MH final

A young adult diagnosed with bulimia nervosa presents at the mental health clinic telling the nurse, "I just can't seem to maintain any friendships." Which classic behaviors associated with diagnosis would impact interpersonal relationships?

Need to lie and keep secrets

A client diagnosed with obsessive-compulsive disorder is constantly checking the oven to make sure it is off. This is an example of which type of obsessive thought content?

Repeated doubts

Which statement is true regarding therapeutic communication?

The focus is on the client.

Which nursing characteristic is vital to the nurse-client relationship?

Trust

Which side effect of chronic alcohol abuse is treated in the detoxification phase with multivitamin therapy that provides niacin and thiamine replacement? Selected Answer:

Wernicke--Korsakoff syndrome

Which type of parental behavior is associated with the etiology of anorexia nervosa?

Child is made to be dependent on the parents.

When the nurse asks a client, "Did I understand you correctly...," the nurse is using which verbal communication technique?

Clarification

Which parameter is considered an effect of secondary aging?

Life experiences

Which intervention demonstrates the nurse's best effort to maintain a milieu where clients are accepted regardless of their mental illness?

Nurse makes sure it is possible for every client regardless of their physical or mental limitations to take part in the unit's holiday program.

The nurse, recognizing the need to allow time for clients with obsessive—compulsive disorder to carry out compulsions, understands this is necessary in order for the client to:

Relieve anxiety

A 10-year-old child repeatedly has been abused physically by both parents. This environment has caused the child to behave aggressively when faced with frustrations or disappointments. Which nursing intervention will have the greatest impact on modifying these behaviors?

Role modeling coping skills that appropriately manage frustration and disappointment

Which psychotic disorder is exhibited by a combination of a mood disorder and the active symptoms of schizophrenia?

Schizoaffective disorder

A client is being discharged on a tricyclic antidepressant (TCA). The nurse should reinforce which statement from the discharge teaching?

This medication should not be taken when pregnant

How does the nurse use communication to best affect mental health care for a client diagnosed with a mental illness?

Using therapeutic communication to build a trusting nurse-client relationship

All antipsychotic drugs are used in the treatment of (select all that apply):

acute and chronic psychoses mania dementia-induced psychosis

Which assessment data would support a diagnosis of an eating disorder? (Select all that apply.)

amenorrhea kidney failure depression and decreased libido lethargy

The nurse observes a client having thrusting tongue movements that were not present on admission and reports this to the charge nurse and the physician. In which of the following roles is the nurse functioning?

caregiver

A client presents at the clinic with a possible diagnosis of hypoactive sexual desire disorder. The nurse should assess for this sexual disorder by asking the client:

if he has lost interest in a sexual relationship.

Which condition is considered a negative symptom of schizophrenia?

lack of energy

A client diagnosed with schizophrenia states, "Everyone is out to get me. They are trying to get into my head. They are watching me." The nurse identifies the client's form of schizophrenia as:

paranoid

A client with illness anxiety disorder will display which characteristics of the disorder?

perceived incompetence of medical professionals

A client has had five mood shifts within 1 year, alternating between mania and depression. The nurse would correctly document this assessment finding as:

rapid cycling.

The nurse is assessing a client diagnosed with borderline personality disorder. The most important assessment for the nurse should be:

scars or cuts

A young girl confides to the nurse that she has recently become sexually active but that "having sex doesn't feel good." Which type of disorder should the nurse suspect is involved in this client's lack of pleasure in the sexual act?

sexual pain

The nurse documents a positive reaction in the client's affect based on the client:

smiling when told that he had received mail.

A client is exhibiting lip smacking, facial grimacing, and protruding tongue movements. These extrapyramidal side effects would accurately be documented as:

tardive dyskinesia.

An individual has shared that he is suicidal and has a plan he will implement soon. The nurse should give priority to asking which question?

"How do you plan to harm yourself?"

Which client statement supports the nurse's suspicions that a client being treated for chronic depression is experiencing severe emotional distress produced by external circumstances?

"My professional life is ruined because my boss never recognizes my worth and value."

Which statement made by the partner of a client who has recently expressed suicidal ideations supports the nurse's belief that the partner understands the concept of crisis prevention?

"All the medications in the home are locked up in a safe cabinet and only I have the key."

An older adult client is prescribed an anti-psychotic medication for the management of psychotic behaviors. Which should be the nurse's response when the family asks why the dose being prescribed is low compared with the range for adults identified in the educational materials they were provided?

"Changes to liver and kidney function normally experienced with age require smaller doses."

The nurse is admitting a client with avoidant personality disorder. The documentation of the admission assessment might include which of the following observations of this client?

"Client avoids eye contact. Asks if she would have to participate in any group activities".

When a client appears to be denying the finality of her terminal diagnosis, her daughter expresses concern. Which response by the nurse will best serve to explain the therapeutic value of denial?

"Denial allows your mother the time to prepare for her death."

Which question will best aid the nurse in assessing a client's current state of mental health?

"How pleased are you with both yourself and your life?"

A client tells the nurse, "The voices say that I am evil and I am going to be punished." Which of the following would be the most therapeutic response?

"I don't hear the voices, but the words must be frightening for you."

The first-priority short-term goal for the client with an antisocial personality disorder should be "The client will:

"Not harm others."

The client explains that he has recently been diagnosed with a substance problem and was told it is "an abuse issue."How can the nurse best describe what abuse means in relationship to this statement?

"Substance abuse means the person has a maladaptive pattern of use that shows physiologic, cognitive, and behavioral indications that the person continues to use the substance despite the resulting negative effects."

Which statement made by a mental health nurse demonstrates a need for additional education regarding the importance of maintaining professional boundaries?

"The best part of this job is knowing that the clients really need me."

A client who will be having several diagnostic tests the following day complains of being unable to sleep. When the clients says, "I am so afraid something is really wrong with me," which of the following responses would be most therapeutic?

"You seem worried about the results of your tests. Would you like to talk about it?"

Which behavior exemplifies how suppressed anger is often displayed in situations where a parent directed physical abuse toward a child, who is now an adult?

Adult child bans both sets of grandparents from having contact with the grandchildren

Which is the therapeutic blood level for a client receiving lithium carbonate?

1.0 mEq/L

Which would be consistent with the characteristics of a therapeutic relationship? (Select all that apply.)

>Develops goals for improvement of existing problems >Focuses on identifying client problems >Dependent on the situation and needs of the client >Promotes a return to independent living within societal norms

Research has shown that social learning involves imitation, the effects of modeling, and identification behaviors. Which best explains the results of this research in the etiology of substance abuse?

>Chaotic home environments increase the likelihood of substance-abuse issues. >The risk for alcohol abuse is increased by 50% in first-generation relatives of alcoholics. >Social learning involves the imitation of behaviors. >Children of substance-abusing parents are at a greater risk for substance abuse.

Mood-stabilizing treatment would be contraindicated for which clients? (Select all that apply.)

70-year-old client with a history of diabetes 35-year-old client who is pregnant 45-year-old with a history of chronic renal failure 20-year-old client who has a history of seizures

Which situation is a factor that could be part of a person's cultural identity? (Select all that apply.)

> Preferring to live among those from their native country >Speaking their native language at family gatherings >Naming their children to honor family elders

The nurse is updating the assessment of a client diagnosed with obsessive-compulsive disorder (OCD). The nurse extends the interview to include questions to assess for other related comorbid mental health disorders. Which questions should the nurse ask? (Select all that apply.)

>"Are you familiar with the term body dysmorphic disorder?" >"Do you get anxious when you are asked to give away something of yours?" >"Have you ever resorted to pulling out your own hair when you are anxious?"

Which statement demonstrates the client's ability to implement an adaptive coping strategy? (Select all that apply.)

>"I know that I can find another job; I've done it before." >"I'm better at managing stress since I meditate daily." >"Being able to laugh instead of cry is an invaluable skill."

Which area of focus should be included in the care planning of an individual diagnosed with chronic anxiety in order to assist in symptomatology management? (Select all that apply.)

>Energy conservation strategies >Strategies to strengthen the ability to concentrate >Good sleep hygiene techniques >Identification of dependable support system

Which focus will have the greatest influence on an individual's ability to manage stress effectively?

Being flexible when handling daily stress

When developing a plan of care for a client identified with substance-abuse issues, initially the nurse selects appropriate nursing diagnoses resulting from which identified problem area?

Ability to perform ADLs safely

The nurse evaluates a client with dissociative identity disorder. What characteristics will be noted?

Acknowledgment of the existence of more than one personality

Which client, diagnosed with a personality disorder, exhibits disregard and infringement on the rights of others?

Anti-social

A client begins demonstrating signs of anxiety when preparing to speak in front of others during a group therapy session. This behavior is consistent with which type of anxiety?

Anticipatory

Drugs used to treat mental disorders are categorized by what? Select all that apply

Antipsychotic agents Antianxiety agents Antidepressents Antiparkinson Antimanic agents

Which outcome is specifically appropriate for a client in the recovery phase of substance-abuse treatment?

Begins to develop a support system with non-substance-using friends

Codependent people internalize a form of guilt for the behavior of the abuser. Which is the primary outcome of this guilt for the codependent person?

Behaviors aimed at sustaining the relationship

A 14-year-old girl is brought to the clinic by her mother for possible depression. Her mother reports that, "On several occasions, I've found her in the middle of the night eating a whole pizza and a carton of ice cream." When asked to discuss the situation the girl begins to cry. The nurse knows that this behavior supports which diagnosis?

Bulimia nervosa

An inmate arrives at the correctional facility and asks to speak to the nurse concerning the need for "some pills to calm my nerves." Considering the value inmates place on medical care, which should be the nurse's initial response?

Conduct the mental health assessment in a calm, matter-of-fact manner being alert for possible manipulative behaviors on the part of the inmate

A client diagnosed with a somatic illness threatens to "kill myself" if the nurse doesn't arrange for a sophisticated diagnostic test. Which outcome will the nurse add to the client's plan of care to help the client deal with the safety issues related to this behavior?

Demonstrates reduced manipulative behavior to secure attention

Which is the most serious long-term psychosocial outcome of childhood bullying?

Demonstrating serious problems developing and maintaining healthy relationships

Ronald tells the nurse he is not an alcoholic. He states he drinks "two or three beers with his buddies every day after work and maybe he gets home. "I can handle it. I've never missed work because of it." The nurse would recognize Ronald is using the mental mechanism of:

Denial

Which personality disorder is associated with an increased risk for physical, verbal, emotional, or sexual abuse?

Dependent

When the nurse suggests to a client that, "You and I need to take a walk" the client responds with "walk, walk, walk...." This is an example of which speech pattern?

Echolalia

Which nursing action best demonstrates the nurse's understanding of the grieving process and the most effective means of facilitating the client's ability to bring about closure and display hope for the future?

Devoting time each meeting to discussing the feelings the client has described in his or her daily journal entries

Which nursing intervention provides the best method of educating newly admitted clients of their client rights?

Discussing with all new clients the Client Bill of Rights that is posted on the unit

When assessing a client diagnosed with antisocial personality disorder, the nurse should expect to observe which personal characteristic?

Dishonesty

A 42-year-old male is brought to the emergency department by his brother. The brother tells the nurse that the client has traveled across the country for a week. The brother tells the nurse that the client claims to be someone he is not but otherwise seems quite normal. Which disorder should the nurse suspect for this client?

Dissociative Fugue

After a train accident, a 19-year-old male is admitted to a local hospital unable to remember any personal information covering the entire scope of his life. Which disorder do these symptoms describe?

Dissociative amnesia

Which diagnosis is supported when a client suddenly becomes unaware of her identity and cannot recognize family members or personal information?

Dissociative disorder

An anti-psychotic drug that is considered " a high potency" drug would be?

Haldol

Which intervention would be effective in refocusing the attention of a client diagnosed with an eating disorder?

Restricting time devoting to meals to 30 minutes

The nurse is managing the care of a client diagnosed with dementia. To minimize impulsive aggressive behavior and facilitate a sense of calmness, which intervention will be included in the plan of care?

Keeping the client's daily routine simple and consistent

A client is diagnosed with a conversion disorder related to the loss of feeling in his right hand. Which phrase should the nurse use to demonstrate the client's lack of concern over his symptoms?

La belle indifference

Which thought pattern is consistent with the diagnosis of schizotypal personality disorder?

Magical thinking

When a client's anger begins to become hostile, which action should the nurse take to deescalate the situation?

Offer the client suggestions concerning how to regain control

Which personality disorder is associated with the nursing diagnosis of impaired social interaction, related to indifference toward others?

Schizoid

Which term is used to identify the social advantages gained indirectly from the display of somatic symptoms (subsequent attention)?

Secondary gain

Which type of amnesia is characterized by partial memory of some portions of an event but not all details are remembered?

Selective

A client tells the nurse she knows she is married and has three children but does not remember she recently had a baby who died from sudden infant death syndrome. The nurse would recognize this type of dissociation:

Selective amnesia

A new female client with schizophrenia has been admitted to the psychiatric unit. If the client were experiencing catatonic behavior, what would the nurse expect to see?

The client sitting stiffly in a chair, seemingly oblivious to everything around her or making strange motions with their arms while walking with rigid posture

A client reports chronic pain that health care professionals believe to be somatic in nature and reports self-managing the pain. What is the nurse's primary safety concern regarding this self-management?

The client will develop a dependency on pain medication.

Which resource should a student nurse use to find the scope and minimum standard of practice for the care she provides?

The state's Nurse Practice Act

The nurse states to the client, "It is time for your dinner." The client responds with "For your dinner, for your dinner, for your dinner...." The nurse would document this as which type of speech pattern?

Verbigeration

Which phase of nurse-client relationship is the nurse facilitating when teaching appropriate coping skills to a client diagnosed with an anxiety disorder?

Working

The nurse is addressing the needs presented by a woman who has just left an abusive spouse. Which is the nurse's initial focus?

Working with the client to identify a safe place to live

Your patient states, "I do not want to take that one medicine that make severely nauseous and have a throbbing headache to treat my withdrawal from alcohol!" You know the drug he is referring to is?

antabuse

A client is observed pacing back and forth in his room. When the nurse attempts to assess the reason behind the behavior, the client responds, "I don't know why but I'm really feeling uneasy." This response is most characteristic of:

anxiety

Which of the following drugs has the potential to be detected in a urine sample for up to 4 weeks, causes blood shot eyes, dry mouth, and increased appetite?

cannabis

The priority focus of an admission assessment on a client hospitalized for substance-abuse intoxication is data regarding:

drug use and the last time the substance was used.

The nurse must use extreme caution when using touch to convey caring with a client who is:

sexually preoccupied.

What signs and symptoms are unique and support a diagnosis of dissociative fugue? (Select all that apply.)

unable to recall their past Inability to recall relevant personal information forget where they live Assumption of a new identity

Which should be the nurse's initial intervention when admitting a client who is demonstrating behaviors associated with severe depression?

"Do you have any thoughts about hurting yourself?"

When considering the various aspects of stress, which statement accurately describes eustress?

"I generally do my best work when I feel some stress."

In which groups of people is sexual dysfunction more commonly seen? (Select all that apply.)

>Alcohol users >Dilantin users >Benzodiazepine abusers

How long can a client be held under an involuntary emergency protective custody order?

48 to 72 hours

Which client statement best describes the fight or flight response?

"When I feel stressed, I get this surge of energy."

The nurse is assisting the client to overcome the fear of public places. The nurse and the client are in which phase of the therapeutic relationship?

Working

A nurse on the psychiatric unit had the following clients on the unit today. Which of these should the nurse consider to be closest to exhibiting potentially violent behavior?

A client who has a history of paranoid personality disorder who has become increasingly frightened during the day

A client admitted with symptoms associated with methamphetamine intoxication is at increased risk for injury. Which nursing interventions should be the focus of nursing care during the initial treatment period? (Select all that apply.)

>Monitoring for auditory hallucinations >Monitoring for hyperventilation tachycardia or bradycardia >keep them safe if they are becoming violent >Implementing seizure precautions

Which physiological observation would be consistent as a diagnostic manifestation of Alzheimer's disease?

>Neurofibrillary tangles >Neuritic plaques in the brain >Reduced brain activity

Which outcome would be appropriate for a client with a diagnosis of dissociative identity disorder? (Select all that apply.)

>Performs self-care activities independently >Demonstrates self-control over behaviors toward self and others >Verbalizes reality-based perceptions of environmental stimuli when faced with stressful situations >Associates memory deficit with past stressful events

When caring for a client with a dissociative disorder, which intervention is most important for the nurse to implement when attempting to prevent the client's regression further into the dissociative state?

Avoid flooding the client with details of past traumatic events

Which mood disorder is less severe than major depressive disorder but tends to be more chronic?

Dysthymic

During the termination phase, which event is a nursing focus?

Encouraging independence

Which behavior should the nurse expect to assess in the client diagnosed with delirium?

Fluctuating periods of confusion

During your nursing assessment on a patient with a substance-related disorder you will assess, select all that apply:

>vital signs >changes in weight or appetite >affect >support system >arrhythmias >skin for any lesions or needle tracks

A client is admitted to the inpatient mental health unit with Lewy body dementia. It is most important for the nurse to observe which assessment parameter?

Parkinson-like symptoms

Opiate withdrawal symptoms can be minimized with the use of what drug?

clonidine

What response best educates the client to the events and outcome expected that is associated with electroconvulsive (ECT) therapy treatment?

"A controlled seizure occurs that helps to restore a chemical balance within the brain."

When the spouse of an alcoholic attending an Al-anon meeting asks what codependency means, which is the nurse's best response?

"A multigenerational pattern of coping that discourages all family members from expressing their needs and take responsibility for the user's problems and internalize a form of guilt for the behavior of the abuser."

Which is the nurse's best response when asked to define a therapeutic milieu? Selected Answer:

"A safe place that provides the clients with the opportunity to work on their problems with members of their health care team."

The loss of hearing in a 9-year-old child has been diagnosed as a conversion disorder. Which question is directly associated with determining the root cause of the child's symptoms?

"Do you think your mother and father yell too much?"

A client being treated for chronic stress and moderate anxiety questions the usefulness of relaxation techniques. Which response by the nurse will best explain the benefit of relaxation techniques?

"Each time you successfully use the techniques, you increase your chances of being able to manage those feelings."

Which response by the nurse manager would best address the concerns of a nurse who expresses uncertainty about how to evaluate the short-term progress of a client being treated for borderline personality disorder?

"Focus on how his use of effective impulse control has improved since admission."

What statement made by the RN to the unit's LPN, best demonstrates the goal of therapeutic communication?

"Has the client talked with you about how he feels about being hospitalized?"

When assessing an adult client for signs and symptoms of dissociative amnesia what questions could you ask? (Select all that apply.)

"Have you experienced anxiety?" "Do you have depression?"

The nurse is leading a group session when a member reacts to the discussion with an angry verbal outburst. Which statement by the nurse demonstrates an understanding of the pathology often found to cause the display of extreme anger and resentment?

"I acknowledge the pain you feel and the need you feel to be heard, but I cannot allow you to manipulate and control the group with your anger."

A client with dependent personality disorder has been admitted with pneumonia. The nurse notices that the client has the nursing assistant fill out the menu choices each day. The client asks the CNA when to shower and what to watch on TV. The nurse's best approach to the nursing assistant would be:

"I appreciate the fact that you want to help the client. The next time the client asks you to fill out the menu, offer to help, but have the client make the choices. You might limit the choices to two, so the client is not overwhelmed."

When educating a client who is prescribed lithium, the nurse should review with the patient the risks of taking lithium when they make which statement regarding their diet.

"I can eat a little bit of salt one day and a lot the next."

Which statement made by the nurse best demonstrates the concepts of empathy and objectivity when working with a client diagnosed with anger management issues?

"I can see why you are so angry but throwing the chair is not an acceptable way to handle that anger."

A male LPN is caring for another male on a medical -surgical unit. The client has a diagnosis of Paranoid Personality Disorder in addition to his medical diagnosis. The client confides in the nurse that he thinks his wife is unfaithful to him. As he is talking, he says, "As a matter of fact, I've seen the way you look at her. You're probably interested in her yourself." How should the nurse best respond to this comment?

"I do not intend to get involved in your personal life. I am your nurse here, and my job is to ensure that you have good, competent care."

The nurse is doing an assessment of a client with a known diagnosis of illness anxiety disorder. Which of the following statements made by the client would the nurse recognize as most typical of a client with this disorder

"I know I have colon cancer just like my dad."

Which statement by the client indicates an understanding of the process of anger?

"I know it's natural to be angry but I can't keep hurting my children like I do."

A client approaches the nurse and states, "This little elf keeps following me with a leash, and it really is getting on my nerves." Which of the following would be the most appropriate response for the nurse to make at this time?

"I know seeing the elf is frustrating to you, but no one else sees it."

Which statement made by the client supports the nurse's belief that the client understands the concept of being mentally healthy?

"I make every effort to keep a balance between work, play, and my relationships."

Which statement made by a nurse indicates a need for future instructions on maintaining professional boundaries?

"I promised to call the client's mother and tell her he's sorry for hurting her."

Which statement by the nurse best demonstrates the nurse as a counselor in the therapeutic process?

"I respect your right to disagree with your roommate but let's talk about doing that without offending them."

Which client statement demonstrates evidence that the goal of crisis intervention has been achieved?

"I start deep breathing techniques when I first start getting panicky about speaking in public."

Which statement made by a client diagnosed with a somatic disorder demonstrates an understanding of the disorder that will be most effective in preventing a relapse of the symptoms?

"I understand that I must manage my stress daily."

A client who is very angry about his terminal prognosis yells at the nurse when she brings in his pain medication, "Why do you bother? You know this medicine won't make me well." The best response by the nurse would be:

"I understand that you are angry over your illness. Would you like to talk about it now, or after your pain has eased?"

When asked by a client what type of treatment she can expect for acute depression, how will the nurse respond?

"I'd expect that you will be prescribed both psychotherapy and medication."

A young adult student recently failed a major exam. Which statement supports the nurse's belief that the client is using reframing to cope with the resulting anxiety?

"I've arranged to join a study group so I'll do better on the next exam."

Which statement made by a client being treated for a somatic symptom disorder, supports the nurse's evaluation that the client has developed the skills necessary to achieve full recovery?

"I've learned how to cope with the stress that triggered my physical problems in the past."

Which statement made by a client being treated for acute depression supports the nurse's evaluation that the risk for relapse is minimal?

"I've scheduled evening counseling sessions so I'll have no problem attending all of them."

A woman confides to the nurse that she does not want any more children and no longer desires to have sex. To best explore the client's current disinterest in sex, which assessment question should the nurse ask?

"Is sex associated with unpleasant memories for you?"

A client has a history of verbally abusing her children. Which question asked by the nurse should best determine the client's sense of self-awareness regarding therapy for this problem?

"Is your relationship with your children important enough to you to make changes in the way you interact with them?"

Which statement by the client supports the nurse's belief that the individual has the skills to cope with the emotional crisis associated with the death of a spouse?

"It is so difficult; I can remember what it was like losing my father."

The nurse is evaluating a client's ability to engage in adaptive stress management. Which client statement supports the nurse's belief that the client is successfully managing the stress of a recent divorce?

"It's not my fault that I loved someone who was incapable of being faithful."

Which statement demonstrates the nurse's use of focusing when communicating with a client about relationships with family members?

"Let's get back to how you feel about your son's decision to leave school."

A client is talking about his family and suddenly changes the subject to what tv show is his favorite. which of the following strategies by the nurse would best elicit more information about the client's family situation?

"Let's get back to your family....."

A client just admitted to a psychiatric unit is described as having positive symptoms of schizophrenia. Which of the following statements by the client would indicate the presence of positive symptoms?

"My friend whispers in my ear at night when everyone has gone to bed. She tells me you are trying to poison me."

Which statement made by a client best demonstrates the existence of a therapeutic nurse-client relationship?

"My nurse and I have discussed what changes I need to make in my life."

A nurse is overheard responding to a client by stating, "Why would you think that was acceptable?" Which statement by the nurse manager to the nurse would be most effective in addressing this barrier to therapeutic verbal communication?

"Such a response puts the client on the defensive, making him embarrassed and ashamed."

Which statement by the nurse demonstrates an understanding of the impact of personal space on a conversation?

"The client appeared much more relaxed and willing to talk when we sit across from each other at the table."

Which statement made by the nurse best demonstrates an understanding of the management of manipulative behaviors by a client?

"You seem to need to control all the discussions we have in group sessions. Let's talk about what makes you feel that need."

A client diagnosed with anxiety and with a history of abuse as an adult is currently engaged in weekly psychotherapy sessions. The client asks the advanced practice nurse (APN), "What is the goal of my treatment?" Which is the nurse practitioner's best response?

"The goal is to reduce the symptoms you are experiencing."

Which statement by the nurse demonstrates an understanding of the impact of the Omnibus Budget Reconciliation Act (OBRA) on the administration of psychotropic drugs?

"The medication was prescribed when none of the other interventions to control the hallucinations were successful."

While the client is willing to take a prescribed antidepressant medication, she is very resistant to attending cognitive behavioral therapy sessions. What response should the nurse provide to best educate the client on the importance of compliance with all aspects of treatment for depression?

"The medication will help improve your mood while the therapy helps you learn how to cope with the feelings that are triggering the depression."

Which statement by an individual with a history of anger management issues best demonstrates where anger and resentment originate?

"The way I see it is that I was wronged and had a right to get angry."

A 16 -year-old girl tells her mother she is being bullied by other kids at school. She is distraught and doesn't want to go tot school. Which statement by the girl would separate his situation from other reasons for not wanting to attend class?

"They wait for me in the hall every day and make fun of me in front of everyone. "

Which statement made by the nurse is included when supporting the teaching plan for a client being prepared for electroconvulsive therapy (ECT)?

"This type of therapy is intended to induce a seizure that will be managed by the staff."

The nurse suspects a client is demonstrating signs of dysfunctional grief. Which question would best help assess for that disorder?

"What gives your life meaning?"

An adolescent has been diagnosed with conversion disorder that involves the loss of vision. The client's mother asks the nurse about the prognosis for this disorder. Which should be the nurse's best response?

"With effective treatment, most clients recover in 2 to 4 weeks without reoccurrence."

Which nursing statement demonstrates an understanding of the barriers presented to the delivery of nursing care in correctional facilities?

"You are aware of the rules; you'll get your medication at 3 PM as always."

A client who has been admitted after a suicide attempt from an overdose of antidepressant medication tells the nurse, "Why couldn't I just die?" there is nothing left here for me." The most therapeutic response for the nurse is:

"You are feeling as though life is meaningless right now?"

A client who is experiencing a panic attack states, "I am going to die. I feel like I am suffocating." Which is the nurse's best response?

"You are having a panic attack. I will not leave you alone."

The nurse would anticipate legal issues when addressing the need for informed consent during the care of which client?

45-year-old who lives in a group home for the cognitively impaired

To be diagnosed with generalized anxiety disorder, the client must have had symptoms on most days for at least:

6 months

A nurse is providing education for a client who will begin taking alprazolam (Xanax) for anxiety. Which statements should the nurse include in the discussion? (Select all that apply.)

>"Be particularly careful going up and down stairs since you will be more prone to falling." >"If you experience sight problems like blurred vision, we need to know that immediately."

Which statements by the nurse demonstrate an understanding of a constructive method of handling anger? (Select all that apply.)

>"Have you ever tried going for a run when you find yourself getting angry?" >"Is what they are doing really worth getting so angry about?" >"It often helps to plan 'quiet alone time' for short periods during the day." >"When you find yourself getting angry come find me and we can talk."

Which clients present the nurse with the obligation to disclose what might be considered confidential client information? (Select all that apply.)

>35-year-old whose blood tests positve for the presence of HIV >9-year-old reported missing by family who was found after being physically assaulted >6-year-old whose admission physical revealed bruising of various stages

Which client statements will the nurse use to identify possible risk factors for violence in a newly admitted client? (Select all that apply.)

>Acknowledges a history of drug and alcohol abuse >States "things are fine when people just do like I say" >Reports a need to "always win" when competing with peers

Which classification of medication does the nurse plan to reinforce when addressing education needs for a client diagnosed with a dissociative disorder? (Select all that apply.)

>Antidepressants >Anti-anxiety

Considering clinical criteria, which behavior is associated with mental illness? (Select all that apply.)

>Becomes nauseous at the thought of entering an elevator >Eats alone to mask how much is really being eaten >Will not drink water because all water has been poisoned

Which medical conditions are related to the cause of delirium in older adults? (Select all that apply.)

>Dehydration >Renal disease >Anxiolytic intoxication >Alcohol intoxication

The nurse works with the client diagnosed with a dissociative identity disorder. Which intervention should the nurse implement to help identify actions to remain safe? (Select all that apply.)

>Engaging in physical exercise as a substitute for self-harm >Identifying feeling that precedes urges to self-harm >Keeping a daily written journal of thoughts and feelings >Participating in task-oriented activities that allow for expression of feelings

The client demonstrating potential for risk domestic violence is the client who: (Select all that apply.)

>Has been arrested for intentionally breaking the neighbor's windows. >Made the statement, "Women need to stay home and raise the children." >Reported, "My dad beat us with a belt when we didn't obey him." >has a history of drug abuse.

What assessment data suggest that this individual demonstrates mental health and wellness? (Select all that apply.)

>Has been happily married for 35 years >Identifies having a sense of humor as being a personal strength >Always views challenges with a sense of hope

Which treatments would be considered when treating a client who has been diagnosed with a dissociative disorder? (Select all that apply.)

>Hypnosis >Antidepressant >Creative art >Cognitive

Which considerations are relevant to the use of psychotropic drugs among the older client population? (Select all that apply.)

>Increase in their body fat and a loss of muscle >Increased risk for dehydration >Decrease in renal function >Decrease in the amount of albumin in their blood

The nurse should consider which interventions when dealing with a client experiencing a panic attack? (Select all that apply.)

>Maintaining a calm environment >Providing a safe environment >Communicating in a nonthreatening manner

Which individual is at risk for an unresolved grieving process? (Select all that apply.)

>Man who accidentally shot and killed a close friend >Sole survivor of a multiple automobile accident >Young man whose abusive father drowned >Woman whose son committed suicide

Which symptomatology are associated with illness anxiety disorder? (Select all that apply.)

>Physician shopping >Concerns continue despite medical testing and reassurance that a disease does not exist >Demonstrates obsession that an illness exists >Disproportionate level of anxiety and worry even if symptoms are minor

Which information should the nurse reinforce for a client about her newly prescribed anti-anxiety medication? (Select all that apply.)

>Report any easy bruising or bleeding to your physician immediately. >Common side effects include confusion and loss of coordination. >Do not combine the medication with over-the-counter (OTC) pain medications.

A 10-year-old client's parents recently died in an automobile accident. The nurse bases the client's mental health care on which known facts about that age group's conception of loss? (Select all that apply.)

>Responds best to concrete explanations of new concepts >Can differentiate between temporary and permanent loss

When initiating a therapeutic conversation with a client, the nurse uses which therapeutic communication techniques to establish an understanding of the client's message? (Select all that apply.)

>Validation >Clarification

The nurse in a pediatric clinic cares for a 16-year-old female client. When conducting a history and assessment on an underweight 16-year-old female, which signs would indicate a possible eating disorder? (Select all that apply.)

>constipation >eroded tooth enamel >gastric bleeding >Calluses on the back of the hands

Expected outcomes and the nursing goals for someone who has a substance-abuse disorder would be, select all that apply:

>prevent seizures >promote a restful sleep pattern >decrease anxiety and promote relaxation >promote and maintain fluid and electrolyte balance >promote safety and protection of the client

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 holds mental health care professionals legally and ethically responsible for: (Select all that apply.)

>protecting the client's privacy. >providing clients with access to the information contained in their medical records. >who they provide information contained in a client's medical records. >disclosure of what information contained in their medical record is being shared.

Which of the following behaviors by the nurse would be considered a violation of professional boundaries in the nurse-client relationship?

Accepting a gift from a client.

The nurse is caring for a client with a dissociative disorder. The nurse attempts to teach the client the skills she will need to minimize the reoccurrence of symptoms. Which intervention is most important to implement?

Act as a role model to affect positive and desired client behaviors

The nurse observes an elderly man diagnosed with Alzheimer's disease brushing his hair with a toothbrush. Which term would be used to document this inability to process information?

Agnosia

Which is the nurse assessing when using the CAGE questionnaire screening tool?

Alcohol dependency

Initially, which nursing intervention would receive the highest priority for the client with OCD?

Allow extra time for the client to perform rituals

When reviewing a care plan of a client diagnosed with obsessive-compulsive disorder, the nurse should expect to see which nursing intervention early in treatment?

Allow time for the client to perform the ritual

Which treatment approach has been proven to be the most beneficial for the client diagnosed with an anxiety disorder?

Anti-anxiety medications combined with psychotherapy

Medications that have been to be effective in combination with psychotherapy to address the symptoms related to bulimia nervosa are:

Anti-depressants

A client is being seen in the mental health clinic. When taking the health history, the nurse notes that the client has a history of vandalism, verbal assaults, and truancy. These behaviors are consistent with which personality disorder?

Anti-social

Which is the expected outcome for a client undergoing biofeedback training?

Anxiety management through the control of involuntary nervous system responses

When taking a health history on a new client diagnosed with a somatic disorder, the existence of which information has the greatest significance?

Any pattern of repeated complaints

Which assessment data best support the suspicion that a client possesses what is medically referred to as an anger trait?

History of arrests for assault and battery

How can the nurse best determine that a client has an understanding of the psychiatric condition?

Ask the client to use their own words to describe their illness

A student has been ill and unable to properly prepare for an exam scheduled in 3 days. This situation has resulted in an elevated stress level. Which client action to manage this stressor is an example of palliative coping?

Ask the instructor for a week postponement of the exam

The nurse determines that a client is attempting to manipulate staff into allowing unauthorized use of the telephone. Which should be the nurse's initial response?

Asking the client to describe the feelings he is currently experiencing

A client prescribed phenelzine (Nardil) has spent the afternoon away from the unit with family. Which intervention should the nurse initiate immediately upon learning that the client had smoked meats and wine for lunch?

Assess and document the client's blood pressure.

The nurse engages in a therapeutic relationship with a client diagnosed with a dissociative disorder. Why is it important to use stimuli that arouse pleasant memories and pleasurable feelings for the client?

Assists the client to remember past experiences without the risk of precipitating increased trauma

Which intervention has priority when a client reports to the nurse that he "really wants to die?"

Assuring the client that he will not be left alone

A nurse working on an inpatient unit hears a client shouting at other clients in the hallway. Knowing the client has a history of aggressive behavior, which of the following actions should the nurse initiate first?

Attempt to de-escalate the situation and redirect other clients.

The nurse is caring for a client who has recently been diagnosed with leukemia. Which of the following should the nurse include in a psychological assessment of this client?

Available coping behaviors

The nurse educating a client prescribed a monoamine oxidase inhibitor (MAOI) should stress the importance of avoiding which food?

Avocados

A client diagnosed with schizophrenia comes to the outpatient mental health clinic displaying a very disheveled appearance, with body odor and an unkempt beard. The nurse suspects the client is demonstrating which negative symptom of schizophrenia?

Avolition

Creating an overly dramatic scene of emotional behavior to attract the attention of others is typical in which of the following personalities?

Histrionic

How will the clinic nurse best minimize the barriers to mental health care that exist for the Hispanic and Asian immigrants in an urban community?

By gaining an understanding of the belief and value systems of the clients culture groups

Which is the primary principle to consider when determining where mental health treatment can be received?

Care must be delivered in the least restrictive but safe environment.

Why is it most important for a client newly diagnosed with a dissociative disorder to be supported by the nurse in her ability to control situations that have triggered symptoms in the past?

Clients are overwhelmed with fear of not knowing or being out of control.

A client with schizophrenia has a nursing diagnosis of Impaired Social Interaction. In the client's plan of care, which of the following would be the best intervention by the nurse to help the client develop better social skills?

Correct Interact with the client, and model appropriate social behavior.

The nurse is reviewing a care plan for a client diagnosed with Alzheimer's dementia who is receiving antipsychotic medication. Which is an expected outcome for this medication therapy?

Decrease in hallucinations

The nurse is reviewing a care plan for a client diagnosed with dementia who is receiving antipsychotics. The nurse should expect to find which priority outcome for this client?

Decreased physical aggression

What mental health concept gained acceptance in the mid 1950s as antipsychotic drugs were introduced?

Deinstitutionalization of mentally ill clients

A 37-year-old female client presents at the mental health clinic reporting a reoccurring feeling of "not being real." The client's history includes the loss of her husband and two children in an automobile accident 3 months ago. These assessment data support which mental health diagnosis?

Depersonalization disorder

In addition to substance dependence, which of the following poses the most significant mental health risk to the client experiencing chronic pain?

Depressed mood

Which of the following best prepares the nurse to assist the client in viewing themselves and their behavior more realistically?

Developing an honest evaluation of oneself.

A women who claims to be Ryan's biological sister visits him in his home. She tells him that he has a family in another location. When she asks Ryan why he doesn't come home, he replies, "I'm sorry, but I don't know who you are." Ryan is demonstrating symptoms of:

Dissociative fugue

Which dissociative disorder is characterized by alternating personalities assuming control of a person's behavior?

Dissociative identity disorder

A nurse working in a long-term care facility is preparing to administer an antidepressant medication to an elderly client. Which of the following assessments would alert the nurse to an increased potential for accumulated effects of this drug?

Dry skin with decreased intake of fluids.

A client has just been diagnosed with panic disorder. Which of the following symptoms would the nurse expect to observe?

Feelings of suffocation

A woman has experienced physical abuse by her spouse. Which exemplifies the emotional response demonstrated by most abused women to their spouse's remorseful promise that "it will never happen again"?

Feels guilty and accepts the blame for the abuse

Which should be the nurse's initial intervention when during an assessment interview a client volunteers being dissatisfied sexually?

Encourage the client to share feelings and concerns regarding the statement

Which of the following statement best describes the role of the nurse in terminating the therapeutic relationship with the client?

Encouraging independence and self-reliance of the client.

Which is a major factor in the onset and continued use of alcohol and other drugs?

Environmental stress factors

The nurse is documenting observations of a client experiencing a manic episode who is very talkative, extremely happy, and laughing. Which of the following would be most appropriate to include regarding this client?

Euphoric with appropriate affect

Which is considered the nursing standard of care for monitoring vital signs during a client's acute substance withdrawal?

Every 1-2 hours during the first 3-4 days of withdrawal

Nursing interventions toward preventing injury to the client during acute substance withdrawal include seizure precautions. How often are these performed?

Every 15 minutes

A client with narcissistic personality disorder states, "I want only the nurse to care for me, no aides." What is the best response by the nurse?

Explain calmly and confidently the role of the aides who will do some of his care at this facility.

The parents of a teenager diagnosed with anorexia nervosa ask "Why do we need to attend family therapy?" How can the nurse best meet the needs of the child?

Explain that the sessions will help them see the connection between family behaviors and their teen's eating habits

How can the nurse best comfort a spouse who is concerned that the client, newly diagnosed with dementia, has "started lying to me?"

Explain to the spouse that the client is compensating for memory loss with a process called confabulation

A client is diagnosed with histrionic personality disorder. The interventions should focus on which classic behavior?

Extreme egocentricity

The nurse is interviewing a client diagnosed with avoidant personality disorder. The nurse would expect this client to exhibit which behavior?

Extreme shyness

When reviewing the chart of a client diagnosed with acute depression, the nurse notes that the client has demonstrated behaviors associated with anhedonia. Which assessment data support this observation?

Family shares that the client "loved to knit but now don't seem interested in doing so."

When the client states, "I am hungry. Will you buy me a car? Can we go to the movie?" the nurse will use which phrasing to document this response?

Flight of ideas

A client with an eating disorder is found to have altered oral mucous membranes. This assessment finding supports the client's reliance on which classic weight control behavior?

Frequent self-induced vomiting

A client diagnosed with agoraphobia associated with panic disorder has been unable to leave her home for the last 6 months. In reviewing the care plan, the nurse should expect to find which goal for this client?

Function effectively within the environment

Which communication technique used by a nurse would indicate a lack of knowledge regarding therapeutic communication?

Giving advice

Jeff is admitted to the psychiatric unit with a blood alcohol level of 0.194%. He is disorientated with slurred speech and a staggering gait. The nurse would correctly assess that this client:

Has symptoms of intoxication

Which assessment data are associated with a client diagnosed with a somatic disorder? (Select all that apply.)

Has threatened to attempt suicide twice Has not been able to hold a job for 3 years Reports visual problems and limited range of motion in both hands Currently being treated for depression Is female

The nurse is documenting observations made during an initial contact with a client who has recently been diagnosed with acute schizophrenia, undifferentiated type. Which of the following behavior assessments would be considered a positive symptom of schizophrenia?

Having auditory hallucinations

When establishing a therapeutic environment, which of the following factors would be most important in forming the foundation for a trusting nurse-client relationship?

Honesty and consistent integrity of the nurse.

Which type of individual therapy is nondirective and focuses on helping the client to clarify his or her own feelings?

Humanistic

A 48-year-old female tells the nurse that she is no longer sexually active, even though she is married. This statement supports the possibility of which sexual dysfunction?

Hypoactive sexual desire

Which statement made by the student nurse regarding the care of clients with somatic disorders would require further teaching?

I should confront the client in order to assess which psychological defense mechanisms is being used.

The nurse is talking with a client who has a diagnosis of substance abuse. The client states, "I don't know what to do to handle the stress in my life that makes me want to take drugs." Based on the client's statement, which expected outcome should the nurse identify when updating the client's plan of care?

Identifies alternative coping mechanisms

Which is an appropriate expected outcome for a client in the recovery phase of substance abuse striving for sobriety?

Identifies the drug as a problem and takes ownership of the problem

The nurse is working with a client who has made a sexually inappropriate remark. To maintain appropriate professional boundaries while continuing to preserve a therapeutic nurse-patient relationship, the nurse will initially implement which intervention?

In a direct manner, explain immediately why the remark was unacceptable

Which physiological response would the nurse associate as a sympathetic nervous system response to panic anxiety?

Increased heart rate

A client is diagnosed with an eating disorder. Which behavior best indicates progress toward recovery?

Independently makes healthy eating choice on a regular basis and verbalizes the importance of appropriate eating patterns.

A young woman, aged 25, has come to the clinic for a premarital physical examination. She tells the nurse that she is a virgin and really does not want to have sex. The client says that she has always been taught that sex is "dirty" and "nice girls" did not do things like that. She wonders what she will do after her wedding. Which nursing diagnosis would the nurse use when writing this client's care plan?

Ineffective Coping, individual, related to one's sexuality

It may be legally required that client information is disclosed. These may include the following, (select all that apply)

Infection of HIV Intent to commit a crime Duty to warn endangered individuals Evidence of child abuse

Which of the following terms would be characteristics common to all personality disorders?

Inflexible and maladaptive behaviors

When considering the scope of holistic nursing, which principles guide nursing care?

Initiate interventions to address the client's psychosocial, physical, spiritual, and cultural needs

Which is the priority nursing intervention for clients diagnosed with delirium?

Initiate safety precautions

Which statement demonstrates the best understanding of the complex process used to define the term mental illness?

Mental illness can be and is often defined differently based on specific views, beliefs, and behaviors.

What are the signs and symptoms of Conversion Disorder? (Select all that apply)

Lack of conscious control over the symptoms Loss of pain or touch sensation Lack of physical change or disability Functional ability and symptoms inconsistent with usual neurological disorders.

When considering a client newly diagnosed with an eating disorder, why is it important to assess bowel elimination and urine output?

Laxative or diuretic use is commonly associated with this diagnosis.

After a tornado flattens her home, a 65-year-old female is brought to the local clinic by her son. He tells the nurse that his mother cannot remember anything that has happened since the storm hit. During the assessment interview, the client cannot remember personal facts like where she was when the storm hit. Which type of amnesia is the client demonstrating?

Localized

A client has been diagnosed with generalized anxiety disorder. To establish a nurse-client relationship, which should be the nurse's initial goal?

Lower the client's anxiety level

The role of the nurse working with the client who has a mental disorder includes:

Monitoring behavioral responses to therapy

Which intervention is the sole responsibility of a licensed practical nurse working on a psychiatric unit?

Monitoring for side effects when a client is prescribed a new medication

Which physiologic response would the nurse anticipate a client diagnosed with generalized anxiety to demonstrate?

Muscle tension

A client is prescribed a new medication, haloperidol (Haldol), for chronic schizophrenia. The nursing assessment reveals muscular rigidity, hyperthermia, and an altered level of consciousness. These symptoms are consistent with which condition?

Neuroleptic malignant syndrome

On a psychiatric unit the LPN is responsible for which interventions? (Select all that apply.)

Observing behaviors and collecting data Changing the dressing on to a client's wrist wound Obtaining vital signs and monitoring for medication side effects.

When considering client care, which intervention may be delegated to a licensed practical nurse on a mental health unit?

Observing for inappropriate behaviors

A man diagnosed with premature ejaculation has which type of sexual disorder?

Orgasmic

The nurse is reinforcing rules and boundaries to a newly admitted client. These actions are part of which phase of the therapeutic relationship?

Orientation

A client is being treated under court order for a sexual offense. Which outcome is of PARTICULAR importance to this client's plan of care?

Participates and cooperates in a treatment plan to change behavior

To best manage the risk of relapse for the client diagnosed with a paraphilia disorder, the nurse includes which intervention in the client's plan of care?

Participating in a 12-step program

During adolescence, which etiologic factor contributing to substance abuse is at its highest?

Peer pressure

A client has been diagnosed with obsessive-compulsive disorder. The nurse would expect to find which clinical manifestation?

Persistent unwanted thoughts

Which individual meets the criteria for an involuntary psychiatric admission?

Person clearly intent upon hurting himself or others

An Iraqi military veteran has been seen in the outpatient mental health clinic due to reports of inability to sleep, nightmares, and flashbacks. The nurse would expect the client to be diagnosed with which anxiety disorder?

Posttraumatic stress

Which statement describes chronic sorrow?

Prolonged and intensified reaction to a loss

While providing care to a client who has moderate to severe Alzheimer's disease, which is the nurse's primary legal obligation to the client?

Protecting the client's rights

Which intervention should the mental health nurse implement when a client expresses the wish to register a complaint about the care he is receiving?

Provide the client with the information on how to file a complaint

A mental health nurse teaches clients to recognize what triggers their anger responses. Which is the purpose of this trigger identification?

Provides the opportunity to gain control of their anger

Which responsibilities associated with the care of a psychiatric client admitted for severe depression and suicidal ideations can be assigned to the LPN on the unit? (Select all that apply.)

Providing one-on-one observation of the client Administering a PRN antidiarrheal medication as prescribed Providing documentation about a rash noted after the client began a new antidepressant Changing the dressing on the wrist wound the client created during his or her suicide attempt

When evaluating the nursing interventions used with a client exhibiting psychophysiologic behaviors, which should be the nurse's initial focus regarding the client's abilities?

Recognize the underlying psychologic stress and anxiety

The nurse notes that a client is monopolizing most of the conversation during breakfast. He is loud and criticizing other clients. Which of the following is the most appropriate interventions for the nurse to make at this time?

Redirect and reinforce limits on his behavior.

How should the nurse plan for a common postprocedure manifestation of electroconvulsive therapy (ECT)?

Reinforce the client for time, place, and person

A college student is very anxious about auditioning for the school's famous chorale. Which coping strategy implemented by the student would the nurse recognize as being maladaptive?

Repeatedly telling friends it's okay to fail

Which assessment data collected from a client who reports experiencing significant levels of both apprehension and worry support the diagnosis of generalized anxiety disorder? (Select all that apply.)

Reports gastrointestinal discomfort as, "always having to deal with a nervous stomach." Difficulty falling or staying asleep States, "My neck and shoulder muscles are always tense and really hurt."

A client reports experiencing a feeling of detachment from his body. When considering a trigger event, which nursing assessment data support the possible diagnosis of depersonalization?

Reports, "I feel like a robot or sometimes I can see my thoughts."

To foster a sense of safety in a client demonstrating paranoid behavior, which nonverbal technique should the nurse implement?

Respecting an extended area of personal space when interacting with the client

Which should be the first nursing intervention when caring for a client with a somatic disorder?

Responding to the patient with patience and understanding in order to establish a trusting relationship

When reviewing the care plan, the nurse should expect to see which nursing diagnosis is specific to Lewy body dementia?

Risk for Injury, related to shuffling gait

Which nursing diagnosis should the nurse expect to be the priority in the care plan for a client diagnosed with borderline personality disorder?

Risk for Violence, self-directed, related to self-mutilating behaviors

The nurse best assures the positive forward progression in the client's treatment process by addressing which client need?

Safe and trusting environment

A client has been diagnosed with dissociative fugue. Which represents an appropriate nursing diagnosis for this client?

Self-Care Deficit, related to aimless wandering

Which characteristic provides insight into how people respond to their environment and how others react to their behavior?

Self-awareness

The nurse in the clinic is evaluating outcomes on care plans for a group of clients with sexual disorders. The nurse knows that because of the chronic nature of many sexual disorders, criteria for positive progress in the plan of care include a measure of:

Self-control

Which classic behavior should the nurse expect to assess in the client diagnosed with narcissistic personality disorder?

Sense of entitlement

What is the foundational principle regarding the administration of diazepam to an older adult diagnosed with moderate anxiety and alcohol dependency?

Sensitivity to benzodiazepines appears to increase with age.

Which nursing diagnosis is specific to a client diagnosed with depersonalization disorder?

Sensory Perceptual Alteration, related to a sense of detachment from one's body

The school nurse is presenting a class on "sexual health" for the 8th grade students at the middle school. How should the nurse explain sexual orientation?

Sexual attraction

Which nonverbal communication technique would be a barrier to conveying a sense of openness to the client?

Sitting with crossed legs and arms during a group session

A depressed client underwent electroconvulsive therapy (ECT). After the procedure, the nurse would expect the client to be:

Sleepy, with some mental confusion and memory loss.

The client for whom an MAOI is prescribed should be taught to avoid which of the following dietary items?

Smoked or processed meat

Which nursing diagnosis best addresses a paroled sexual offender's reluctance to engage in interpersonal relationships?

Social Isolation, related to sexual beliefs and practices

When reviewing the history, the nurse notes that the client stated, "I spend so much of my time and money on doctor visits and he still doesn't know what is causing my pain but I know there is something seriously wrong." Which medical diagnosis is supported by this statement?

Somatic symptom disorder

Which client has the greatest risk for the development of dissociative fugue?

Spends 4 hours trapped in the rubble after a severe earthquake

Which should be the nurse's immediate intervention when a teenager shares, "I just want to die?"

Stay with the teen and demonstrate calm, caring concern for the situation

When providing client education to the parents of the client diagnosed with bulimia nervosa, the nurse suggests screening for which comorbid mental health condition?

Substance abuse

The nurse understands that which antidepressant can result in a fatal cardiac arrhythmia in overdose situations?

TCAs

A nurse in a long- term care facility notices a client who is experiencing facial grimacing, tongue protrusion, and lip smacking. Continual involuntary arm movements also are present. The client has been taking thioridazine (Mellaril) for five years. When reporting these observations to a physician, the nurse would categorize them as:

Tardive dyskinesia.

A client with schizophrenia tells the nurse that he sees ghostly shadows moving about in the commons area. He says they are black and scary, and he thinks they are here to punish him. He does not want to go into the commons room. What is the nurse's best response to this?

That must be very frightening for you. I don't see anything like that. You are safe here."

Which statements are true of factitious disorders? (Select all that app

The individual is consciously falsifying the symptoms. Intentional infliction of harm to oneself or another is a characteristic of the disorder. The individual's primary goal is to get attention for being sick. The individual has a detailed, textbook knowledge of the reported illness. Extensive knowledge of medical terminology.

How do families contribute to the continuation of a member's substance-abuse behaviors?

They enable the person, commonly making excuses or lying to others about behaviors related to the substance abuse.

A client is being seen in the emergency room for acute symptoms of anxiety and situational crisis. The examining physician asks that arrangements be made to refer this client to a mental health clinic for counseling. This action by the physician recognizes which of the client rights to appropriate treatment?

To be treated in the least restrictive setting.

Which assessment parameter is consistent with severe Alzheimer's disease?

Total loss of speech

The nurse is preparing information for a community-focused presentation and is using the Americans with Disabilities Act (ADA) as a primary reference. Which is the likely focus of the nurse's presentation regarding patient rights of the mentally ill?

Use and availability of public transportation

Which should be the initial intervention when a nurse prepares to assist a client to deal with her grief associated with the death of a loved one?

Use open-ended questions to explore the client's feelings about her grief and encourage communication

In completing nursing care for an older client diagnosed with dementia, which intervention would be therapeutic for this individual?

Use simple one-step commands to minimize frustration

Which is an appropriate outcome for the family of a client diagnosed with a dissociative disorder?

Verbalizes realistic expectations for the client's behavior and treatment process

Which statement made by a family member of a client diagnosed with factitious disorder demonstrates the need for further teaching?

When my wife becomes clingy, I'll not give in to her by giving her extra attention.

A client has been compliant with long-term treatment prescribed for obsessive-compulsive disorder (OCD). Which assessment data support the conclusion that the client is experiencing a decline in the generally observed characteristics of this disorder? (They are improving)(Select all that apply.)

Work attendance has improved with only one absence in the last 5 months. Client states, "I know that these thoughts are produced in my own head." Hand washing is confined to premeals and when hands are visible soiled. Client recently completed an online college level English literature course.

Common signs and symptoms of depersonalization disorder include all but:

flashbacks

A person diagnosed with delirium is seeing "monkeys in the corner of my room." The nurse documents this behavior as:

hallucinations

To evaluate the client's progress toward understanding the relationship between the dissociative state and the increased presence of anxiety, the nurse will see that the client will ?

have the ability to recall past traumatic events

The spouse of a client diagnosed with a somatic disorder shares that, "I don't really believe her pain is so great that she can't go to work; the kids and I need to tell her to go back to work." The nurse should educate the spouse concerning the likely possibility of the client to threaten to:

kill herself

A client states, "Little green men are implanting destructive asteroids in my brain." This statement is reflective of:

thought insertion

The focus of the nurse's efforts in assisting the client in reaching the identified long-term sobriety treatment goals and expected outcomes would be the client...

verbalizes understanding of substance abuse and dependence as an illness requiring continued treatment and support.