose of the medication when I get up each morning." "My mood should improve within 7-28 days after starting my medicine." "It may take up to 6-8 weeks for me to experience the full effect of the medication." "The side effects of drowsiness and dizziness usually go away after the first few weeks."
"It is best for me to take the full dose of the medication when I get up each morning." Rationale If possible, the client should take the full dose of tricyclic antidepressants at bedtime to reduce the experience of side effects during the day.
An adolescent client diagnosed with bulimia nervosa and an underlying depression is prescribed fluoxetine (Prozac) 10mg daily. The client asks, "What will this medicine do inside my brain?" The nurse is correct to provide which response? "It will regulate a neurotransmitter called serotonin." "It will raise the levels norepinephrine in your brain." "It will balance blood glucose and dopamine levels." "It will block the overproduction of the neurotransmitter GABA."
"It will regulate a neurotransmitter called serotonin." Rationale Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI); it helps to keep serotonin in the synapses where it is needed. Low serotonin levels contribute to both of the client's diagnoses. It is important for the nurse to answer the adolescent in an accurate and factual way that can be understood without sounding oversimplified or demeaning.
The nurse is interviewing a client about substance abuse. Which responses from the client should alert the nurse that further assessment is needed? "It's just marijuana and everyone does it." "I figured you asked me that question." "I only drink a six pack in the evening." "I have a glass of wine occasionally with a meal." "I smoked ten years ago but that's old news."
"It's just marijuana and everyone does it." "I figured you asked me that question." "I only drink a six pack in the evening." Rationale Rationalization, minimizing, anticipation and avoidance of questions being asked about alcohol and illicit drug use should alert the nurse for further investigation of potential substance abuse.
The nurse is preparing to administer an initial dose of memantine (Namenda) to a newly admitted client with moderate-stage Alzheimer's disease. The client's daughter asks why this new medication was ordered. The daughter states that her mother has been taking rivastigmine (Exelon) to stabilize her memory impairment, but without improvement. Which explanation for the addition of memantine should the nurse provide? "Memantine may be prescribed in combination with rivastigmine, to enhance its effects ." "Memantine increases the appetite and promotes better eating habits." "Memantine reverses the symptoms of dementia and has fewer side effects." "Memantine works like a sedative to relieve anxiety and improve sleep."
"Memantine may be prescribed in combination with rivastigmine, to enhance its effects ." Rationale Memantine (Namenda) is an NMDA receptor antagonist that helps prevent neurodegeneration by reducing excess calcium. Memantine may be prescribed in combination with rivastigmine, a cholinesterase inhibitor, for patients who do not respond to rivastigmine alone.
During a meeting with the interdisciplinary treatment team, a client in the acute phase of schizophrenia states that she cannot return to live with her parents because they are trying to kill her. Which statement by the team leader represents a correct therapeutic response? "We met with your parents; they do not appear to be violent people." "You are having a delusion; your parents would never hurt you." "That must be very frightening; tell us why you believe you are in danger." "You are being paranoid; your parents referred you here so that you can be helped."
"That must be very frightening; tell us why you believe you are in danger."
A client diagnosed with obsessive-compulsive personality disorder with a comorbid depression has been receiving dialectic behavior therapy (DBT). Which statement by the client indicates that the treatment has been effective? "Yoga and deep breathing help me when I get anxious about upcoming family visits." "I can feel my heart pounding when I practice deep breathing and it gives me a headache." "Listening to relaxing music reminds me of my ex-husband and how I messed up our marriage." "I feel like I can become a movie star after I finish my meditation and exercise sessions."
"Yoga and deep breathing help me when I get anxious about upcoming family visits."
A client who is experiencing tremendous stress and anxiety while being admitted to a drug detoxication facility asks the nurse, "Do you think saying a prayer would help?" Which response by the nurse is best? "To be honest, prayer may be the best way to help you cope." "You may find that prayer gives comfort and lowers your stress." "I could help you feel calmer by teaching you to meditate." "Guided imagery could be an effective alternative."
"You may find that prayer gives comfort and lowers your stress."
A 4-year-old child is referred to a mental health clinic for evaluation of hyperactivity and impulsive behaviors. At the first visit, nursing staff begin observing and assessing the child's behavior. Which developmental task should the child have achieved by this age? A sense of autonomy. Satisfactory relationships with peers. The ability to establish goals. Separation from parents and the ability to socialize.
A sense of autonomy. Rationale A 4-year-old child should have attained the developmental task of autonomy. According to Erikson's eight stages of development theory, the second stage is autonomy versus shame and doubt, which should occur between the ages of 1 and 1/2 to 3 years old. Unsuccessful resolution of the developmental task at this stage could lead to severe feelings of self-doubt and an internal independence/fear conflict.
The nurse is educating a new staff member about the causes of personality disorders. The nurse is correct to identify which causes? Abnormal brain structure and disturbances involving serotonin and GABA. Abnormal brain structure and disturbances involving dopamine and GABA. Nutrition al deficiencies and damage to the brain stem. Nutritional deficiencies and damage to the limbic system.
Abnormal brain structure and disturbances involving serotonin and GABA.
Which behaviors indicate that the treatment plan for a client in alcohol rehabilitation has been effective? Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has spoken with employer about returning to work. Abstinent 15 days; states that the drinking problem has been overcome; plans to find a new line of work with new coworkers. Attends Alcoholics Anonymous daily; states that many of the members are real alcoholics; denies having any problems at work. Attends Alcoholics Anonymous once per week; states a willingness to stop drinking during the day; plans to drink occasionally after work.
Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has spoken with employer about returning to work. Rationale The statement "one day at a time" reflects the Alcoholics Anonymous (AA) philosophy. AA promotes a 12-step program that has been successful in helping individuals who desire to stop drinking and abusing substances. Individuals learn about sobriety and responsibility through the support of other members.
The nurse is teaching a group parents and teachers about preventing substance abuse in children. What practices during childhood are known to minimize substance abuse later in life? Adults who teach and display self-control behaviors in difficult situations. Encouraging and praising academic achievement. A strong sense of community and neighborhood attachment. Parents who are involved and monitor their children's daily lives. Implementing strict rules with severe yet consistent consequences.
Adults who teach and display self-control behaviors in difficult situations. Encouraging and praising academic achievement. A strong sense of community and neighborhood attachment. Parents who are involved and monitor their children's daily lives. Rationale Research has shown that children who are exposed to self-control behavior, experience academic achievement, have a sense of belonging to a community/neighborhood and have parents who are actively involve and monitor their children's everyday lives are less likely to be substance abusers later on in life.
A client seeks assistance at a crisis center. The client describes being extremely anxious and unable to sleep since helping with clean-up duties at a school where a student fatally shot a teacher and some classmates. Which intervention is the priority when assisting this client? Allow ventilation of feelings. Refer the client to a member of the clergy. Advise the client to avoid going near the school for at least six weeks. Send the client to an emergency department for further evaluation.
Allow ventilation of feelings. Rationale The client is feeling overwhelmed by feelings associated the crisis. Before initiating other interventions, the nurse should allow the client to freely express troubling emotions before exploring habitual coping styles and assisting with problem solving.
The health care provider mentions to the nurse that a child with attention-deficit/hyperactivity disorder (ADHD) will begin medication therapy. Which medication should the nurse teach the client's family about before they leave the clinic? Amphetamine salts (Adderall). Fluoxetine (Prozac). Lithobid (Lithium). Haloperidol (Haldol).
Amphetamine salts (Adderall). Rationale Central nervous system stimulants, such as amphetamine salts (Adderall), increase blood flow to the brain. They have been proven helpful in reducing hyperactivity in children and adolescents with attention deficit hyperactivity disorder.
A client who compulsively performs handwashing rituals throughout the day is being treated for obsessive compulsive disorder (OCD). Which behavior change indicates that treatment has been effective? Arrives at the dining hall on time for every meal for the last 2 days. Exhibits good hygiene habits for the last week. Reads educational material regarding his illness. Begins to wash the floors after returning from outside excursions.
Arrives at the dining hall on time for every meal for the last 2 days. Rationale A client diagnosed with obsessive compulsive disorder (OCD) who performs a hand washing ritual can be so consumed by the ritual that it interferes with normal activities, including regular meals. A decrease in the ritualistic behavior and eating regular meals in a social setting indicates that symptoms have improved.
During a follow-up visit to the mental health clinic, the mother of a 7-year-old client reports that her son has been having side effects from the medication that was ordered to treat ADHD. The mother states that the client has a decreased appetite, complains of abdominal pain, and has been unable to sleep. The health care provider recommends that the medication be changed to a nonstimulant ADHD drug. Which medication should be recommended for this client? Atomoxetine (Strattera). Methylphenidate (Ritalin). Fluphenazine (Prolixin). Fluoxetine (Prozac).
Atomoxetine (Strattera).
The nurse is planning a community education program about childhood mental health problems that appear to be genetically transmitted. While conducting the program, which problem should the nurse emphasize? Autistic disorders. Sleepwalking. Anxiety states. Conduct disorder.
Autistic disorders. Rationale Researchers have discovered several sporadic genetic mutations in children with autism spectrum disorder (ASD). A program that focuses on childhood mental health disorders that have a possible genetic link should include information about ASD.
The nurse is preparing to supervise a group meeting in the day room. The group consists of clients diagnosed with paranoid personality disorder. Which is the best approach when greeting clients diagnosed with this disorder? Avoid being too warm and friendly to the clients. Call the clients by name and shake their hand. Avoid eye contact with the clients. Express to the clients how happy you are to see them.
Avoid being too warm and friendly to the clients. Rationale Clients diagnosed with paranoid personality disorder are suspicious and mistrustful. They can be hostile and violent due to cognitive and perceptual distortions. The best approach during interactions is to avoid being too warm and friendly, projecting a neutral but kind affect.
A client was admitted to the inpatient unit 48 hours ago with a diagnosis of a Cluster "C" personality disorder. The client is well rested, but refuses to attend meals or group sessions. The client has been started on a SSRI for anxiety but has not demonstrated an effective response. Which other category of anxiolytic medication may be prescribed to produce a more immediate decrease in symptoms? MAOIs. Benzodiazepines. Lithium salts. Psychotropic medications.
Benzodiazepines.
A client has recently been admitted for evaluation of sudden onset psychosis. In addition to a medical assessment and serum drug screen, which other tests should the nurse expect the client will undergo to find a cause for this change in mental status? Brain MRI, PET scan. Skull radiographs, free thyroxin. CT angiography, electromyogram. Carotid Doppler, electrocardiogram.
Brain MRI, PET scan.
A client has recently been admitted for evaluation of sudden onset psychosis. In addition to a medical assessment and serum drug screen, which other tests should the nurse expect the client will undergo to find a cause for this change in mental status? Brain MRI, PET scan. Skull radiographs, free thyroxin. CT angiography, electromyogram. Carotid Doppler, electrocardiogram.
Brain MRI, PET scan.
The sibling of a young client with borderline personality disorder asks the nurse why the client has frequent mood changes. Which is the best response by the nurse to explain the neurobiological basis of this behavior? Brief shifts in mood are caused by an imbalance of nervous system chemicals that help regulate emotions. Shifts in mood are the result of an intolerance to certain chemicals found in food substances. Mood changes are due to the client's emotional immaturity and lack of insight into this behavior. Mood changes are common in clients during this phase of life due to hormonal changes.
Brief shifts in mood are caused by an imbalance of nervous system chemicals that help regulate emotions. Rationale Affective instability is characterized by brief shifts in mood. This condition is attributed to excessive limbic reactivity in the neurological circuits responsible for the regulation of the neurotransmitter, GABA.
The community health nurse is teaching a class of high school students about bullying. One of the students asks about social factors that might contribute to violent behavior. Which response by the nurse is correct? Children consuming too much sugar have a tendency to become violent. Children can learn aggressive behaviors by observing violence in the home. Individuals who are raised in poor families usually become violent. Children of overprotective parents usually develop aggressive behaviors.
Children can learn aggressive behaviors by observing violence in the home.
In which age groups is depression often often underdiagnosed? Children. Adolescents. Young adults. Middle aged adults. Older adults.
Children. Adolescents. Older adults.
A client is admitted due to alcohol intoxication and injuries sustained in a fall. The client appears anxious, agitated, and diaphoretic. Vital signs include a pulse of 140 and a blood pressure of 170/98. Delirium is suspected due to the client's claim that bugs are crawling on the bed. Which medication should the nurse expect will be administered to the client? Chlordiazepoxide (Librium). Disulfiram (Antabuse). Acamprosate calcium (Campral). Mesalamine (Asacol HD).
Chlordiazepoxide (Librium). Rationale The information provided indicates that the client is experiencing alcohol withdrawal, and is therefore at an increased risk for seizures. Chlordiazepoxide (Librium) raises the seizure threshold to reduce the risk of convulsions.
A 12-year-old boy is known as the neighborhood bully. His peers avoid him, and his mother says she cannot believe anything he tells her. He was recently observed shooting at several dogs with a pellet gun and was caught setting fire to a dumpster. Which disorder should the nurse document in the electronic medical record to describe the child's behavior? Conduct disorder. Attention deficit disorder. Defiance of authority. Oppositional defiant disorder.
Conduct disorder. Rationale The behavior displayed by the client meets the criteria for the diagnosis of conduct disorder. Bullying, cruelty to animals, setting fires, and consistently lying are indications that the behaviors are more serious than oppositional defiant disorder, attention deficit, or defiance of authority.
The nurse is caring for a client who has delusions of infidelity. The client's wife asks if there is any circumstance under which the treatment team is justified in violating the client's right to confidentiality. Which response is correct regarding exceptions to the client's right to confidentiality? Confidentiality is waived if the client threatens the life of another person. Confidentiality is waived when law enforcement requests information. Confidentiality is waived only at the discretion of the psychiatrist. Confidentiality is to be maintained without exception.
Confidentiality is waived if the client threatens the life of another person. Rationale The duty to warn a person whose life has been threatened by a psychiatric client overrides the client's right to confidentiality. It is the legal responsibility of any health care personnel, the duty to warn when an individual threatens to harm or hurt themselves or another individual.
An interdisciplinary treatment team meets to discuss a client diagnosed with paranoid schizophrenia and cannabis abuse who is experiencing increased hallucinations and delusions. How should the team plan an effective treatment? Consider each diagnosis primary and provide simultaneous treatment. Treat the schizophrenia before establishing goals for substance abuse treatment. Withdraw the client from cannabis before treating the symptoms of schizophrenia. Hospitalize the client for the longest possible stay that insurance will allow.
Consider each diagnosis primary and provide simultaneous treatment. Rationale Clients with dual or co-occurring diagnoses, such as a substance use disorder with a psychiatric disorder, should be treated for both conditions simultaneously. They are both considered a primary diagnosis and need to be addressed for treatment to be effective.
A client with stage 3 Alzheimer's disease is admitted to a behavioral health hospital. Due to the progression of the disease, the client is experiencing an increase in amnesia and agnosia, and has declined to the point of not recognizing familiar objects and people. Which action should the nurse take to help reduce the client's fear and anxiety and adjust to the new setting? Cover mirrors and pictures if they are upsetting the client. Keep the TV on in the room throughout the day. Provide the client with a stuffed animal. Serve the client's meals in a private room.
Cover mirrors and pictures if they are upsetting the client. Agnosia is the inability to recognize familiar objects. Clients that experience this cognitive impairment do not recognize themselves in a mirror; this may result in the client thinking that there is a stranger in the room. Covering the mirror provides the client with an increased sense of safety.
A student nurse working as an aide in a memory care facility asks the charge nurse if there is a neurobiological basis for the deterioration in cognitive function in Alzheimer's disease. Which explanation by the nurse is correct regarding the etiology of neurocognitive decline? "Decreases in neurotransmitters affect parts of the brain responsible for memory." "A decrease in body mass causes a decrease in the mass of the brain." "Untreated psychological problems slow down the thinking and reasoning processes." "Nutritional deficiencies cause a decrease in metabolism that inhibits the amount of glucose available to the brain."
Decreases in neurotransmitters affect parts of the brain responsible for memory." Rationale Neurocognitive decline is associated with changes in neurotransmitter concentration. Alzheimer's disease has been linked with a decrease in the production and function of acetylcholine (ACh). Alzheimer's disease affects an area of the brain called the nucleus basalis, which contains cholinergic neurons. These neurons provide ACh to areas of the brain responsible for memory and learning.
A client with long-term alcohol addiction is admitted to the emergency department. Which medications should the nurse anticipate the healthcare provider will prescribe for this client? Diazepam. Methadone. Multivitamins. Thiamine (vitamin B1). Monoamine oxidase inhibitors.
Diazepam. Multivitamins. Thiamine (vitamin B1). Rationale Alcohol withdrawal delirium usually peaks 48-72 hours since last consumption of alcohol. The diazepam has sedative and anticonvulsant properties. Thiamine and multivitamins are usually given to help with nutritional and malabsorption deficiencies common in clients with alcohol addiction.
The nurse is reviewing labs for a client who is taking clozapine, 25mg QD for treatment of disorganized schizophrenia. The labs are documented as follows: RBC 4.5 million/mcL, WBC 1000/mcL, TSH 1.2 mc-IU. Based on these results, which order should the nurse anticipate the health care provider to write? Discontinue clozapine. Administer levothyroxine sodium 25 mcg QD. Administer ferrous sulfate 100mg QD. Decrease clozapine to 12.5 mg QD, start levothyroxine sodium 50 mcg QD.
Discontinue clozapine. Rationale Agranulocytosis is an adverse side effect of clozapine that can cause lethal infections. Based on the client's results, clozapine should be discontinued; the thyroid and RBC results are normal and do not need to be treated.
A newly admitted client diagnosed with schizophrenia who is physically healthy believes that they are in the process of dying and their body is actively decaying and falling apart. Which intervention for this client should the nurse implement? Discuss what they are feeling and acknowledge their fear and anxiety. Discourage the client from discussing their belief of dying and correct their falsehood. Speak to them quietly while holding their hand and maintain eye contact. Allow the client as much privacy and quiet time as possible .
Discuss what they are feeling and acknowledge their fear and anxiety. Rationale The client's delusion of dying and their body decaying is their reality. The nurse should identify and focus on the client's feelings and discuss those and try to divert the client's preoccupation of the delusion.
The nursing instructor is teaching a student about the role of neurotransmitters as a contributing factor to the etiology of schizophrenia. The nurse is correct to include which information regarding neurotransmitter levels in clients with schizophrenia? Dopamine and norepinephrine are decreased; GABA is increased. Dopamine and norepinephrine are increased; GABA is decreased. Dopamine, norepinephrine, and GABA are all increased. Dopamine, norepinephrine, and GABA are all decreased.
Dopamine and norepinephrine are increased; GABA is decreased. Rationale The neurotransmitters that are known to contribute to the etiology of schizophrenia are dopamine, norepinephrine, and GABA. Dopamine and norepinephrine are increased, while GABA is decreased.
he nurse is interacting with the spouse of a client being treated for substance abuse. During the interview, the spouse makes excuses and takes the blame for the client's actions. Which terms best describe the spouse's behavior? Loyal. Enabling. Tolerance. Antagonistic. Co-dependency.
Enabling. Co-dependency. Rationale Individual's who enable another or create a co-dependent relationship often enjoy the feeling of being needed.
Which elements have been shown to be beneficial when incorporated into a stress management plan? Retreating from friends. Exercise. Mindfulness practices. Social media. Balanced diet.
Exercise. Mindfulness practices. Balanced diet. Rationale Sleep is essential to engage in activities of daily living. Exercise has been found to decrease stress levels and cortisol levels and increase sense of well-being. Relaxation reduces psychological or physiological distress. Multitasking facilitated by technology has been identified as a significant source of stress. Well-balanced diet can facilitate stress reduction and improve physical well-being.
he interdisciplinary team is planning treatment for a client with stage 2 Alzheimer's disease. The team agrees that involving the client in more therapy groups and activities could help improve memory and relieve some depressive symptoms. The team leader recommends reminiscence therapy. Which statement Facilitates discussions of life's transitions and evokes memories from the client's past. Encourages clients to pick a topic of concern and discuss their fears. Introduces the client to new forms of recreational therapy that may improve memory. Enables clients to develop new skills based on their previous skill sets.
Facilitates discussions of life's transitions and evokes memories from the client's past.
A health care provider informs family members that their grandfather has a reversible form of dementia. Which condition is associated with reversible dementia? HIV infection. Parkinson's disease. Fluid and electrolyte imbalance. Vascular disease.
Fluid and electrolyte imbalance.
The school nurse is providing an in-service program to high school girls about date rape drugs. A student expresses interest about particular drugs and asks the nurse what these drugs look like and how they affect the body. Which response by the nurse it correct? Flunitrazepam (Rohypnol) is a pill that dissolves in liquids and causes muscle relaxation and amnesia. Diphenhydramine (Compose) is a pill or capsule that is used to induce sleep. Acetaminophen plus ephedrine (NyQuil) comes in pill and liquid form and causes drowsiness. Cyclobenzaprine (Flexeril) comes in a pill form and causes drowsiness and relaxation.
Flunitrazepam (Rohypnol) is a pill that dissolves in liquids and causes muscle relaxation and amnesia. Rationale Flunitrazepam (Rohypnol) is a date rape pill that is also called "forget-me-not." It dissolves in water, becomes more potent when combined with alcohol, and causes relaxation and amnesia.
An addiction counselor is teaching a client and family about cross tolerance, cross addiction and alcohol, benzodiazepines, and barbiturates. The counselor is also teaching about the dangers of concurrent use. The nurse is correct to state that alcohol and CNS depressants act on which receptors? GABA. Serotonin. Dopamine. Opioid.
GABA. Rationale Alcohol and other CNS depressants act specifically on GABA receptors. The fact that these substances produce the same effect in the neurobiological system explains how cross tolerance and cross addiction readily occur. When taken together, they have a synergistic effect that causes an increase in the level and duration of central nervous system (CNS) depression; the combined effect can result in respiratory arrest.
The health care provider is performing a follow-up exam on a 17-year-old-client who was raped six months ago. The client states that she completed counseling and has been feeling like she is starting to put the experience behind her. Which action by the client is a sign of recovery? Going to her senior prom with her boyfriend. Taking sertraline (Zoloft) for anxiety. Expressing a need for more counseling. Refusing to go out alone in public.
Going to her senior prom with her boyfriend. Rationale A rape survivor experiences a wide range of feelings, including fear, depression, sleep disturbances, degradation, nervousness, and anxiety. Returning to pre-rape social functioning and interests, such as attending the senior prom, is a sign of recovery. The closer the survivor's lifestyle to the pattern before the rape, the more complete the recovery.
The nurse is interviewing a client who has recently been admitted for evaluation of a thought disorder manifested by paranoid behavior. According to the client's mother, the client was previously treated for anxiety, but has become more isolated and withdrawn over the last few weeks. He refuses to leave his room, and he states that he is the "King of Mars" and someone is trying to assassinate him. Which type of delusion should the nurse document? Jealous. Grandiose. Somatic. Erotomanic.
Grandiose. Rationale Individuals may suffer from several different types of delusions. In this example, the client is experiencing grandiose delusions (irrational ideas regarding his self-worth and identity), as well as persecutory delusions (thoughts of being persecuted or treated malevolently).
Which characteristics have been associated with substance abuse? Self reflection. Grandiosity. Manipulation. Low risk taking. Dysfunctional anger.
Grandiosity. Manipulation. Dysfunctional anger. Rationale Most substance abusers have in common behaviors consisting of grandiosity, manipulation, impulsiveness and dysfunctional anger.
The nurse is caring for a 72-year-old client who was admitted for treatment of depression. The nurse notices that the health care provider's order for an antidepressant calls for a dose greater than the usual adult dose. Which action is the correct action for the nurse to take? Hold the medication and consult the health care provider. Check the electronic formulary on the unit's computer. Give the usual adult dose. Implement the order as prescribed.
Hold the medication and consult the health care provider. Rationale The dose of antidepressants for an elderly client is often less than the usual adult dose. The nurse should withhold the order and consult the health care provider who prescribed the order. Medication safety is critical to protect the client from harm and it is the nurse's duty to intervene in this situation.
A 15-year-old female student visits the school nurse to ask about date rape and pregnancy. She confides to the nurse that her boyfriend forced her to have sex against her will. Which initial intervention is the priority for the nurse to implement? Identify the student's immediate concerns and feelings. Administer a pregnancy test. Teach methods of birth control. Explain safe sex practices.
Identify the student's immediate concerns and feelings. Rationale When the nurse discovers a client has been raped, the nurse needs to respond to the client's immediate concerns. It is most important for the nurse to allow the student to ventilate feelings at the beginning of the interview. The nurse should listen patiently and supportively, understanding that compulsive retelling helps the victim to become gradually desensitized to the rape.
Failure to keep medical appointments, arriving late, and being non-compliant with prescribed medications are common behaviors exhibited by clients with personality disorders. Which intervention should be incorporated into the plan of care when a client demonstrates any of these behaviors? Designate a staff member to be responsible for imposing compliance with treatments and appointments. Include the client in the decision-making process regarding treatments and appointments. Designate a family member to help the client remain compliant with treatments and appointments. Restrict privileges until the client demonstrates compliance with treatments and appointments.
Include the client in the decision-making process regarding treatments and appointments.
The treatment team is reviewing the plan of care for a client diagnosed with borderline personality disorder. The client has been acting out during group meetings and creating conflict between staff members. Which interventions by the staff will be most effective to decrease the behavior of "splitting" the staff? Increase frequency of staff meetings to discuss concerns and plan strategies. Designate one staff member to work with the client. Plan a meeting with the client's family to discuss the client's disruptive behavior. Exclude the client from attending groups until the behavior improves.
Increase frequency of staff meetings to discuss concerns and plan strategies. Rationale Clients with personality disorders challenge the ability of therapeutic staff to work as a team. One of the manipulative behaviors used by the client is known as "splitting," which causes the staff to disagree about the client's abilities and needs resulting in inconsistent treatment. Frequent and ongoing communication is needed to maintain firm and consistent expectations of the client's behavior.
An 85-year-old client is bought to the emergency department after a fall at home. The client appears confused, malnourished, and is severely dehydrated. The client appears reluctant to explain how the fall happened. The client's daughter speaks for the client and does not allow the client to answer questions. Based on this information, which nursing intervention is a priority? Interview the client alone and assess for abuse. Take the history from the daughter because the client is confused. Provide the daughter with nutritional counseling. Request a psychiatric evaluation for the client.
Interview the client alone and assess for abuse.
A health care provider prescribed donepezil (Aricept), for a client newly diagnosed with early-stage dementia. The client asks the nurse, how the medication is going to slow down the process of memory impairment. Which explanation by the nurse is accurate regarding the purpose of this medication? It prevents the breakdown of acetylcholine, which assists in transmission of nerve impulses. It acts as a sleep aid to address sleep difficulties that may accelerate dementia. It decreases the circulation of calcium in the cardiovascular system, which is responsible for memory loss. It increases the amount of glucose available to the brain to maintain current brain function.
It prevents the breakdown of acetylcholine, which assists in transmission of nerve impulses. Rationale Donepezil is a cholinesterase inhibitor, which blocks the enzyme that breaks down acetylcholine. Donepezil also stimulates the production of acetylcholine, a chemical that assists in nerve transmission. Individuals treated with this medication usually see an improvement with behavior and activities of daily living.
The treatment team discusses plans regarding two clients who both exhibit self-mutilating behavior. The nurse expresses concerns about the decision to use restraints on one client, while assigning one-to-one supervision for the other. Which ethical principal is the nurse concerned about violating? Justice. Autonomy. Beneficence. Fidelity.
Justice. Rationale Implementing different plans of care for clients with the same condition brings into question the issue of fairness. The nurse is concerned about justice, which refers to the fair treatment of both clients with the least restrictive method.
A female client diagnosed with posttraumatic stress disorder after a rape tells the health care provider that she feels anxious all the time. The client is learning yoga to help with her anxiety, but she is still unable to relax. Which medication is indicated to support the client's stress management routine by providing short-term relief of anxiety? Lorazepam (Ativan). Quetiapine (Seroquel). Olanzapine (Zyprexa). Zolpidem (Ambien).
Lorazepam (Ativan). Rationale Lorazepam (Ativan) is an anxiolytic prescribed for short-term relief of anxiety, and it can be taken on an as-needed (prn) basis. If long-term anxiety management is required, an SSRI or antidepressant may be indicated.
The family and friends of a client with a heroin addiction are planning an intervention meeting to convince the client to seek help. Which strategy should the group employ to help ensure a successful intervention? Make notes on what to say to the client and rehearse before the meeting. Attempt the intervention at a time when the client is under the influence. Stage the intervention in a public place that is familiar to the client. Set boundaries and be prepared to act in case the client behaves defensively.
Make notes on what to say to the client and rehearse before the meeting. Rationale An intervention is a useful tool to help an addict who is resistant to treatment. Members of the intervention team should prepare ahead of time, and each member should write down and rehearse what is to be said to the client.
What are some of the family risk factors the nurse should look for when interviewing a client who is suspected of being in an abusive relationship? Mental health problems in the nuclear family.. Substance abuse by household members. Family relationships that appear dysfunctional. The ethnic and cultural background of the family. Educational background of client and family members.
Mental health problems in the nuclear family.. Substance abuse by household members. Family relationships that appear dysfunctional.
The spouse of a heroin addict asks the nurse, "What is methadone maintenance all about?" Which response by the nurse is correct? Methadone reduces cravings and blocks the action of opiates. Methadone reduces craving without any sedative effects. Methadone is less potent than other replacement drugs. Methadone is a deterrent to the use of both "hard" and "soft" drugs.
Methadone reduces cravings and blocks the action of opiates.
The nurse is interviewing a newly admitted client with major depression. Which statement by the client is evidence of a genetic etiology of this mood disorder? My mother was diagnosed with bipolar affective disorder. My uncle was diagnosed with schizophrenia. My cousin was hospitalized with suicidal ideation last year. My niece is being evaluated for borderline personality disorder.
My mother was diagnosed with bipolar affective disorder. Rationale Studies show that genetic factors play a role in the development of depressive disorders. Individuals who have a first-degree family member with the diagnosis are two to four times more likely to become depressed.
The nurse is caring for a client diagnosed with a personality disorder. The client states that he must constantly fend off females who seek his attention. He boasts that he is a former high school baseball player who was once voted most valuable player, and he claims that no other baseball player will ever be as good as he was in baseball and he should play professionally, but his salary would be too high for the professioal leagues to pay him. These statements reflect which personality disorder? Narcissistic personality disorder. Obsessive-compulsive disorder. Histrionic personality disorder. Borderline personality disorder.
Narcissistic personality disorder.
An adolescent client was recently admitted to the eating disorder unit and is complaining of severe muscle aches, fatigue, and weakness. The nurse completes a physical assessment and reviews the client's most recent lab results. All lab values are within normal limits except the potassium level, which is 2.7 meq/L. Based on this assessment, which nursing intervention is the priority? Notify the health care provider that the client is hypokalemic and complaining of muscle aches. Medicate the client with cyclobenzaprine 5mg every 8 hours PRN for muscle aches. Encourage the client to take a hot shower to relieve aches and pains. Assess the client's pain and administer pain medication as ordered.
Notify the health care provider that the client is hypokalemic and complaining of muscle aches.
The health care provider is evaluating a client with bulimia who is being treated with fluoxetine (Prozac), a selective serotonin reuptake inhibitor. It is determined that medication has been ineffective because the client's mood and obsessive compulsive behaviors have not improved. Which unconventional antipsychotic agent should the health care provider recommend for the client? Olanzapine (Zyprexa). Sertraline (Zoloft). Lorazepam (Ativan). Zolpidem (Ambien).
Olanzapine (Zyprexa). Rationale Olanzapine (Zyprexa) is an unconventional antipsychotic agent used to treat some mental disorders. It has proven successful in some clients by decreasing compulsions and improving mood.
A client is undergoing treatment for schizophrenia. Which outcome provides evidence that the client's negative symptoms are improving? Refrains from yelling and trying to touch the health care provider for the last 48 hours. Participates in music therapy and states that he enjoys playing the drums. Eats meals in his room instead of causing disturbances during mealtime. Reports having no hallucinations for the last week.
Participates in music therapy and states that he enjoys playing the drums..
A 7-year-old client with attention-deficit/hyperactivity disorder (ADHD) is being evaluated at a mental health clinic. A nursing diagnosis of delayed growth and development related to neurological status has been established, as evidenced by hyperactivity that prevents participation in play. The plan for care includes the administration of methylphenidate (Ritalin). Which outcome indicator should the nurse monitor? Expressive communication. Correct Participation in group play activities. Child socialization skills. Decreased fear and anxiety.
Participation in group play activities. Rationale The nursing diagnosis identifies the child's inability to play. Participation in group play activities is the expected outcome based on the nursing assessment and diagnosis.
The nurse is caring for a victim of severe emotional violence inflicted by her husband. The client states that the abuse occurs most often when her husband is intoxicated, and that he is always remorseful afterwards. She also tells the nurse that her husband's father was an alcoholic who beat him and his mother. What evidence exists that the husband is at risk of becoming a perpetrator of physical abuse? Past childhood abuse. Feelings of remorse. Temporary behavioral changes. Excessive alcohol consumption.
Past childhood abuse. Rationale An abuse-prone individual is one who has experienced family violence and has likely been abused as a child. The client's husband is at risk for becoming a perpetrator of physical abuse because he witnessed and experienced similar abuse as a child.
A client with stage 2 Alzheimer's disease is being cared for at home by the spouse. The client's spouse tells the nurse about the emotional difficulties involved in providing fulltime care at home. Which self-care activity is most important for the nurse to recommend to the spouse? Periodic times of respite from caregiving. Regular attendance at church services. Participation in reminiscence therapy. Establishment of a predictable daily schedule.
Periodic times of respite from caregiving. Rationale Caregiver role strain may be attributed to many different factors. The nurse must become familiar with this diagnosis in order to accurately assess the caregiver and offer effective interventions. One important recommendation is to have the caregiver incorporate periodic breaks as part of the daily routine to relieve stress. The nurse should contact the client's manager and provide the client's caregiver a list of agencies offering "Respite Care".
The nurse is teaching a client with atypical depression who is being treated with a monoamine oxidase inhibitor. The nurse explains that certain foods may cause a severe reaction if consumed while taking this drug. The nurse should tell the client to avoid which foods while taking this medication? Apples, oranges, and milk. Pickles, sausages, and most cheeses. Yogurt, pork, and sweet potatoes. Brussel sprouts, steak, and grapefruit juice.
Pickles, sausages, and most cheeses. Rationale Monoamine oxidase inhibitors (MAOIs) inhibit the breakdown of tyramine in the liver. Individuals who are prescribed this class of medication need to avoid foods high in tyramine in order to avoid dangerously high levels of tyramine, which can cause high blood pressure, hypertensive crisis, stroke, and death. In general, the rule of thumb it is best to advise clients who are prescribed MAOIs to avoid any type of food or liquids that is aged, cured or fermented to avoid a drug interaction resulting in a hypertensive crisis.
The nurse notes that a client is experiencing panic-level anxiety during a group meeting in the community room. Which intervention should be implemented immediately? Provide calm, brief, and directive communication. Administer anxiolytic medication, as ordered. Teach the client relaxation techniques. Prepare staff members to restrain the client.
Provide calm, brief, and directive communication. Rationale Clients experiencing severe- to panic-level anxiety often feel out of control and need to know they are safe from their own impulses. This can be achieved through firm, short, and simple statements. Reinforcing commonalities in the environment and pointing out reality when there are distortions can also be useful when caring for a severely anxious client.
The emergency department nurse is providing care for a rape victim. Which action represents an essential element of care for this client? Providing nonjudgmental care. Conveying outrage that this occurred. Sympathizing with the client's sense of shame. Encouraging the client to divulge all the details
Providing nonjudgmental care.
The emergency department nurse is providing care for a rape victim. Which action represents an essential element of care for this client? Providing nonjudgmental care. Conveying outrage that this occurred. Sympathizing with the client's sense of shame. Encouraging the client to divulge all the details
Providing nonjudgmental care.
During a home care visit for a client diagnosed with schizophrenia, the spouse complains to the nurse that the client is refusing to eat or drink anything that is prepared for them. Which intervention should the nurse recommend? Instruct the caregiver to place the prepared food next to the client and leave the room. Teach the caregiver how to gentle force feed the client with soft mechanical diet. Recommend that unopened, prepackaged food to be given to the client. Suggest that a tube feeding nutrition therapy be initiated.
Recommend that unopened, prepackaged food to be given to the client. Rationale Clients diagnosed with schizophrenia can experience periods of paranoia and this client may believe their food has been tampered and posioned. Offering the client prepackaged food that has not been open, may be the only alternative to get the client to eat and drink.
Which assessment data supports a diagnosis of acrophobia? Refuses to drive or walk across any type of bridge. Avoids leaving the house for more than an hour. Refuses to go outside to watch baseball even though he loves the sport. Avoids basements due to a fear of encountering spiders.
Refuses to drive or walk across any type of bridge.
The nurse is providing care to a client suspected of Munchausen. The nurse should understand that which example demonstrates a breach of a client's constitutional right to privacy? Releasing information to the client's employer without consent. Discussing the client's history with other staff during care planning. Documenting the client's daily behaviors during hospitalization. Asking the family to share information about the client's behavior before hospitalization.
Releasing information to the client's employer without consent. Asking the family to share information about the client's behavior before hospitalization. Rationale Munchausen is a psychiatric disorder in which an individual either pretends or causes injury deliberately to themselves as an attention seeking out type of behavior. Releasing any medical information about a client without consent is a breach of confidentiality. This subjects the nurse to liability for invasion of privacy and is considered a violation of the Health Insurance Portability and Accountability Act (HIPAA).
Which nursing diagnosis is the priority for a client who is being treated with lithium? Risk for Infection. Self-care deficit. Risk for fluid imbalance. Nutritional deficit.
Risk for fluid imbalance. Rationale Lithium has a narrow therapeutic window in which blood levels should range between 0.4 and 1.3 mEq/L; levels of 2 mEq/L or greater can result in a life-threatening emergency. Blood levels are dependent on kidney function, and any change in sodium and hydration levels affects the excretion of lithium. A decrease in sodium levels can cause an increase in lithium levels leading to toxicity.
During a homecare visit, the nurse is assessing an elderly client diagnosed with bipolar depression who lives alone. The client appears disheveled and is wearing slippers on the wrong feet. The nurse observes various throw rugs, old food containers, and other trash scattered throughout the house. No smoke detectors are visible. The client is unable to recall the date or time of year and not able to have a coherent conversation. Which nursing diagnosis is the priority concern? Risk for injury. Self-care deficit. Nutritional deficit. Risk for depression.
Risk for injury. Rationale Safety is always the primary concern when assessing a client. Other nursing diagnoses may need to be addressed, but only after safety needs are met. Information provided in this example includes several factors that contribute to the client's risk for injury (e.g., cognitive decline, trip hazards, etc.).
A client is admitted to the medical unit with needle tracks on both arms. A friend has stated that the client uses heroin. The nurse should recognize which group of signs and symptoms in clients suffering from opioid withdrawal? Runny nose, yawning, insomnia, and chills. Slurred speech, excessive drowsiness, and bradycardia. Anxiety, agitation, and aggression. Paranoid delusions, tactile hallucinations, and panic attacks.
Runny nose, yawning, insomnia, and chills. Rationale Early withdrawal from opioids resembles a flu-like illness without the temperature elevation. Runny nose, chills, insomnia, and yawning are commonly experienced by clients during opioid withdrawal.
A client diagnosed with borderline personality disorder has been hospitalized several times for self-mutilation and suicide attempts. Dialectical behavioral therapy has been initiated in an outpatient setting. The client describes feelings of mild depression and anger over a breakup with a significant other and agrees to be treated with medication to help manage the symptoms. The nurse should prepare a teaching plan for which medication? Monoamine oxidase inhibitors (MAOIs). Benzodiazepines. Selective serotonin reuptake inhibitors (SSRIs). Antipsychotics.
Selective serotonin reuptake inhibitors (SSRIs). Rationale SSRIs are less toxic in the event of an overdose and are therefore considered the drug of choice for clients who are suicidal.
A newly admitted adolescent client is being worked up for possible diagnosis of bipolar disorder. What is a distinctive sign indicative of bipolar disorder in children? Hyperactivity and attention deficit. Impulsiveness and carelessness. Severe mood swings different from typical mood swings. Lack of empathy for family members and others.
Severe mood swings different from typical mood swings. Rationale Children diagnosed with bipolar disorder exhibited the same signs and symptoms as diagnosed adults, but their manner of bipolar episodes occur vary greatly from adults and can change rapidly from a manic to depressive or hypomanic phase quickly and erratically. The most noticeable sign of bipolar disorder in children is their severe mood swings in comparison to the normal anticipated mood swings of children and adolescents.
A 16-year-old female is bought to the emergency department following a suicide attempt. The client reports to the nurse that she is doing poorly in school, is engaging in high-risk sexual activity, and has a history of running away from home. Which assessment is the priority at this time? Sexual abuse. Pregnancy. Physical abuse. Sexually transmitted infections.
Sexual abuse. Rationale The client's sexual behavior, suicide attempt, and running away indicate possible sexual abuse. Assessing for sexual abuse is the priority.
The nurse is providing information about codependent behaviors to the wife of a client with alcoholism. The nurse is correct to identify and point out to the wife which behavior as an example of codependency? She calls in sick for her husband when he is too hung over to work. She prepares dinner for her husband every night. She shops for all her husband's clothes. She frequently drives her husband to work.
She calls in sick for her husband when he is too hung over to work. Rationale Lying or covering up the client's drinking or drug use, and shielding the client from the consequences, is a behavior that reflects codependency. Calling in sick for her husband because he has a hangover is an example of codependent behavior. Codependency also involves deception and a reflection of a dysfunctional relationship in which an individual feels responsible for covering up and enabling another's destructive action.
During a therapy session, the nurse is teaching family members of a psychotic client to be alert for command hallucinations. Which risk is of primary concern regarding this type of hallucination? Elopement. Drug abuse. Suicide. Legal problems.
Suicide. Rationale During command hallucinations, a client may experience "voices" that call for certain behavior. The priority risk to an individual who is experiencing command hallucinations is suicide or homicide because the "voices" may command the person to kill.
The nurse is performing a pre-op assessment on an 18-month-old client who is scheduled for minor surgery. The nurse observes numerous bruises of different stages over the client's back and buttocks. The mother states that the child must have fallen down while playing alone outside, but she does not provide any specific information. Which statement regarding the assessment data should the nurse enter into the electronic medical record? Suspected child abuse and neglect. Immature parenting. Normal findings in an 18-month-old. Indications of tissue fragility.
Suspected child abuse and neglect. Rationale The findings described are not normal, even though toddlers can be unsteady while walking. The number, location, and various stages of the bruises, as well as the mother's vague explanation that the child was unsupervised while playing outside, indicate possible child abuse. Bruising is common in childhood, especially the more mobile a child becomes learning how to walk and exploring their world. Common areas of normal childhood bruising are usually located on shins and knees and over bony prominences in the front of the body. Abnormal patterns of bruising that is located on the back, buttocks, forearm or upper arm, face, ears, abdomen, or hip, back of the leg, foot or hands require further investigation for suspected child abuse or neglect.
A 5-year-old cries and screams continuously from the time their mother drops them off at kindergarten until she picks him up 4 hours later. He is calm and relaxed when he is with his mother. The mother seeks advice from a friend who is a nurse. Which response by the nurse is best? "Talk with your healthcare provider about referring him to a mental health clinic." "Talk with the school principal about withdrawing him until he is more mature." "Arrange with the teacher to let him call home during play time." "Send a picture of yourself to school to keep with him."
Talk with your healthcare provider about referring him to a mental health clinic." Rationale Separation anxiety disorder becomes apparent when the child is separated from the attachment figure. The first evidence of this disorder often occurs when the child begins going to school, and it may be based of the child's fear that something will happen to the attachment figure. Professional help is needed to learn how to cope with anxiety effectively. Separation anxiety is common childhood condition that usually becomes evident around seven months of age, but should subside around three years of age.
The nurse documents that a client diagnosed with stage 3 Alzheimer's disease presents with aphasia. Which client behavior supports this finding? The client is no longer able to speak. The client cannot recognize pictures of family members. The client has lost the ability to walk. The client cannot recall where personal items are located.
The client is no longer able to speak. As Alzheimer's disease progress, an individual will present with amnesia, apraxia, agnosia, and aphasia. Aphasia is the loss of ability to speak and understand words.
The visiting nurse is assessing a client with early-stage dementia who has recently been prescribed donepezil (Aricept). Which information obtained from the client's family member demonstrates that the medication is effective? The client is showering and getting dressed with minimal assistance. The client uses confabulation to cover up memory loss. The client did not attend the family reunion last weekend. The client arranges to have groceries delivered.
The client is showering and getting dressed with minimal assistance. An expected outcome of donepezil (Aricept) is to help the client maintain some independence in the early stages of dementia. Being able to shower and dress with minimal assistance is evidence of achieving this short term goal.
The psychiatric home care nurse is visiting a Hispanic client who is being treated for depression. The client greets the nurse with a smile and offers to make coffee. The nurse politely declines the coffee and asks how the client is doing. During the session, the nurse notes that the client seems less spontaneous in affect and becomes more withdrawn. Which is the most likely reason for the client's change in behavior? The client may feel rejected by the nurse. The client is experiencing rapid cycling. The client feels the nurse has broached a taboo subject. The client feels nurse's social touch is inappropriate.
The client may feel rejected by the nurse. Rationale In the Hispanic culture, good etiquette requires accepting offers of food and spending some time engaging in small talk before discussing more serious issues. The client may be feeling rejected because the nurse did not accept the offer of coffee.
A client with schizophrenia is attending group therapy sessions. Which actions by the client demonstrate that he is progressing to the stabilizing phase of illness? The client participates and attempts to convince others that his delusions are real. The client admits to past delusions but states that he is a rock star who no longer needs group therapy. The client participates and states that his delusions are not real, but that he needs them to feel better. The client denies having delusions but states that he writes to government officials to report his spy activities.
The client participates and states that his delusions are not real, but that he needs them to feel better. Rationale In the stabilization phase of recovery from schizophrenia, a client begins to understand the illness and shows improvement in the ability to function in social situations. The client demonstrates he is in the stabilization phase of recovery by participating in group therapy and acknowledging that his delusions are not real.
The nurse is counseling a client who is dealing with complicated grief over the death of a spouse. Which statement reflects the most desirable outcome for the client? The client will attend a surviving spousal support groups. The client will plan a memorial tribute for the spouse. The client will stop expressing feelings of loss every day. The client will plan a vacation after finalizing the burial arrangements.
The client will attend a surviving spousal support groups. Rationale A major outcome of grief counseling is to assist the client in sharing their loss and to accept support from others. It is critical for the spouse to share the feelings of loss and grief in a supportive interpersonal environment. Complicated grief is a consistent state of sadness associated with a great loss. It is suspected that there may be a relationship between complicated grief and adjustment disorder. Most people go through the stages of grief at their own pace. Individuals dealing with complicated grief have difficulty progressing through the stages and it may take over a year or more to resolve their sense of lost.
A client with delirium keeps attempting to get out of bed and has fallen twice, despite being under close-observation. The charge nurse calls the health care provider to obtain an order for mechanical restraints. Which statement is correct regarding the mechanical restraint policy? The client will need to remain on close-observation with a documentation note every 15 minutes. The client no longer require close-observation, but must be checked at regular intervals. The client may be sedated and left alone as long as the restraints remain in place. Restraints may be applied based on verbal orders received over the phone.
The client will need to remain on close-observation with a documentation note every 15 minutes. Rationale Restraints are the last option to use to ensure client safety. A written order is required by a health care provider and the client require continued close-observation, even if mechanical restrained.
The interdisciplinary treatment team is designing a plan for a client with antisocial personality. The client's behaviors include lying to other clients, flattering the primary nurse, verbally abusing a client who has Alzheimer's disease, and being argumentative at counseling sessions. Which behavior is the priority for the treatment team to address? Verbal abuse of another client. Lying to the other clients. Flattering his primary nurse. Arguing during counseling sessions.
Verbal abuse of another client.
The nurse is assessing a client who expresses feeling overwhelmed with the care of an elderly parent. Which question best uncovers the client's perception of this event as a stressor? Have you started drinking or smoking as a result of this stressor? What impact does this stressor have on your life? Are you having trouble getting to sleep or staying asleep? What do you believe is causing you stress right now? Who else is helping with the caregiving and household chores?
What impact does this stressor have on your life? What do you believe is causing you stress right now? Rationale A change in someone's financial status, other stressors present, and an unanticipated stress are factors that have an affect on individuals regardless of their social cultural background or age or gender.
The nurse is preparing to administer haloperidol (Haldol) to a client diagnosed with schizophrenia. While performing a nursing assessment prior to medication administration, the nurse observes that the client is diaphoretic and disoriented. Vital signs include a temperature of 102° F (38.8° C), a pulse of 120, and a blood pressure of 160/98. Which nursing intervention takes priority? Withhold haloperidol and notify the health care provider of the client's status. Administer benztropine (Cogentin) 1 mg IM to counteract the autonomic side effects. Evaluate the client for dehydration as a cause of hyperpyrexia and tachycardia. Administer Tylenol 500mg PO PRN as ordered for temperature elevation.
Withhold haloperidol and notify the health care provider of the client's status. Rationale The antipsychotic agent, haloperidol (Haldol), should be stopped immediately if the client develops signs of neuroleptic malignant syndrome (NMS). Symptoms include an increase in temperature, pulse, and blood pressure, as well as severe muscle rigidity, confusion, and agitation. The other choices are correct interventions to treat the symptoms but discontinuing the drug which is causing the reaction is the priority.
