MH L2

A patient being treated with paroxetine (Paxil) 50 mg/day orally for depression reports to the clinic nurse, "I took a few extra tablets earlier in the day and now I feel bad." Which assessments are most critical? Select all that apply.

Vital signs. Presence of abdominal pain and diarrhea. Hyperactivity or feelings of restlessness.

A nursing diagnosis for a patient with bulimia nervosa is: Ineffective coping, related to feelings of loneliness as evidenced by overeating to comfort self, followed by self-induced vomiting. TNhUeRbSeINstGoTuBtc.CoOmMe related to this diagnosis is that within 2 weeks the patient will:

identify two alternative methods of coping with lonliness.

A tearful, anxious patient at the outpatient clinic reports, "I should be dead." The initial task of the nurse conducting the assessment interview is to:

establish a rapport with the patient.

A rape victim tells the emergency department nurse, "I feel so dirty. Please let me take a shower before the doctor examines me." The nurse should:

explain that washing would destroy evidence.

A nurse worked with a patient with major depression who displayed severely withdrawn behavior and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of:

ineffectiveness and frustration.

A staff nurse tells another nurse "I evaluated a new patient using the SAD PERSONS scale and got a score of 10. I'm wondering if I should send the patient home." Select the best reply by the second nurse.

"A score over 8 requires immediate hospitalization."

The parents of identical twins ask a nurse for advice. One twin committed suicide a month ago. Now the parents are concerned that the other twin may also have suicidal tendencies. Which reply by the nurse would be most helpful?

"Genetics are associated with suicide risk. Monitoring and support are important."

A patient with bipolar disorder and who takes lithium telephones the nurse at the clinic to say, "I've had severe diarrhea for 4 days. I feel very weak and unsteady when I walk. My usual hand tremor has gotten worse. What should I do?" The nurse should advise the patient:

"Have someone bring you to the clinic immediately."

The nurse is seeing a patient who has been in the clinic eight times in the past 6 months for injuries from an abusive partner. The patient states, "I don't see any way to get away from my partner, and I can't keep going on like this." What assessment question is most important for the nurse to ask?

"Have you thought about hurting yourself or someone else?"

A nurse talks with the caregiver of a combat veteran with severe traumatic brain injuries. The caregiver says, "I don't know how much longer I can do it. My whole life is consumed with taking care of my partner." Select the nurse's best response.

"How are you taking care of yourself?"

A married individual has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns to work wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority question?

"How did this happen to you?"

Which statement by a patient during an assessment interview should alert the nurse to the patient's need for immediate, active intervention?

"I have no one to turn to for help or support."

The nurse assessed an elderly person who was abused by the caregiver. Afterward, which initial dialogue should prompt the nurse to seek guidance?

"I hope the abuser gets victimized so they know what it feels like."

A patient who has been diagnosed with depression is scheduled for cognitive therapy in addition to receiving prescribed antidepressant medication. The nurse understands that the goal of cognitive therapy will be met when what is reported by the patient?

"I will tell myself that I am a good person when things don't go well at work."

A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, "No one cares about me. I'm not worth anything." Which response by the nurse would be the most helpful?

"I'll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon."

A client has been receiving treatment for posttraumatic stress disorder (PTSD) after experiencing a sexual assault. Which statement supports that the client is able to resume pre-trauma function?

"I'm being considered for a promotion at work."

Which statement by a client scheduled for a series of electroconvulsive therapy (ECT) treatments indicates to the nurse that the client has an understanding of the goals of this treatment?

"It is expected that my chance for remission is very good."

A patient has come to the health clinic for an annual checkup. He reports an increase of stress at work and having to work a lot of mandatory overtime hours. He has not been able to do his usual daily exercise for several weeks. What is the best response by the nurse?

"Regular exercise would be good because it helps the body deal with stress."

A community mental health nurse counsels a group of patients about the upcoming flu season. What instructions does the nurse provide for patients who are prescribed lithium?

"Stop taking your medicine and contact me if you have nausea, vomiting, and/or diarrhea."

A patient being treated for depression has taken 300 mg amitriptyline (Elavli) daily for a year. That patient calls the case manager at the clinic and says, "I stopped taking my antidepressant 2 days ago. Not I am having cold sweater, nausea, a rapid heartbeat, and nightmares." The nurse should advise the patient:

"Take one dose of the antidepressant. Come to the clinic to see the health care provider."

Shortly after hospitalization, an adolescent diagnosed with anorexia nervosa says to the nurse, "Being fat is the worst thing in the world. I hope it never happens to me." Which response by the nurse is appropriate?

"Tell me how your world would be different if you were fat."

A client, being cared for in the emergency department (ED) after a sexual assault, asks that a friend be allowed to stay in the examination room as he or she waits for the SANE nurse to arrive. The client is observably anxious and states, "I don't want to be alone." What response will the ED nurse make in order to best assure the client's safety and emotional health?

"That's a good idea."

A patient who is referred to the eating disorders clinic has lost 35 pounds during 3 months. To assess eating patterns, the nurse should ask the patient:

"What do you eat in a typical day?"

A patient reports that he is overwhelmed with anxiety. Which question would be most important to use in assessing the patient during your first meeting?

"What kinds of things do you do to reduce or cope with your stress?"

An emergency department nurse talks with a news admitted victim of reported rape. Which communication should the nurse offer to comfort this patient?

"You are safe now. I will stay with you in this private room."

A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response?

"You believe this would not have happened if you had not been alone?"

The school nurse assess four adolescents, all of whom outwardly appear healthy. Which adolescent meets one criterion for anorexia nervosa with mild severity?

5'7" tall, weight 110 pounds.

When assessing a patient's plan for suicide, what aspect has priority?

Availability of means and lethality of method

A client recently diagnosed as being obese is experiencing stress related to the need to lose weight. How can the nurse best help the client focus on the eustress nature of this stressor?

Discuss weight loss strategies with the client.

A patient who was hospitalized for 2 weeks committed suicide during the night. Which initial measure will be most helpful for staff members and other patients regarding this event?

Hold a staff meeting to express feelings and plan the care for other patients.

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem?

Major depression

There is reason to believe that a client unknowingly ingested flunitrazepam prior to being sexually assaulted. Which intervention will the nurse implement in order to confirm this suspicion?

Obtain a urine sample

After assessing a victim of sexual assault, which terms could the nurse use in the documentation? Select all that apply.

Reported. Penetration. Declined.

A patient who is at a health clinic with complaints of a sore throat is exhibiting signs of depression. The nurse administers a basic screening for depression. What level of prevention is the nurse performing?

Secondary prevention.

A person with a fear of heights drives across a high bridge. Which division of the autonomic nervous system is stimulated in response to this experience?

Sympathetic nervous system

22. Which assessment finding for a patient with an eating disorder meets a criterion for hospitalization?

Systolic blood pressure: 62 mm Hg

A female patient arrives at the emergency department visibly upset and tearful. She refuses to have a male caregiver, asks for a room close to an exit door, and does not make eye contact with staff. What does the nurse suspect is happening with the patient?

The patient may have been the victim of an acute assault.

The nurse is assessing a patient's coping abilities related to expected placement in a long-term care facility. Which risk factor is of most concern to the nurse?

The patient was recently diagnosed with Alzheimer's disease.

A patient with depression is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?

Urinary retention

A disheveled patient with severe depression and psychomotor retardation has not showered for several days. The nurse should:

firmly and neutrally assist the patient with showering.

When working with rape victims, immediate care focuses first on:

helping the victim feel safe.

A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant to:

suicide potential.

A parent tells the nurse about the death of a child 2 years ago. Which comment by the parent warrants the nurse's priority assessment?

"A parent should never have to lie longer than their child."

Which question demonstrates the nurse's understanding of the need to assess a client who has been physically abused for additional forms of trauma?

"Can you tell me when the physical abuse began?"

Which documentation indicates that the treatment plan for a patient with acute mania has been effective?

"Converses without interrupting, clothing matches, participates in activities."

A patient with bipolar disorder is hyperactive after discontinuing lithium and has not slept for 3 days. The patient threatens to hit another patient. Which comment by the nurse is appropriate?

"Do not hit anyone. If you are unable to control yourself, we will help you."

An adolescent tells the school nurse, "My friend threatened to take an overdose of pills." The nurse talks to the friend who verbalized the suicide threat. The most critical question for the nurse to ask would be:

"Do you have access to medications?"

Over the past 2 months a patient made eight suicide attempts with increasing lethality. The health care provider informs the patient and family that electroconvulsive therapy (ECT) is needed. The family whispers to the nurse, "Isn't this a dangerous treatment?" How should the nurse reply?

"Electroconvulsive therapy is very effective when urgent help is needed. Your family member was carefully evaluated for possible risks."

A community health nurse visits a family with four children. The father behaves angrily, finds fault with a child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate the interview with these parents? Select all that apply.

"Tell me how you punish your children." "How do you stop your baby from crying?" "Caring for four small children must be difficult."

Which nursing assessment question is focused on determining the client's motivation for binge eating?

"Would you say that you are less depressed after binging?"

Which comment by a patient diagnosed with bipolar disorder best indicated the patient is experiencing mania?

"Yesterday I made 487 post on my social media network page."

A soldier who served in a combat zone returned to the United States. The soldier's spouse complains to the nurse, "We had planned to start a family, but now he won't talk about it. He won't even look at children." The spouse is describing which symptom associated with post-traumatic stress disorder (PTSD)?

Avoidance

A nurse visits the home of an 11-year-old child and finds the child caring for three younger siblings. Both parents are at work. The child says, "I want to go to school but we can't afford a babysitter. It doesn't matter though; I'm too dumb to learn." What preliminary assessment is evident?

Child and siblings are experiencing neglect.

Which nursing intervention will best address the intense need to control demonstrated by a client receiving treatment of bulimia nervosa?

Clearly stating expectations and admitting that they differ from those of the client

Which assessment data confirms that the client diagnosed with anorexia nervosa has achieved a fundamental treatment outcome?

Client has maintained weight at 87% of ideal body weight for 2 months

A nurse prepares the plan of care for a patient having a manic episode. Which nursing diagnoses are most likely? Select all that apply.

Disturbed thought processes. Sleep deprivation.

A 28-year-old second-grade teacher is diagnoses with major depressive disorder. She grew up in Texas but moved to Alaska 10 years ago to separate from an abusive mother. Her father died by suicide when she was 12 years old. Which combinations of factors in this scenario best demonstrates the stress-diathesis model?

Family history of mental illness coupled with history of abuse.

Outpatient treatment is planned for a patient diagnosed with anorexia nervosa. Select the most important desired outcome related to the nursing diagnosis: Imbalanced nutrition: less than body requirements. Within 1 week, the patient will:

Gain 1 to 2 pounds.

Disturbed body image is the nursing diagnosis for a patient with an eating disorder. Which outcome indicator is most appropriate to monitor?

Patient expresses satisfaction with body appearance.

A patient with anorexia nervosa is resistant to weight gain. What is the rationale for establishing a contract with the patient to participate in measures designed to produce a specified weekly weight gain?

Patient involvement in decision-making increases a sense of control and promotes compliance with the treatment.

A patient diagnosed with major depressive disorder was hospitalized for 2 weeks on an acute psychiatric ruin. One day after discharge, the patient completed suicide. recognizing likely reactions among staff, which action should the nursing supervisor implement first?

Provide a private setting for staff members to talk about feelings associated with the event.

A patient with mania dances around the unit, seldom sits, monopolizes conversations, interrupts, and intrudes. Which nursing intervention will best assist the patient with energy conservation?

Provide a subdued environment.

A female patient is anxious after receiving the news that she needs a breast biopsy to rule out breast cancer. The nurse is assisting with a breast biopsy. Which relaxation technique will be best to use at this time?

Relaxation breathing

The nurse is admitting a child with a history of abuse. The nurse understands that the child may exhibit what behaviors that are consequences of being in an abusive environment? (Select all that apply.)

Reliving abuse incidents. Sleep disturbance. Acting out behaviors.

A person at the emergency department is diagnosed with a concussion. The individual is accompanied by a spouse who insists on staying in the room and answering all questions. The patient avoids eye contact and has a sad affect and slumped shoulders. Assessment of which additional problem has priority?

Risk of domestic abuse

A patient coming to the health clinic for a blood pressure check reports to the nurse that she just does not have the energy to go out much in winter but looks forward to gardening in summer. The nurse realizes that this patient is describing a major symptom of what condition?

Seasonal affective disorder

A patient with a diagnosis of depression and suicidal ideation was started on an antidepressant 1 month ago. When the patient comes to the community health clinic for a follow-up appointment he is cheerful and talkative. What priority assessment must the nurse consider for this patient?

Specific assessment for suicide plan must be evaluated.

A patient with liver failure has been on the transplant waiting list for 8 months. The patient says to the nurse, "Why is it taking so long to have the surgery? Maybe I'm meant to die for all the bad things I've done." The nurse should document the patient's comment in which section of the assessment?

Spiritual

What feelings are most commonly experienced by nurses working with abusive families?

Sympathy for the victim and anger toward the abuser

A patient is brought to the emergency department after a motorcycle accident. The patient is alert, responsive, and diagnosed with a broken leg. The patient's vital signs are temperature (T), 98.6° F; pulse (P), 72 beats per minute (bpm); and respirations (R), 16 breaths per minute. After being informed that surgery is required for the broken leg, which vital sign readings would be expected?

T, 98.6°; P, 84; R, 22

Critical Thinking: A crisis intervention nurse is training emergency department staff on treatment needs of persons in abusive relationships. What is a common difficulty staff encounter when caring for this population?

The abused person may return to the abusive home setting.

A patient with bipolar disorder has rapid cycles. The health care provider prescribes an anticonvulsant medication. To prepare teaching materials, which drug should the nurse anticipate will be prescribed?

carbamazepine (Tegretol)

The nurse working at a women's health clinic is seeing a teenage female patient who has come in for a refill on her birth control medication and with a complaint of abdominal pain. When the nurse enters the room, the patient is sitting in the chair with her head down, rocking back and forth, does not make eye contact, and answers questions with no expression on her face. What assessment question would be important for the nurse to ask the patient?

"Do you feel safe in your current relationship?"

The nurse is assessing the coping abilities of a patient recently diagnosed with a degenerative neuromuscular disease with no known cure. Which statement by the patient alerts the nurse that more intervention is needed?

"I am sleeping much better when I have two drinks and smoke before bed."

A patient with anorexia nervosa virtually stopped eating 5 months ago and has lost 25% of body weight. A nurse asks, "Describe what you think about your present weight and how you look." Which response by the patient is most consistent with the diagnosis?

"I'm fat and ugly."

As a nurse escorts a patient being discharged after treatment for major depression, the patient gives the nurse a necklace with a heart pendant and says, "Thank you for helping mend my broken heart." Which is the nurse's best response?

"I'm glad I could help you, but I can't accept the gift. My reward is seeing you with a renewed sense of hope."

An adult has recently been absent from work on several occasions. Each time, the adult returns wearing dark NglUaRssSeIsN.GFTaBci.aClOaMnd body bruises are apparent. During the occupational health nurse's interview, the adult says, "My partner beat me, but it was because there are problems at work." What should the nurse's next action be?

Document injuries with a body map.

A patient has been resistant to treatment with antidepressant therapy. The care provider prescribes phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI) medication. What teaching is critical for the nurse to give the patient?

Eating foods such as blue cheese or red wine will cause side effects.

What are some primary prevention activities a nurse can perform related to substance abuse? Select all that apply.

Education to prevent substance abuse. Identification of risk factors for abuse. Referral to a self-help group for stress relief and meditation.

What classic characteristic is noted in clients diagnosed with bulimia nervosa?

Onset in late adolescence

A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, "I feel like a failure. I can't take care of my baby. This baby is the root of my problems." The priority nursing diagnosis is:

Risk for other-directed violence

A patient with depression repeatedly tells staff members, "I have cancer. It's my punishment for being a bad person." Diagnostic tests reveal no cancer. Select the priority nursing diagnosis.

Risk for suicide.

A college student has been experiencing significant stress associated with academic demands. Last month, the student began attending yoga sessions three times a week. Which outcome indicates this activity has been successful?

This student reports improves feelings of well-being.

A nurse assesses the health status of soldiers returning from Afghanistan. Screening for which health problems will be a priority? Select all that apply.

Traumatic brain disorder. Posttraumatic stress disorder.

The nurse cares for a victim of a violent sexual assault. What is the most therapeutic intervention?

Use accepting, nurturing, and empathetic communication techniques.

Which referral is most appropriate for a woman who is severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, and has limited financial resources?

Women's shelter

An outpatient diagnosed with anorexia nervosa has begun refeeding. Between the first and second appointments, the patient gained 8 pounds. The nurse should:

assess lung sounds and extremities.

Several children are seen in the emergency department for treatment of illnesses and injuries. Which finding would create a high index of suspicion for child abuse? the child who has:

bite marks

A college student who attempts suicide by overdose is hospitalized. When the parents are contacted they respond, "There must be a mistake. This could not have happened. We've given our child everything." The parents' reaction reflects:

denial

A patient in the long-term reorganization phase of the rape trauma syndrome has experienced intrusive thoughts of the rape and developed a fear of being alone. Which finding demonstrates the patient has made improvement? The patient:

plans coping strategies for fearful situations.

Which scenario best demonstrates an example of eustress? An individual:

prepares to take a 1 week vacation to a tropical island with a group of close friends.

Physical assessment of a patient with bulimia often reveals:

prominent parotid glands.

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?

"Are you experiencing a flashback of the rape right now?"

A victim of a violent rape has been in the emergency department for 3 hours. Evidence collection is complete. As discharge counseling begins, the patient says softly, "I will never be the same again. I can't face my friends. There is no sense of trying to go on." Select the nurse's most important response.

"Are you thinking of suicide?"

A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response?

"Because we are concerned about your safety, we will continue with our plan."

Select the most helpful response for a nurse to make when a patient being treated as an outpatient states, "I am considering committing suicide."

"Bringing this up is a very positive action on your part."

The nurse is teaching a hospitalized patient to use mindfulness to reduce anxiety. Which statement by the nurse is appropriate?

"How do you feel about what is going on right now?"

A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk? Select all that apply.

82-year-old white man. 17-year-old white female adolescent. 22-year-old man with traumatic brain injury.

A patient is being treated for an illicit drug addiction. The nurse understands that the treatment may include which of the following? Select all that apply.

A motivational interview. Observing for stress reaction. Encouraging involvement in Narcotics Anonymous.

Which action should the nurse take to monitor the effects of an acute stressor on a hospitalized patient? (Select all that apply)

Ask about epigastric pain. Observe for increased appetite. Check for elevated blood glucose levels.

Which nursing intervention has the highest priority for a patient with bulimia nervosa?

Assist the patient to identify triggers to binge eating.

The nurse is completing a care plan for a patient who is exhibiting poor coping after receiving a serious medical diagnosis. Which interventions would the nurse consider? Select all that apply.

Compile a list of activities that are of interest to to the patient. Review pamphlets about treatment options with the patient. Identify positive aspects of the illness, such as the chance to spend more time with family.

When an emergency department nurse teaches a victim of the rape trauma syndrome about reactions that may occur during the long-term reorganization phase, which symptoms should be included? Select all that apply.

Development of fears and phobias. Feelings of numbness. Flashbacks, dreams.

A soldier returned 3 months ago from Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). Which social event would most likely be disturbing for this soldier?

Fireworks displayed of July 4th

A patient with acute mania has exhausted the staff members by noon. The patient has joked, manipulated, insulted, and fought all morning. Staff members are feeling defensive and fatigued. Which is the best action?

Hold a staff meeting to discuss consistency and limit-setting approaches.

A woman in a relationship characterized by a long history of battering and abuse tells the nurse, "We've had a rough time lately. I admit it: he beat me last night but then said he was sorry." Which event would the nurse expect to occur next in the relationship?

Love, gifts, and praise form the partner.

A client diagnosed with depression has been prescribed various first-line antidepressant agents but has demonstrated only minimal improvement. In preparation for the prescription of a second-line agent, the nurse will educate the client on which classification of antidepressant

Monoamine oxidase inhibitors

The nursing diagnosis rape trauma syndrome applies to a rape victim in the emergency department. Which outcome should occur before the patient's discharge?

Patient agrees to keep a follow-up appointment with the rape victim advocate.

A patient referred to the eating disorders clinic has lost 35 pounds in 3 months and has developed amenorrhea. For which physical manifestations of anorexia nervosa should a nurse assess? Select all that apply.

Peripheral edema. Constipation. Hypotension. Lanugo.

A client is seeking treatment in the emergency department (ED) after a sexual assault. Which notation made by the ED nurse demonstrates appropriate non-judgmental documentation?

Physical evidence supports that vaginal penetration occurred

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returns wearing dark glasses. Facial and body bruises are apparent. What is the occupational health nurse's priority assessment?

Physical injuries

A patient has been admitted with major depressive disorder. What typical signs and symptoms would the nurse expect to assess? (Select all that apply.)

Poor eye contact. Slowed speech.

A person is directing traffic on a busy street and shouting, "To work, you jerk, for perks," and making obscene gestures at cars. The person has not slept or eaten for 3 days. What features of mania are evident?

Poor judgment and hyperactivity

A nurse conducting group therapy on the eating disorders unit schedules the sessions immediately after meals for the primary purpose of:

Processing the heightened anxiety levels associated with eating.

Which suggestions are appropriate for the family of a patient with bipolar disorder who is being treated as an outpatient during a hypomanic episode? Select all that apply.

Provide structure. Limit credit card access. Monitor the patients sleep patterns.

Which nursing intervention has priority during the acute phase of a client's manic episode?

Providing fluids frequently to promote hydration

After hospital discharge, what is the priority intervention for a patient with bipolar disorder, who is taking antimanic medication, and for the patient's family?

Psychoeducation

When describing the results of the fight or flight response, the nursing students require further teaching when making which statement?

Pupils constrict when a patient is anxious.

Which life event related to a client demonstrating depressive symptoms supports a diagnosis of persistent depressive disorder (PDD)?

Recognized symptoms of depression over 2 years ago

An adult required a heart transplant 5 years ago. Multiple medal complications followed, resulting in persistent irritability, depression, and insomnia. The adult's spouse says, "I've walked on eggshells for five years, never knowing when something else will go wrong." What is the nurse's priority intervention regarding the spouse?

Refer the spouse to the primary care provider for health assessment.

A soldier served in combat zones in Iraq in 2010 and was deployed to Afghanistan in 2011. When is it most important for the nurse to screen for signs and symptoms of post-traumatic stress disorder (PTSD)?

Screening should be ongoing

Which changes in brain biochemical function is most associated with suicidal behavior?

Serotonin deficiency

A patient's employment is terminated and major depression results. The patient says to the nurse, "I'm not worth the time you spend with me. I'm the most useless person in the world." Which nursing diagnosis applies?

Situational low self-esteem

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence?

Strong negative feelings interfere with assessment and judgment.

A client has made a successful suicide attempt while hospitalized on a unit that specializes on the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement?

Suicide precautions for a full 24 hours will be implemented for all clients

An adult attempts suicide after declaring bankruptcy. The patient is hospitalized and takes an antidepressant medication for 5 days. The patient is now more talkative and shows increased energy on the unit. Select the highest priority nursing intervention.

Supervise the patient 24 hours a day.

A nurse is planning interventions for a veteran who has recently been discharged from the military and is reporting difficulty sleeping. When considering the client's past medical history, which data is most relevant to the development of posttraumatic stress disorder (PTSD)?

Sustained a concussion a month before discharge

A nurse is conducting a family assessment to identify possible triggers for abusive behaviors. Which family characteristic will the nurse identify as such a trigger?

The parents were teenagers when the children were born

The nurse is assessing a patient using the CAGE questionnaire. The nurse suspects possible alcoholism when the patient makes which of the following statements? Select all that apply.

The patient states, "My wife keeps nagging me about my drinking." The patient states, "I am going to try to cut down on drinking. I have been partying too much." The patient states, "I usually have a Bloody Mary or Mimosa with breakfast." The patient says to the nurse, "I am ashamed of how much I have been drinking lately."

A nurse assesses the health status of soldiers returning from Afghanistan. Screening will be a priority for signs and symptoms of which health problems? Select all that apply.

Traumatic brain injury. Posttraumatic stress disorder.

A nurse is discussing the possible existence of abuse related to a 4-year-old currently being treated in the emergency department. Which statement by the nurse requires immediateintervention?

"A 4-year-old can be an unreliable source since they have such wonderful imaginations."

Which nursing interventions are likely to help the patient to cope by addressing the mediators of stress? Select all that apply.

"A divorce, while stressful, can be the beginning of a new, better phase of life." "Journaling gives one more awareness of how experiences have affected them." "Perhaps a short-term loan from your father will make your layoff less stressful." "I have found a support group for newly divorced persons in your neighborhood."

The spouse of a patient with bipolar disorder asks what evidence supports the possibility of genetic transmission of bipolar disorders. Select the nurse's best response.

"A higher rate of relatives with bipolar disorder is found among patients with bipolar disorder."

A nurse and patient construct a no-suicide contract. Select the preferable wording.

"For the next 24 hours, I will not kill or harm myself in any way."

Which statement is a nurse most likely to hear from a patient with anorexia nervosa?

"I'm fat and ugly."

A victim of reported sexual assault tells the nurse, " This was entirely my fault. I should have never gone to that party alone." Which response by the nurse is most therapeutic?

"It sounds like you are blaming yourself for the assailant's behavior."

A patient tells the nurse, "I was raped 8 years ago but never told anyone. Nevertheless, the memories haunt me everyday. I should be over it by now." Which comment should the nurse offer next?

"It sounds like you are judging yourself for continuing to struggle with your reaction."

A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI) antidepressant. After taking the new medication, the patient states, "This medication isn't working. I don't feel any different." What is the best response by the nurse?

"It usually takes a few weeks for you to notice improvement from this medication."

An emergency department nurse prepares to discharge a victim of reported rape. Which comment by the victim indicates the nurse's teaching was effective?

"It's important for me to follow up with my counseling."

A patent experiencing depression says to the nurse, "My healthcare provider said I need 'talk' therapy but I think I need a prescription for an antidepressant medication. What should I do?" Select the nurse's best response.

"Let's consider some ways to address your concerns with you health care provider."

A nurse counsels a patient with recent suicidal ideation. Which is the nurse's most therapeutic comment?

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

A patient with depression tells the nurse, "Bad things that happen are always my fault." To assist the patient in reframing this overgeneralization, the nurse should respond:

"Let's look at one bad thing that happened to see if another explanation exists."

A client has expressed great concern over "feeling like I'm going crazy" since experiencing anxiety, depression, and nightmares after being sexually assaulted. What response will the nurse make initially to address the client's concerns?

"What you are experiencing must be frightening. These symptoms are shared by many who have been sexually assaulted."

A patient with major depression says, "No one cares about me anymore. I'm not worth anything." The nurse wants to reinforce positive self-esteem. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate?

"You're wearing a new shirt."

A patient was diagnosed with bipolar disorder many years ago. The patient tells the nurse, " When I have a manic episode, there's always a feeling of gloom behind it and I know I will soon be totally depressed." What is the nurse's best response?

"Your comment indicates you have an understanding and insight about your disorder."

A patient with acute mania is dancing atop the pool table in the recreation room. The patient waves a cue in one hand and says, "I'll throw the pool balls if anyone comes near me." The nurse's first intervention is to:

clear the room of all other patients.

An unconscious person is brought to the emergency department by a friend. The friend found the person in a bedroom at a college fraternity party. Semen is observed on the person's underclothes. The priority actions of staff members should focus on:

maintaining the airway.

A patient with bipolar disorder, who is being treated on an outpatient basis, takes lithium carbonate 300 mg three times daily. The patient complains of nausea. To reduce the nausea, the nurse can suggest that the lithium be taken with:

meals

When a victim of sexual assault is discharged from the emergency department, the nurse should:

provide referral information verbally and in writing.

A patient comes to the hospital for treatment of injuries sustained during rape. The patient abruptly decides to decline treatment and return home. Before the patient leaves, the nurse should

provide written information concerning the physical and emotional reactions that may be experienced.

A patient with depression begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy, and priority information is given to the patient and family. This information should include a directive to:

report increased suicidal thoughts.

A nurse cares for a rape victim who received flunitrazepam (Rohypnol) from the assailant. Which intervention has priority? Monitoring for:

respiratory depression

Outcome identification for the treatment plan of a patient with grandiose thinking associated with acute mania focuses on:

self-control of distorted thinking

The cause of bipolar disorder has not been determined, but:

several factors, including genetics, are implicated.

A psychiatric clinical nurse specialist uses cognitive therapy techniques with a patient diagnosed with anorexia nervosa. Which statement by the staff nurse supports this type of therapy?

"Being thin doesn't seem to solve your problems. You're thin now but still unhappy."

Which statement demonstrates a characteristic of depression-associated behaviors that is especially associated with children and adolescents?

"I don't care that friends say I'm grumpy."

A nurse assesses a patient who reports a 3-week history of depression and crying spells. The patient says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the patient alerts the nurse to a concealed suicidal message?

"I have a plan that will fix everything."

A nurse assesses four adolescents diagnosed with various eating disorders. Which comment would the nurse expect from the adolescent diagnosed with anorexia nervosa?

"I've lost 60 pounds but I'm still a size 2. I want to be a size 0."

A patient diagnosed with bipolar disorder lives in the community and is showing early signs of mania. The patient says, "I need to go visit my daughter but she lives across the country. I put some requests on the internet to get a ride. Im sure someone will take me." What is the nurse's most therapeutic response?

"Im concerned about your safety when meeting or riding with strangers."

A new nurse says to a peer, "My newest patient has schizophrenia. At least I won't have to worry about suicide risk." Which response by the peer would be most helpful?

"Let's reconsider your plan. Suicide risk is high in patients with schizophrenia."

A patient newly diagnosed with depression states, "I have had other people in my family say that they have depression. Is this an inherited problem?" What is the nurse's best response?

"Members of the same family may have the same biological predisposition to experiencing mood disorders."

A soldier returned home last year after deployment to a war zone. The soldier's spouse complains, "We were going to start a family but now he won't talk about it. He will not look at children. I wonder if we're going to make it as a couple." Select the nurse's best response.

"Posttraumatic stress disorder often strains relationships. Here are some community resources for help and support."

A patient with bipolar disorder is in the maintenance phase of treatment. The patient asks, "Do I have to keep taking this lithium even though my mood is stable now?" Select the nurse's most appropriate response.

"Taking the medication every day helps prevent relapses and recurrences."

A nurse managing the care of a client diagnosed with an eating disorder has begun to experience frustration when the client consistently pushes back against the planned interventions. What action on the part of the nurse is indicated to help strengthen the nurse-client relationship?

Acknowledging to the client that working toward these treatment goals must be very frightening

A nurse assesses soldiers in a combat zone in Afghanistan. When is it most important for the nurse to screen for signs and symptoms of traumatic brain injury (TBI)?

After a fall, vehicle crash, or exposure to a blast

A nurse is presenting a workshop on interpersonal violence prevention. Which is a common risk factor for most interpersonal violence incidents that should be addressed?

Alcohol use.

Which experiences are most likely to precipitate post-traumatic stress disorder (PTSD)? Select all that apply.

An adolescent is kidnapped and held for 2 years in the home of a sexual predator. A passenger is in a bus that overturns on a sharp curve in the road, tumbling down an embankment. An adult is trapped for 3 hours at an angle in an elevator after a portion of the supporting cable breaks.

Which of the following statements is true regarding anxiety? (Select all that apply)

Anxiety is a response to stress. Anxiety can cause elevations in blood pressure and heart rate. Many conditions are exacerbated by stress and anxiety. Patients with anxiety respond well to relaxation techniques.

A university football coach invites the campus nurse to talk to the team about healthy relationships in the community. Which topic has priority for the nurse to include?

Appropriate behavior with intimate partners.

As a nurse in the emergency department, you are caring for a patient who is exhibiting signs of depression. What is a priority nursing intervention you should perform for this patient?

Assess for depression and ask directly about suicide thoughts.

A veteran of the war in Afghanistan tells the nurse, "Everyday something happens that makes me feels like Im still there. My family has grown impatient with me. They say it's time for me to move on from what time in my life but I can't." What is the nurse's first priority?

Assess the veteran for suicide risk.

Which intervention should a nurse recommend for the distressed family and friends of someone who has committed suicide?

Attending a self-help group for survivors

A diabetic patient who is hospitalized asks the nurse what factors are associated with increased blood glucose while in the hospital. Which response(s) by the nurse are appropriate?Select all that apply.

Blood sugar may be higher in the hospital due to the increased bed rest. Stressors such as illness cause the release of hormones that increase blood sugar. Medications such as steroids may increase glucose levels.

An 11-year-old child says, "My parents don't like me. They call me stupid and say I never do anything right, but it doesn't matter. I'm too dumb to learn." Which nursing diagnosis applies to this child?

Chronic low self-esteem, related to negative feedback from parents

A student nurse caring for a patient with depression reads in the patient's medical record, "This patient shows vegetative signs of depression." Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply.

Chronic low self-esteem. Sexual dysfunction. Self-care deficit. Insomnia.

A patient receiving lithium should be assessed for which evidence of complications?

Diaphoresis, weakness, and nausea

The nurse is assessing a 4-year-old child in a health clinic. Which of the following situations would cause the nurse to explore for possible abuse?

Different explanations of the injury from the child's parents

A person with a fear of heights drives across a high bridge. Which structure will stimulate a response from the autonomic nervous system?

Hypothalamus

An emergency department nurse assesses a woman suspected of being abused by an intimate partner. Which assessment finding clearly confirms the suspicion?

Injuries in a bikini pattern

After the admission interview and assessment the emergency department nurse has reason to believe that a child is being abused physically. Which intervention will the nurse implement to best determine if the child has been abused?

Insist that the child be further assessed without the parents being present

The admission note indicates a patient with depression has anergia and anhedonia. For which measures should the nurse plan? Select all that apply.

Instilling a sense of hopefulness. Assisting with self-care activities. Accommodating psychomotor retardation.

A patient with major depression shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply.

Offer laxatives, if needed. Monitor food and fluid intake. Provide a quiet sleep environment.

A 10-year-old child cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources to stabilize the home situation? Select all that apply.

Parental sessions to teach childrearing practices. Anger management counseling for the father. Continuing home visits to provide support.

The nurse has provided information about a safe shelter for a patient who is the victim of abuse. Which of the following is an additional intervention that the nurse must perform?

Report the abuse to the appropriate legal authority.

Which teaching focused intervention will have the greatest impact on reducing the risk of relapsing for a client diagnosed with bipolar disorder?

Role of family as support

An older adult with dementia lives with family and attends day care. After observing poor hygiene, the nurse at the center talks with the patient's adult child. This caregiver becomes defensive and says, "It takes all my time and energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority?

Secure additional resources for the mother's evening and night care.

Which documentation indicates the treatment plan of a patient with major depression was effective?

Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

What behavior by a nurse caring for a patient with an eating disorder indicates the nurse needs supervision?

The nurse uses an authoritarian manner when interacting with the patient.

A nurse is interviewing a patient and assessing the patient's readiness to change. Which statements by the patient in the motivational interview reflect this willingness? Select all that apply.

The patient states, "I will watch the game at my friend's house instead of at the bar." The patient states, "I now realize that the drinking has affected by family life." The patient states, "I have been attending one meeting a day."

A patient who is taking prescribed lithium carbonate is exhibiting signs of diarrhea, blurred vision, frequent urination, and an unsteady gait. Which serum lithium level would the nurse expect for this patient?

1.5 or higher mEq/L

One bed is available on the inpatient eating disorders unit. Which patient should be admitted? The patient whose weight dropped from:

150 to 100 pounds over a 4-month period. Vital signs: temperature, 35.9° C; pulse, 38 beats/min; blood pressure, 60/40 mm Hg

A new case management nurse has been hired at a nursing home to investigate several recent resident deaths at the facility. The nurse understands that because there are many kinds of potential abuse, she will need to assess for what type of factors? (Select all that apply)

Unexplained bruising of residents. Altered cognitive function of residents. Skin breakdown in residents resulting from poor hygiene.

A patient with acute mania has disrobed in the hall three times in 2 hours. The nurse should:

arrange for one-on-one supervision.

A patient diagnosed with anorexia nervosa is hospitalized for treatment. What features should the milieu provide? Select all that apply.

Adherence to a selected menu. Observation during and after meals. Monitoring during bathroom trips.

A patient with major depression will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply.

Administer pretreatment medication 30 to 45 minutes before treatment. Withhold food and fluids for a minimum of 6 hours before treatment. Remove dentures, glasses, contact lenses, and hearing aids.

An appropriate intervention for a patient with bulimia nervosa who binges and purges is to teach the patient to:

avoid skipping meals or restricting food.

When counseling patients with major depression, an advanced practice nurse will address the negative thought patterns by using:

cognitive behavioral therapy

A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient:

Consults the pharmacist when selecting over-the-counter medications.

The nurse is assessing a patient's anxiety related to stress. Which changes reflect the short-term physiological response to stress? (Select all that apply)

Cortisol is released, increasing glycogenesis and reducing fluid loss. Corticosteroid release increases stamina and impedes digestion. Muscular tension, blood pressure, and triglyceride levels increase. Epinephrine is released, increasing the heart and respiratory rates.

A professor's 4-year-old child has a body temperature of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which nursing diagnosis best applies to this scenario?

Decisional conflict

A person attempts suicide by overdose, is treated in the emergency department, and is then hospitalized. What is the best initial outcome? The patient will:

exercise suicide self-restraint by refraining from gestures or attempts to kill self for 24 hours.

Which understanding about individuals who attempt suicide will help a nurse plan the care for a suicidal patient? Every suicidal person should be considered:

experiencing hopelessness.

A patient with depression is taking a tricyclic antidepressant. The patient says, "I don't think I can keep taking these pills. They make me so dizzy, especially when I stand up." The nurse should:

explain how to manage hypotension, and educate the patient that side effects go away after several weeks.

A nurse working a rape telephone hotline should focus communication to:

explain immediate steps that a victim of rape should take.

An older adult with Alzheimer's disease lives with family. During the week, the person attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this patient most vulnerable to abuse?

Dementia

The nurse should document which physiological stressor after performing a screening assessment on a patient?

Dementia

A nurse interviews a person abducted and raped at gunpoint by an unknown assailant. The person says, "I can't talk about it. Nothing happened. I have to forget!" What is the person's present coping strategy?

Denial

A patient has a history of physical violence against family members when frustrated and then experiences periods of remorse after each outburst. Which finding indicates success in the plan of care? The patient:

expresses frustration verbally instead of physically.

What is the primary motivator for most rapists?

Desire to humiliate or control others.

The feeling experienced by a patient that should be assessed by the nurse as most predictive of elevated suicide risk is:

hopelessness

An 11-year-old child is absent from school to care for siblings while the parents work. The family cannot afford a babysitter. When asked about the parents, the child reluctantly says, "My parents don't like me. They call me stupid and say I never do anything right." Which type of abuse is likely?

Emotional

A victim of physical abuse by a domestic partner is treated for a broken wrist. The patient has considered leaving but says, "You stay together, no matter what happens." Which outcome should be met before the patient leaves the emergency department? The patient will:

name two community resources that can be contacted.

A mature, professional couple plans a large wedding in a city 100 miles from their home. Which response is most likely to be associated with this experience?

Eustress

A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate?

Eyes pointed downward

Which individual in the emergency department should be considered at the highest risk for completing suicide?

A 79-year-old single white man with cancer of the prostate gland

The nurse is reviewing case files for children at risk for injury resulting in brain injury. Which child is at most risk for experiencing this type of violence?

A Caucasian, six-month-old infant living with a single mother

A nurse is caring for a patient in the emergency department who has been a victim of intimate partner violence. What is most important for the nurse to include in the plan of care?

A list of community resources

Which situation constitutes consensual sex rather than rape?

A person's lover pleads to have oral sex. The person gives in but then regrets the decision.

A patient is hospitalized with a diagnosis of anorexia nerves. The nurse reviews the patient's laboratory results below. Sodium 143 mEq/L Potassium 3.1 mEq/L Chloride 102 mEq/L Magnesium 2.2 mEq/L Calcium 8.4 mEq/L Phosphate 3.0 mEq/L The nurse should take which action next?

Auscultate the patient's heart rate, rhythm, and sounds.

A patient with acute mania waves a newspaper and says, "I must have my credit card and use the computer right now. A store is having a big sale and I need to order 10 dresses and four pairs of shoes." Select the nurse's most appropriate intervention.

Invite the patient to sit with the nurse and look at new fashion magazines.

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk?

Jumping from a 100-foot-high railroad bridge located in a deserted area late at night

Which activities are in the scope of practice of a sexual assault nurse examiner? Select all that apply.

Collecting and preserving evidence. Obtaining signed consents for photographs and examinations. Providing pregnancy and sexually transmitted disease prophylaxis

An older adult has experienced severe depression for many years and is unable to tolerate most antidepressant medications due to adverse effects of the medications. He is scheduled for electroconvulsive therapy (ECT) as a treatment for his depression. What teaching should the nurse give the patient regarding this treatment?

Common side effects include headache and short-term memory loss.

A patient has a long history of bipolar disorder with frequent episodes of mania secondary to stopping prescribed medications. The patient says, "I will use my whole check next month to buy lottery tickets. Winning will solve my money problems." Select the nurse's best action.

Confer with the treatment team about appointing a legal guardian of the patient.

A patient was abducted and raped at gunpoint by an unknown assailant. Which assessment finding best indicates the patient is in the acute phase of rape trauma syndrome?

Confusion and disbelief

A patient with bipolar disorder is dressed in a red leotard and brightly colored scarves. The patient says, "I'll punch you, munch you, crunch you," while twirling and shadowboxing. Then the patient says gaily, "Do you like my scarves? Here...they are my gift to you." How should the nurse document the patient's mood?

Labile and euphoric

Lithium is prescribed for a new patient. Which information from the patient's history indicates that monitoring serum concentrations of the drug will be challenging and critical?

Congestive heart failure

A health teaching plan for a patient taking lithium should include instructions to:

Maintain normal salt and fluids in the diet.

A patient with depression does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse's most effective action.

Make observations.

A nurse teaching a patient about a tyramine-restricted diet would approve which meal?

Mashed potatoes, ground beef patty, corn, green beans, apple pie

The nurse is assessing the social support of a patient who is recently divorced and has moved from their hometown to the city due to change in jobs. Which response related to social support would be most therapeutic?

Discuss how divorce support groups could increase coping and social support.

A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?

High level

The nurse is trying a nonpharmacological intervention for a patient with anxiety. Which of the following would most likely benefit this patient?

Performing abdominal breathing exercises

An older adult with Alzheimer disease lives with family. After observing multiple bruises, the home health nurse talks with the older adult's daughter, who becomes defensive and says, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority?

Risk for injury, related to poor judgment, cognitive impairment, and lack of caregiver supervision

A nurse is developing a plan of care for a patient admitted with a diagnosis of bipolar disorder, manic phase. Which nursing diagnoses address priority needs for the patient? (Select all that apply.)

Risk for injury. Imbalanced nutrition, less than body requirements. Sleep deprivation.

Which beverage should the nurse offer to a patient with depression who refuses solid food?

Milk

A client diagnosed with depression has been prescribed various first-line antidepressant agents but has demonstrated only minimal improvement. In preparation for the prescription of a second-line agent, the nurse will educate the client on which classification of antidepressant?

Monoamine oxidase inhibitors

Which nursing intervention has priority as a patient with anorexia nervosa begins to gain weight?

Observe for adverse effects of refeeding.

Which personality characteristic is a nurse most likely to assess in a patient with anorexia nervosa?

Rigidity, perfectionism

A patient with mania has not eaten or slept for 3 days. Which nursing diagnosis has priority?

Risk for injury

The nurse is counseling women at a crisis shelter about risk factors for increased intimate partner violence. What event is most likely to trigger an increase in abusive behaviors?

Becoming pregnant

A patient has begun smoking again and drinks six alcoholic beverages per day since experiencing the loss of his job. The nurse recognizes that the patient is exhibiting symptoms of which type of stress?

Behavioral

When a hyperactive patient with acute mania is hospitalized, what initial nursing intervention is a priority?

Set limits on patient behavior as necessary.

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

Setting and maintaining consistent unit policies that are enforced by all staff

A person was abducted and raped at gunpoint. The nurse observes this victim is confused, talks rapidly in disconnected phrases, and is unable to concentrate or make simple decisions. What is the patient's level of anxiety?

Severe

An individual lives in a community adjacent to a military base. Loud jets fly overhead multiple times daily. The person tells the nurse, "They're so loud I can't hear myself think." What is the nurse's best first action?

Teach relaxation and stress reduction techniques to the individual.

A professor's 4-year-old child has a temperature of 101.6° F, diarrhea, and complains of stomach pain. The professor is scheduled to teach three classes today. Which actions by the professor demonstrate effective parenting? Select all that apply.

Telephoning a grandparent to stay with the child at home for the day. Telephoning a colleague to teach his classes and stays home with the sick child.

A patient with major depression was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.

Temporary memory impairments and confusion are associated with electroconvulsive therapy.

When considering an individual's risk for suicide, which client will the nurse consider the priority?

The teenager recovering from a self-inflicted gunshot wound

A woman was grabbed by an attacker as she walked home from work. The attacker put a gun to her head, taped her mouth, tied her hands, took her to a remote location, and raped her. Which aspect of this crisis produced the greatest amount of psychologic trauma?

Threat to her life

A clinic nurse interviews a patient who reports fatigue, back pain, headaches, and sleep disturbances. The patient seems tense, then becomes reluctant to provide more information, and is in a hurry to leave. How can the nurse best serve the patient?

Have the patient fill out an abuse assessment screen.

An individual says to the nurse, "I feel so stressed out lately. I think the stress is affecting my body also." Which somatic complaints are most likely to accompany this feeling? Select all that apply.

Headache Neck pain Insomnia Anorexia

A priority intervention for a patient with major depression is:

carefully and unobtrusively observing the patient around the clock.

A nurse assists a victim of spousal abuse to create a plan for escape if it becomes necessary. The plan should include which components? Select all that apply.

Keep a cell phone fully charged. Have the telephone number for the nearest shelter. Secure a supply of current medications for self and children. Determine a code word to signal children that it is time to leave. Assemble birth certificates, Social Security cards, and licenses.

An older adult with dementia lives with family and attends a day care center. A nurse at the day care center notices the adult has a disheveled appearance, a strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring?

Physical

An elderly widow tells the nurse, "Since my sister-in-laws death, her husband has been making advances at me. He tried to come in my home with a bottle of wine. Even though he is family, I'm afraid of what might happen if I let him in." Which action should the nurse take first?

Positively reinforce the widow for addressing the problem with a caring professional.

A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, but I keep seeing bits of flesh everywhere. I see something red and the visions race back to my mind." Which phenomenon associated with post-traumatic stress disorder (PTSD) is this soldier describing?

Reexperiencing

What is a nurse's legal responsibility if child abuse or neglect is suspected?

Report the suspected abuse or neglect according to state regulations.

After treatment for a detached retina, a victim of domestic violence says, "My partner only abuses me when intoxicated. I've considered leaving, but I was brought up to believe you stay together, no matter what happens. I always get an apology, and I can tell my partner feels bad after hitting me." Which nursing diagnosis applies?

Risk for injury, related to partner's physical abuse when intoxicated

A person intentionally overdoses on antidepressant drugs. Which nursing diagnosis has the highest priority?

Risk for suicide

A rape victim asks an emergency department nurse, "Maybe I did something to cause this attack. Was it my fault?" Which response by the nurse is the most therapeutic?

Support the victim to separate issues of vulnerability from blame.

Consider these three drugs: divalproex (Depakote), carbamazepine (Tegretol), and gabapentin (Neurontin). Which drug also belongs to this group?

lamotrigine (Lamictal)

A patient with acute mania undresses in the group room and dances. The nurse's first intervention would be to:

put a blanket around the patient, and walk with the patient to a quiet room.

While providing health teaching for a patient with binge-purge bulimia, a nurse should emphasize information about:

recognizing the symptoms of hypokalemia.

A patient was started on escitalopram (Lexapro) 5 days ago and now says, "This medicine isn't working." The nurse's best intervention would be to:

explain the time lag before antidepressants relieve symptoms.

A nurse instructs a patient taking a drug that inhibits the action of a monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:

hypertensive crisis.

A nurse receives this laboratory result: lithium level 1 mEq/L. This result is:

within therapeutic limits

When a nurse finds a patient with anorexia nervosa vigorously exercising before gaining the agreed-upon weekly weight, the nurse should state:

"According to our agreement, no exercising is permitted until you have gained a specific amount of weight."

On the sixth anniversary of her spouse's death a widow says, "Sometimes like does not seem worth living anymore. I wish I could go to sleep and never wake up." Which response by the nurse has priority?

"Are you considering suicide?"

A depressed patient says, "Nothing matters anymore." What is the most appropriate response by the nurse?

"Are you having thoughts of suicide?"

A client is currently expressing suicidal ideations. Which statement made by the client demonstrates knowledge of appropriate crisis management techniques that are focused on safety?

"I need you to stay with me."

A soldier returns to the United States from active duty in a combat zone in Afghanistan. The soldier is diagnosed with post-traumatic stress disorder (PTSD). Which comment by the soldier requires the nurse's immediate attention?

"I saw my best friend get killed by a roadside bomb. It should have been me instead."

A nurse explains to the family of a patient who is mentally ill how the nurse-patient relationship differs from social relationships. Which is the best explanation?

"The focus is on the patient. Problems are discussed by the nurse and patient, but solutions are implemented by the patient."

A family member of a patient diagnosed with bipolar disorder asks what behaviors would indicate the beginnings of a manic phase. What is the best response by the nurse?

"The person may have excess energy, talk a lot, feel restless, and spend too much money."

A nurse has worked on a mental health unit for an extended period of time. Which statement is best associated with behaviors demonstrated as a result of burnout?

"These clients are like living with my mother and aunt."

An emergency department assesses a child with a fractures ulna. The nurse also observes yellow and purple bruises across the child back and shoulders. Which comment by the parent should prompt the nurse to report to CPS?

"This child is always creating problems for the family."

A patient who is in pain is concerned about becoming addicted to pain medication and asks the nurse, "Can I become addicted to this medication?" What is the nurse's best response? Select all that apply.

"You may develop a tolerance for the medication and need more of it in order for it to be therapeutic." "Before stopping the medication, you may need to taper it so you do not suffer from withdrawal."

Which statement shows a nurse has empathy for a patient who made a suicide attempt?

"You must have been very upset when you tried to hurt yourself."

A victim of a sexual assault that occurred approximately 1 hour earlier sits in the emergency department rocking back and forth and repeatedly saying, "I can't believe I've been raped." This behavior is characteristic of which phase of the rape trauma syndrome?

Acute phase

During a psychiatric assessment, the nurse observes a patient's facial expressions that are without emotion. The patient says, "Life feels so hopeless to me. I've been feeling sad for several months." How should the nurse document the patient's affect and mood?

Affect flat; mood depressed.

A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? Select all that apply.

Allow no glass or metal on meal trays. Remove all potentially harmful objects from the patient's possession. Maintain arm's length, one-on-one nursing observation around the clock.

Which family scenario presents the greatest risk for family violence?

An unemployed husband with low self- esteem, a wife who loses her job, and a developmentally delayed 3-year-old child

Lithium is prescribed for a client admitted with a diagnosis of bipolar disorder. Which other therapy is also initially prescribed to temporarily help manage the client's symptoms?

Antipsychotic medication

A patient complains of insomnia while in the hospital. Which nursing diagnosis would be a top priority for this patient?

Anxiety related to hospitalization

The nurse knows that which of the following medical conditions are most commonly associated with anxiety? Select all that apply:

Cancer. Chronic obstructive pulmonary disease. Dysrhythmias. Encephalitis. Hyperthyroidism.

A nursing care plan for a patient with anorexia nervosa includes the intervention "monitor for complications of refeeding." Which system should a nurse closely monitor for dysfunction?

Cardiovascular

A patient with bipolar disorder was hospitalized 7 days earlier and has been taking lithium 600 mg three times daily. Staff members observe increased agitation, pressured speech, poor personal hygiene, hyperactivity, and bizarre clothing. What is the nurse's best intervention?

Consider the need to check the lithium level. The patient may not be swallowing medications.

Which assessment has priority when a nurse interviews a rape victim in the emergency department?

Coping mechanisms the patient is using

A patient with bipolar disorder commands other patients, "Get me a book. Take this stuff out of here," and other similar demands. The nurse wants to interrupt this behavior without entering into a power struggle. Select the best initial approach by the nurse.

Distraction: "Let's go to the dining room for a snack."

Which nursing diagnosis would most likely apply to both a patient with depression and one with acute mania?

Disturbed sleep pattern

The nurse is managing care for a client who is reporting increased stress related to a new work-related position. What intervention suggested by the nurse is associated with the effects of stress on the hypothalamus-pituitary-adrenal cortex?

Drinking sufficient fluids to stay well hydrated.

Which intervention associated with bipolar disorder best minimizes the risk for the development of suicidal ideations?

Early diagnosis

A soldier returned home from active duty in a combat zone in Afghanistan and was diagnosed with post-traumatic stress disorder (PTSD). The soldier says, "If there's a loud noise at night, I get under my bed because I think we're getting bombed." What type of experience has the soldier described?

Flashback

Which nursing diagnosis is more applicable to a patient with anorexia nervosa who restricts intake and is 20% below normal weight than for a 130-pound patient with bulimia nervosa who purges?

Imbalanced nutrition: less than body requirements

A patient has anorexia nervosa. The history shows the patient virtually stopped eating 5 months ago and has lost 25% of body weight. The serum potassium is 2.7 mg/dl. Which nursing diagnosis applies?

Imbalanced nutrition: less than body requirements, related to reduced oral intake as evidenced by loss of 25% of body weight and hypokalemia

A patient who had a stroke 3 days ago tearfully tells the nurse, "Whats the use living? I'm no good to anybody like this." Which action should the nurse employ first when caring for a patient demonstrating hopelessness?

Implement the institutional protocol for suicide risk.

As a patient admitted to the eating disorders unit undresses, a nurse observes that the patient's body is covered by fine, downy hair. The patient weighs 70 pounds and is 5 feet, 4 inches tall. Which term should be documented?

Lanugo

At a unit meeting, staff members discuss the decor for a special room for patients with mania. Select the best option.

Neutral walls with pale, simple accessories

A patient tells the nurse, "I am so ashamed of being bipolar. When I'm manic, my behavior embarrasses my family. Even if I take my medication, there's no guarantee I won't have a relapse. I am such a burden to my family." These statements support which nursing diagnoses? Select all that apply.

Powerlessness. Chronic low self-esteem.

While weighing patient on an eating disorders unit, the nurse overhears a psychiatric technician say, "I wish I had an eating disorder; maybe then I'd lose a little weight." What is the nurse's best action?

Privately discuss the importance of sensitivity with the psychiatric technician.

A college student failed two examinations. The student cried for hours and then tried to call a parent but got no answer. The student then suspended access to his social networking web site. Which suicide risk factors are present? Select all that apply.

Recent stressful life event. Self-imposed isolation. Shame or humiliation.

A patient tells the nurse, "No matter what I do, I feel like there's always a dark cloud following me." Select the nurses initial reaction.

Say to the patient, "Tell me more about what you mean but 'a dark cloud'."

The nurse will encourage the client to engage in regular involvement with which formalized groups as an intervention directed toward the treatment of a primary risk factor associated with depression?

Sexual assault survivors group. New moms support group. Alcoholics Anonymous (AA).

An adult with depression was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

Social skills training

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment?

Supporting physiologic stability

An older adult has experienced both physical and emotional abuse while living with a family member. The family member has been adherent with required therapy and at the client's request the two will again be living together. Which intervention will best assure that both the client and the family member's needs are being met?

The home will have regular but unscheduled visits by adult protective services agents

A patient is newly diagnosed with anxiety and placed on a selective serotonin reuptake inhibitors (SSRIs). The nurse is developing the plan of care for this patient. How long will it take for this medication to become effective?

The medication may take up to 12 weeks to become effective.

A nurse has begun working in a new unit with high-acuity patients who are scheduled for numerous diagnostic tests before being transferred to the appropriate medical or surgical unit. She also has care responsibilities for her children and her aging parents. The nurse is experiencing signs of being overwhelmed. What counsel might the nurse manager share with the nurse to help her cope with work stress?

Request that another nurse help her focus on essential aspects of care rather than optional aspects of care.

A patient with mania relapsed after discontinuing lithium. New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). The addition of olanzapine to the medication regimen will:

bring hyperactivity under rapid control.

Over the past year, a woman has cooked gourmet meals for her family but eats only tiny servings. This person wears layered loose clothing and now has amenorrhea. Her current weight is 95 pounds, a loss of 35 pounds. Which medical diagnosis is most likely?

Anorexia nervosa

A patient tells the nurse, "My husband is abusive most often when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive?

History of family violence

A college student failed two tests. Afterward, the student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?

Giving away sweaters

An adult tells the nurse, "My partner abuses me most often when drinking. The drinking has increased lately, but I always get an apology afterward and a box of candy. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents the patient from leaving?

Honeymoon

A person is directing traffic on a busy street and rapidly shouting, "To work, you jerk, for perks," and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which assessment findings will have priority concern for this patient's plan of care?

Hyperactivity; not eating and sleeping

As part of the stress response, the HPA axis is stimulated. Which structures make up this system?

Hypothalamus, pituitary gland, and adrenal glands

When considering the lethality of a client's suicide plan, what is the basic principle the nurse will consider?

If the action is reversible, the plan is less lethal

A patient being admitted to the eating disorders unit has a yellow cast to the skin and fine, downy hair covering the body. The patient weighs 70 pounds; height is 5 feet, 4 inches. The patient is quiet and says only, "I won't eat until I look thin." What is the priority initial nursing diagnosis?

Imbalanced nutrition: less than body requirements, related to self-starvation

A single adult says to the nurse, "Both of my parents died several years ago, and my only sibling committed suicide 2 weeks ago. I feel so alone." After determining that the adult has no suicidal ideation, the nurse should:

Refer the adult to a self-help group for suicide survivors.

This nursing diagnosis applies to a patient with mania: Imbalanced nutrition: less than body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-pound weight loss in 4 days. Select the most appropriate outcome. The patient will:

drink six servings of a high-calorie, high- protein drink each day.

A child was abducted and raped. In the emergency department, this victim is confused and crying. Which personal reaction by the nurse could interfere with this victim's care?

Anger

A patient says to the nurse, "My life doesn't have any happiness in it anymore. I once enjoyed holidays, but now they're just another day." How would the nurse document the complaint?

Anhedonia

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?

As depression lifts, physical energy becomes available to carry out suicide.

How will the nurse best assess a client for the current presence of suicidal ideations?

Ask the client directly, "Are you thinking of killing yourself?"

Which dinner menu is best suited for the patient with bipolar disorder experiencing acute mania?

Broiled chicken breast on a roll, an ear of corn, and an apple

Cortisol is released in response to a patient's prolonged stress. Which initial effect would the nurse expect to result from the increased cortisol level?

Focused and alert mental status

A new psychiatric nurse has a parent with bipolar disorder. This nurse angrily recalls embarrassing events concerning the parent's behavior in the community. Select the best ways for this nurse to cope with these feelings. Select all that apply.

Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses. Recognize that the feelings may add sensitivity to the nurse's practice, but supervision is important.

A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, "No one cares about me anymore. I'm not worth anything." Select an appropriate initial outcome for the nursing diagnosis Situational low self-esteem, related to feelings of abandonment. The patient will:

verbalize realistic positive characteristics about self by (date) .

The nurse cares for a hospitalized adolescent diagnosed with major depressive disorder. The HCP prescribes a low-dose antidepressant. In consideration of published warnings about use of antidepressant medications in younger patients, which action should the nurse employ?

Monitor the adolescent closely for evidence of adverse effects, particularly suicidal thinking or behavior.

A person was abducted and raped at gunpoint by an unknown assailant. Which interventions should the nurse use while caring for this person in the emergency department? Select all that apply.

Allow the patient to talk at a comfortable pace. Pose questions in nonjudgmental, empathic ways. Place the patient in a private room with a caregiver.