NSG 2400 Exam 1 EAQ Questions

A nurse is caring for an adolescent with the diagnosis of anorexia nervosa. The plan of care should include helping the client do what? 1 Plan nutritious meals. 2 Change attitudes about nutrition. 3 Understand that more food must be eaten. 4 Recognize how the need to control influences behavior.

4 Recognize how the need to control influences behavior. The client's focus on controlling eating redirects attention away from those areas that are felt to be out of the client's control. This is how life's more difficult problems and challenges are avoided. Planning nutritious meals may not be productive, because these clients believe that they are eating nutritious meals. It is not the client's attitudes or beliefs about food but instead the distorted self-image that is the problem. Understanding that more food must be eaten may not be productive, because these clients believe that they are eating enough food.

A client with chronic depression has a history of suicidal ideations. Place the following nursing assessment questions in the appropriate order to best ensure client safety. 1. "Are you thinking about hurting yourself?" 2. "Have you decided upon a plan to harm yourself?" 3. "What is your plan for killing yourself?" 4. "How would you get what you need to end your life?"

1,2,3,4 The initial action is to determine whether the client intends to commit suicide. The second step is to determine whether the client has made the intention specific by planning a method of suicide. The third step is to determine to what extend the client has decided on the details of the act of suicide. Finally it is necessary to determine whether the client has the means to actually complete the plan.

A nurse is caring for an angry, hostile client with the diagnosis of borderline personality disorder. What is probably an issue for this client? 1 Low self-esteem 2 Inability to test reality 3 Disturbed energy field 4 Ineffective verbal communication

1 Low self-esteem The client is demonstrating a reaction to low self-esteem with hostile behavior. People with borderline personality disorder often have identity disturbances. There is no evidence of an inability to test reality, a disturbed energy field, or impaired verbal communication

. A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks? 1 Lithium 2 Diazepam 3 Fluvoxamine 4 Fluphenazine

4 Fluphenazine Fluphenazine can be given intramuscularly every 2 to 3 weeks to clients who are unreliable about taking oral medications; it allows them to live in the community while keeping the disorder under control. Lithium is a mood-stabilizing medication that is given to clients with bipolar disorder. This drug is not given for schizophrenia. Diazepam is an antianxiety/anticonvulsant/skeletal muscle relaxant that is not given for schizophrenia. Fluvoxamine is a selective serotonin reuptake inhibitor; it is administered for depression, not schizophrenia.

A newly admitted client with an obsessive-compulsive personality disorder frequently performs a handwashing ritual. When attempts are made to set limits on the frequency or length of the ritual, the client's anxiety escalates and the client becomes verbally aggressive. What is most important for the nurse to do when the client performs the ritual? 1 Allow the client sufficient time to carry out the ritual. 2 Promote reality by showing that the ritual serves little purpose. 3 Try to ascertain the meaning of the ritual by discussing it with the client. 4 Interrupt the ritual to demonstrate that the ritual does not control what happens.

1 Allow the client sufficient time to carry out the ritual. Rituals provide a means for the individual to control anxiety. If not permitted to carry out the ritual, the client will probably experience unbearable anxiety. The client has exhibited verbally aggressive behavior in the past, and this behavior may escalate. Safety of the client and others becomes an issue. The client probably already understands that the ritual is useless but is unable to stop the activity. These clients have no idea of what the ritual means, only that they must continue the ritual. Interrupting the ritual will have the effect of increasing anxiety, possibly to a panic level.

When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? 1 Checking on the client frequently 2 Keeping the client's room lights dim 3 Addressing the client in a loud, clear voice 4 Restraining the client during periods of agitation

1 Checking on the client frequently During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.

The nurse assesses a client with bipolar disorder. While reviewing the laboratory reports, the nurse finds the client's lithium levels are 1.3 mEq/L (1.3 mmol/L). Which nursing intervention would be appropriate in this client? 1 Continuing to administer the drug 2 Administering phenothiazine antipsychotics along with lithium 3 Notifying the primary healthcare provider of the lithium levels 4 Withdrawing the drug by consulting primary healthcare provider

1 Continuing to administer the drug The normal range of lithium is below 1.5 mEq/L (1.5 mmol/L). Because the serum lithium level is 1.3 mEq/L (1.3 mmol/L), the nurse should continue administering the drug. Administration of phenothiazine antipsychotics should be avoided because they may cause anticholinergic effects when used with lithium. The primary healthcare provider does not need to be consulted, and the drug should not be withdrawn.

The nurse is caring for a client with a somatoform disorder, conversion-type paralysis. What is the best nursing approach? 1 Discussing topics other than the paralysis 2 Explaining the reason for the physical problem 3 Asking how the client feels about being paralyzed 4 Encouraging the client to slowly walk around the room

1 Discussing topics other than the paralysis Discussion of signs and symptoms should not be initiated by the nurse; the signs and symptoms should be accepted by the nurse. Discussion should be focused on the client's feelings and current situation. Explaining the reason for the physical problem may take away the client's unconscious defense and increase anxiety. Asking how the client feels about being paralyzed focuses on the paralysis rather than feelings. Encouraging the client to slowly walk around the room denies the client's symptoms; in reality this client cannot make the legs move to walk.

A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing? 1 Illusion 2 Delusion 3 Hallucination 4 Confabulation

1 Illusion An illusion is a misinterpretation of an actual sensory stimulus. A delusion is a false, fixed belief. A hallucination is a false sensory perception that occurs with no stimulus. Confabulation is a filling in of blanks in memory.

A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? 1 Mild 2 Panic 3 Severe 4 Moderate

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

A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar disorder, manic phase. In which type of room should the nurse tell the admissions clerk to place this client? 1 Private 2 Isolation 3 Semi-private 4 Negative-airflow

1 Private The client who is manic needs a nonstimulating environment. A person who is bipolar is not contagious and does not require an isolation room. The presence of another person in the room is considered stimulating and may interfere with the rest and sleep of both clients. A client who is bipolar does not need a negative-airflow room. This type of room is appropriate for a client with a communicable disease, such as tuberculosis, that requires airborne precautions.

A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discussing this therapy with the client? 1 Sleep will be induced and the treatment will not cause pain. 2 The treatment is totally safe with the new methods of administration. 3 The client may ask any question, but it is better not to talk about the therapy. 4 The client may experience some unrecoverable short-term and long-term memory loss.

1 Sleep will be induced and the treatment will not cause pain. Clients fear ECT because they think it will be painful. If they are reassured that they will be asleep and will feel no pain, there will be less anxiety. No treatment requiring anesthesia is totally safe. Clients may not realize their own fears and therefore may not know what questions to ask; also, this response cuts off further communication. Temporary, not permanent, memory loss occurs.

A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense mechanism is the client using when identifying the other clients? 1 Splitting 2 Ambivalence 3 Passive aggression 4 Reaction formation

1 Splitting Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others. Ambivalence is the experience of feeling opposite emotions at the same time. Passive aggression is the expression of hostility toward another in an indirect, nonassertive way. Reaction formation is the expression of unacceptable desires by adopting opposite behaviors in an exaggerated way.

A client with a diagnosis of schizophrenia, undifferentiated type, is being admitted to the psychiatric unit. What clinical manifestations does the nurse expect when assessing this client? Select all that apply. 1 Excited behaviors 2 Loose associations 3 Inappropriate affect 4 Feelings of depression 5 Hypervigilant behavior

1 Excited behaviors 2 Loose associations 3 Inappropriate affect Excited behaviors, such as aggressive hitting or biting, often are associated with an acute onset of undifferentiated schizophrenia. Loose association is a characteristic related to thought disorders such as schizophrenia, undifferentiated type. The affect usually is inappropriate, rather than flat, in undifferentiated schizophrenia. Depression is not characteristic of undifferentiated schizophrenia. Hypervigilant behaviors generally are associated with paranoid schizophrenia, not undifferentiated schizophrenia.

A nurse is planning an educational program for family members of clients with bipolar disorder. What clinical manifestations indicating the beginning of an episode of mania should the nurse include? Select all that apply. 1 Insomnia 2 Irritability 3 Excessive eating 4 Decreased libido 5 Financial irresponsibility

1 Insomnia 2 Irritability 5 Financial irresponsibility During a manic episode there is a decreased need for sleep and clients do not feel tired. During a manic episode the primary mood is irritability; the emotions often fluctuate between euphoria and anger. During a manic episode impulsivity, impaired judgment, and involvement in pleasurable activities may result in spending sprees that can have negative consequences. During a manic episode there is a decrease in appetite. The client's increased activity and inability to sit still interfere with the ability to eat and drink. Hypersexuality, rather than decreased libido, is common during a manic episode.

A nurse who is assessing a recently hospitalized client with a diagnosis of opioid addiction should look for signs of withdrawal. What are these signs? Select all that apply. 1 Seizures 2 Yawning 3 Drowsiness 4 Constipation 5 Muscle aches

1 Seizures 2 Yawning 5 Muscle aches Seizures, yawning, and muscle aches are all clinical manifestations of opioid withdrawal, which occurs after cessation or reduction of prolonged moderate or heavy use of opioids. Insomnia, not drowsiness occurs with opioid withdrawal. Diarrhea, not constipation, occurs with opioid withdrawal..

A client who is experiencing acute alcohol withdrawal delirium appears frightened, points toward the bed, and says, "Bugs are crawling all over me and my bed!" What is the most therapeutic response by the nurse? 1 "Just try to brush them off." 2 "I don't see any bugs on you or your bed." 3 "They'll go away when you start feeling better." 4 "The bugs that you see are just the design on the bedspread."

2 "I don't see any bugs on you or your bed." The response "I don't see any bugs on you or your bed" points out reality and does not support the client's hallucinations. The response "Just try to brush them off" supports the client's hallucination and provides false reassurance. The response "They'll go away when you start feeling better" supports the client's hallucination and provides false reassurance. The response "The bugs that you see are just the design on the bedspread" constitutes false information. If the client said that the bugs were only on the bed and the bedspread had a design, then the client might have been experiencing an illusion.

A client who has severe anxiety starts to cry while talking with the nurse. The client is so upset that the crying becomes uncontrollable. What is the best response by the nurse? 1 "Talking about your problem is upsetting you." 2 "It's okay to cry; I'll just stay with you for now." 3 "Sometimes it helps to get it out of your system." 4 "You look upset; let's talk about why you're crying."

2 "It's okay to cry; I'll just stay with you for now." Telling the client that it is alright to cry and offering to stay presents a nonjudgmental attitude that recognizes the client's needs. Pointing out the obvious is unnecessary and not therapeutic. Telling the client that it's good to get it out of the system implies that crying will make the client feel better and therefore is false reassurance. Saying the client looks upset and asking to talk about the client's problem is unrealistic; the anxiety level must be lowered before a discussion can begin.

A nurse is working with a married woman who has come to the emergency department several times with injuries that appear to be related to domestic violence. While talking with the nurse manager, the nurse expresses disgust that the woman keeps returning to the situation. What is the best response by the nurse manager? 1 "She must not have the financial resources to leave her husband." 2 "Most women try to leave about six times before they are successful." 3 "There's nothing the staff can do; people are free to choose their own lives." 4 "These women should be told how stupid they are to stay in that kind of situation."

2 "Most women try to leave about six times before they are successful." Nurses who work with victims of partner abuse need to be supportive and patient. It takes time and several attempts for most victims to leave abusive relationships. It may or may not be true that the client does not have the financial resources to leave her husband; there is not enough information to support this conclusion. The staff can encourage the woman to make plans for addressing various potential events and provide information about social services and telephone help lines. Shaming women in this position will simply make them less likely to seek help.

A client is found to have paranoid schizophrenia, and the healthcare provider prescribes a typical antipsychotic medication. The client is unable to sit or stand still and feels the need to move, pace, rock, swing the legs, or tap the feet What extrapyramidal side effect has developed? 1 Dystonia 2 Akathisia 3 Tardive dyskinesia 4 Pseudoparkinsonism

2 Akathisia Akathisia, an extrapyramidal side effect of typical antipsychotics, is motor restlessness. The client is unable to sit or stand still and feels the need to move, pace, rock, swing the legs, or tap the feet. The condition occurs within 5 to 90 days of the initiation of therapy. Dystonia is muscle spasms of the face, tongue, head, neck, jaw, or back, usually resulting in exaggerated posturing. This extrapyramidal side effect of typical antipsychotics occurs within 1 hour to 1 week of the initiation of therapy. Tardive dyskinesia is facial, ocular, oral/buccal, lingual/masticatory, and systemic movements. This extrapyramidal side effect of typical antipsychotics may occur 6 months or more after the initiation of therapy. Pseudoparkinsonism has characteristics similar to those of Parkinson disease (e.g., shuffling gait, tremors, rigidity, bradykinesia). This extrapyramidal side effect of typical antipsychotics may occur any time after the initiation of therapy.

A client with a diagnosis of paranoid schizophrenia throws a chair across the room and starts screaming at the other clients. Several of these clients have frightened expressions, one starts to cry, and another begins to pace. A nurse removes the agitated client from the room. What should the nurse remaining in the room do next? 1 Continue the unit's activities as if nothing has happened. 2 Arrange a unit meeting to discuss what has just happened. 3 Refocus clients' negative comments to more positive topics. 4 Have a private talk with the clients who cried and started to pace.

2 Arrange a unit meeting to discuss what has just happened. Arranging a unit meeting to discuss what has just happened provides an opportunity for the other clients to voice and share feelings and to identify and separate real from imaginary fears; an open expression of feelings allows the nurse to address clients' fears and provide reassurance. Ignoring the situation denies reality and may precipitate or reinforce feelings of vulnerability and fear in the other clients. Refocusing clients' negative comments to more positive topics denies clients' concerns and could increase their anxiety and fear. Having a private talk with the clients who cried or started to pace may meet the needs of these two clients but ignores the needs of the other clients.

A nurse on the pediatric unit is assigned to care for a 2-year-old child with a history of physical abuse. What does the nurse expect the child to do? 1 Smile readily at anyone who enters the room. 2 Be wary of physical contact initiated by anyone. 3 Begin to scream when the nurse nears the bedside. 4 Pay little attention to the nurse standing at the bedside.

2 Be wary of physical contact initiated by anyone. This child will distrust any approach because approaches by adults commonly result in pain; abused children remain alert in an attempt to ward off an attack. This child will not be open to an approach by a stranger; basic trust of others does not develop in abused children. Abused children will usually not cry out; they learn not to expect comforting or soothing by others. This child will be acutely aware of anyone coming near; abused children try to defend themselves by keeping alert to the possibility of attack.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? 1 Increase in serotonin 2 Deficiency of thiamine 3 Reduction in iron intake 4 Malabsorption of riboflavin

2 Deficiency of thiamine Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism.

A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. What does the nurse remember is the main reason that clients use self-mutilation? 1 Control others 2 Express anger or frustration 3 Convey feelings of autonomy 4 Manipulate family and friends

2 Express anger or frustration Typically, recurrent self-mutilation is an expression of intense anger, helplessness, or guilt or is a form of self-punishment. Self-mutilation is used not to control others but for self-validation; also, it is a means of blocking psychological pain by inducing physical pain. Self-destructive behaviors are not an expression of autonomy but rather an expression of negative feelings of anger, rage, and abandonment. Self-destructive behaviors represent not an attempt to manipulate others but rather a way to blunt emotional pain.

A client who has a history of psychiatric problems, including an antisocial personality disorder, is admitted to the hospital. What typical behavior does the nurse anticipate? 1 Sexual acting out 2 Interpersonal difficulties 3 Diminished contact with reality 4 Compulsive behaviors associated with following rules.

2 Interpersonal difficulties These clients usually have a history of interpersonal difficulties. They are unable to engage in the give-and-take a relationship requires because of their consistent disregard for and exploitation of others. There is no direct relationship between antisocial personality disorders and sexual acting out. These clients are in contact with reality. Compulsive behaviors are typical of clients with obsessive-compulsive disorder, not antisocial personality disorder. These clients typically do not conform to societal rules.

A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" What does the nurse determine that the client is exhibiting? 1 Echolalia 2 Neologism 3 Concretism 4 Perseveration

2 Neologism Neologisms are words that are invented and understood only by the person using them. Echolalia is the verbal repeating of exactly what is heard. Concretism is a pattern of speech characterized by the absence of abstractions or generalizations. Perseveration is a disturbed system of thinking manifested by repetitive verbalizations or motions or by persistent repetition of the same idea in response to different questions.

A client is admitted with the diagnosis of borderline personality disorder and possible depression. The client has a history of abusive acting-out behavior. What is most important to assess when caring for this client? 1 Degree of anger 2 Potential for suicide 3 Level of intelligence 4 Ability to test reality

2 Potential for suicide Depressed clients may use suicide as the ultimate escape from feelings; ensuring safety by protecting the client from self-harm is the priority. Although degree of anger is important, it is not the priority. Assessment of the level of intelligence is unnecessary; clients with a diagnosis of borderline personality disorder are usually of average intelligence. Clients with a diagnosis of borderline personality disorder are more concerned with satisfying their needs than testing reality; they are more concerned about themselves than others or the environment.

A client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention? 1 Encouraging interactions with others 2 Presenting a united, consistent staff approach 3 Assuming a nurturing, forgiving tone in disputes 4 Using seclusion when manipulative behaviors are exhibited

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

Many clients who call a crisis hotline are extremely anxious. The nurse answering the hotline phone remembers what characteristic as distinguishing posttraumatic stress disorders from other anxiety disorders? 1 Lack of interest in family and others 2 Reexperiencing the trauma in dreams and flashbacks 3 Avoidance of situations and activities that resemble the stress 4 Depression and a blunted affect when discussing the traumatic situation

2 Reexperiencing the trauma in dreams and flashbacks Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes posttraumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations and activities that resemble the stress is more common with phobic disorders. Although depression may be generated by discussion of the traumatic situation, the affect is usually exaggerated, not blunted.

What should the nurse do when an adolescent with the diagnosis of anorexia nervosa starts to discuss food and eating? 1 Listen to the client's list of favorite foods and secure these foods for the client. 2 Tell the client gently but firmly to direct the discussion of food to the nutritionist. 3 Use the client's current interest in food to encourage an increase in food intake. 4 Let the client talk about food as long as the client wants and limit discussion about eating.

2 Tell the client gently but firmly to direct the discussion of food to the nutritionist. All food issues should be discussed with the nutritionist, thereby removing a potential source of conflict between the nurse and client. Listening to the client's list of favorite foods and securing these foods will accomplish little, because the client's failure to eat is not based on food likes or dislikes. Using the client's current interest in food to encourage an increased food intake will increase the conflict between the nurse and client. Letting the client talk about food as long as the client wants and limiting discussion about eating may be self-defeating, because a discussion of food will be the major focus of all nurse-client interactions.

The practitioner prescribes a tricyclic antidepressant medication to ease a suicidal client's depression. What factor should the nurse consider when initiating treatment with this type of medication? 1 Eating aged cheese may cause a hypertensive crisis. 2 There may not be a noticeable improvement for 2 to 3 weeks. 3 They must be given with milk to avoid gastrointestinal irritation. 4 Blood specimens are required weekly for 3 months to check for a therapeutic drug level.

2 There may not be a noticeable improvement for 2 to 3 weeks. These drugs do not produce an immediate effect; nursing measures must continue to decrease the risk of suicide. Avoiding aged cheese is a precaution taken with monoamine oxidase (MAO) inhibitors. Giving the medicine with milk is unnecessary. Blood specimens are not necessary; toxicity is not as prevalent a problem with tricyclic antidepressants as it is with medications such as lithium.

A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? Select all that apply. 1 Limiting contact with the abuser 2 Determining a safe place to go in an emergency 3 Memorizing the domestic violence hotline number 4 Obtaining a bank loan to finance leaving the abuser 5 Arranging for a family member to assist her in leaving

2 Determining a safe place to go in an emergency 3 Memorizing the domestic violence hotline number It is important that the client have a safe place to go and a plan for getting there. The client needs to know the hotline number if there is an emergency. It is best to memorize the number because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.

A nurse is implementing interventions to assist an aggressive client in deescalating the agitated behavior. Select all that apply. 1 Physical contact with the client to show caring 2 Encouraging the client to express perceived needs 3 Avoiding verbal struggles in an attempt to demonstrate authority 4 Providing the client with clear options to the unacceptable behavior 5 Referring to the client in an authoritarian manner to demonstrate control of the situation 6 Explaining the expected outcomes if the client is unable to control the unacceptable behavior

2 Encouraging the client to express perceived needs 3 Avoiding verbal struggles in an attempt to demonstrate authority 4 Providing the client with clear options to the unacceptable behavior 6 Explaining the expected outcomes if the client is unable to control the unacceptable behavior Encouraging the client to express perceived needs provides the client with a sense of being heard and respected. Verbal struggling will likely increase the tension and aggressive behavior of the client. Providing options will allow the client to effectively change behaviors if capable of doing so. Explaining outcomes for continued unacceptable behavior allows the client to make a decision to change behaviors if capable of doing so. Touching the client will likely be viewed as aggressive and lead to an increase in the client's agitation. It is important to present a calm, firm persona but avoid being authoritarian, because this will likely lead to a power struggle.

An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? Select all that apply. 1 Demonstrating concern for the injured child 2 Focusing on the child's role in sustaining the injury 3 Changing the story of how the child sustained the injury 4 Asking questions about the injury and the child's prognosis 5 Giving an explanation of how the injury occurred that is not consistent with the injury

2 Focusing on the child's role in sustaining the injury 3 Changing the story of how the child sustained the injury 5 Giving an explanation of how the injury occurred that is not consistent with the injury The child is often made the scapegoat in the situation; the parents blame the child because they have unrealistic expectations of the child. Discrepancies or inconsistencies in the history result from attempts to present a story that is not based in fact. Discrepancies between the parental explanation for the child's injuries and the physical findings or discrepancies in the history that each parent gives are common because the information that is being provided is not based in fact. Abusive parents usually do not ask questions about the injury or prognosis and demonstrate little or no interest in their child's well-being.

A small fire has been set in the dayroom garbage can by a client who is currently demonstrating manic behavior. Place the following nursing interventions in the appropriate order to best ensure client and milieu safety. 1. Activate the unit's fire alarm system. 2. Move all clients to a safe, controlled area. 3. Place the manic client in a quiet environment with low stimulation. 4. Administer appropriate medications as prescribed if indicated.

2,1,3,4 Ensuring the safety of the milieu is the priority. The fire alarm is activated immediately after all clients and staff have been removed from the area of the fire. The next intervention is providing the manic client with a quiet, low-stimulation environment. If the nursing assessment indicates a need for medication to manage the client's behavior, it should then be administered.

A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse? 1 "Okay; we don't have to talk about it." 2 "Why don't you want to talk about it?" 3 "What were you doing yesterday when you first noticed the feeling?" 4 "I understand, but don't be concerned; that feeling probably won't come back."

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

The nurse notices that one of her clients, who has depression, is sitting by the window crying. What is the most appropriate response by the nurse? 1 "It's okay. No need to cry or worry while you're here. We all feel down now and then." 2 "Please don't consider suicide. It really isn't an appropriate way out of your troubles." 3 "You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if you would like." 4 "Why don't you go into the dayroom and join the card game going on? That'll take your mind off of your problems for a while."

3 "You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if you would like." The nurse is acknowledging that the client is feeling especially down and offering to be available for discussion or just to provide a presence. Telling the client not to cry and suggesting a card game do not acknowledge the client's feelings and appear to trivialize the situation. The response regarding suicide is judgmental and may discourage any effort by the client to initiate a discussion.

A nurse, planning care for a client who is an alcoholic, knows that the most serious life-threatening effects of alcohol withdrawal usually begin after a specific time interval. How many hours after the last drink do they occur? 1 8 to 12 2 12 to 24 3 24 to 72 4 72 to 96

3 24 to 72 Alcohol withdrawal delirium, a life-threatening central nervous system response to alcohol withdrawal, occurs in 1 to 3 days, when the blood alcohol level drops as alcohol is detoxified and excreted. Jitteriness, nervousness, and insomnia may occur 8 to 12 hours after withdrawal; these are not life-threatening issues. Nervousness, insomnia, nausea, vomiting, and increased blood pressure and pulse may occur after 12 to 24 hours; these are not life-threatening problems. Withdrawal symptoms will have begun to subside after 72 to 96 hours, and the risk for complications is diminished.

A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? 1 Slow pulse, mild weight loss, and alopecia 2 Compulsive behaviors, excessive fears, and nausea 3 Amenorrhea, excessive weight loss, and abdominal distention 4 Excessive activity, memory lapses, and an increase in the pulse rate

3 Amenorrhea, excessive weight loss, and abdominal distention In anorexia nervosa, weight loss is excessive (15% of expected weight); nutritional deficiencies result in amenorrhea and a distended abdomen. Although pulse irregularities and alopecia are associated with anorexia, weight loss is excessive, not mild. Although compulsive behaviors are common, excessive fears and nausea are not associated with anorexia nervosa. Memory lapses are not associated with anorexia nervosa; excessive exercising and pulse irregularities are.

When working with a client who has a phobia of black cats, what problem does the nurse anticipates for this client? 1 Denying that the phobia exists 2 Anger toward the feared object 3 Anxiety when discussing the phobia 4 Distortion of reality when completing daily routines

3 Anxiety when discussing the phobia Discussion of the feared object triggers an emotional response to the object. People with phobias generally acknowledge their existence. Extreme fear is more of a problem than anger. Distortion of reality related to the daily routine usually is not a problem for a person with a phobia.

A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client? 1 Increased libido 2 Phobic behavior 3 Boundary violations 4 Excessive aggression

3 Boundary violations Clients who have experienced childhood sexual abuse will have difficulty being aware of their personal boundaries and maintaining appropriate boundaries for themselves and others. Clients who have experienced childhood sexual abuse tend to have decreased, not increased, libidos. Phobic behavior, the irrational fear of an object or situation, is not necessarily a concern that the nurse should have for this client more than for other clients. Clients who have experienced childhood sexual abuse can exhibit aggressive behavior, but it does not directly address the identification of inappropriate touching.

A nurse in the mental health unit is working with a group of adolescent girls with the diagnosis of anorexia nervosa. What does the nurse recall is the major health complication associated with intractable anorexia nervosa? 1 Endocrine imbalance causing amenorrhea 2 Decreased metabolism causing cold intolerance 3 Cardiac dysrhythmias resulting in cardiac arrest 4 Glucose intolerance resulting in protracted hypoglycemia

3 Cardiac dysrhythmias resulting in cardiac arrest These clients have severely depleted levels of potassium and sodium because of the starvation diet and energy expenditure; these electrolytes are necessary for adequate cardiac function. Although endocrine imbalance resulting in amenorrhea, slowed metabolism resulting in cold intolerance, and glucose intolerance resulting in protracted hypoglycemia may occur, they are not the major health problem.

A cachectic adolescent with the diagnoses of anorexia nervosa, dehydration, and electrolyte imbalances is admitted to a mental health facility. The adolescent has been obsessed with weight, has exercised for hours every day, has taken enemas and laxatives several times a week, and has engaged in self-induced vomiting. What outcome is a priority for the nurse planning care for this client? 1 Identifying personal strengths 2 Controlling impulsive behaviors 3 Correcting electrolyte imbalances 4 Developing a contract for treatment goals

3 Correcting electrolyte imbalances Electrolyte imbalances can precipitate life-threatening dysrhythmias. Although clients with the diagnosis of anorexia nervosa have low self-esteem, and identifying and supporting strengths promote the development of a positive self-regard, this is not the priority at this time. Clients with anorexia are perfectionists who usually do not display impulsivity. Developing a contract for treatment outcomes is difficult to accomplish initially, because anorexic clients often deny the illness and evade therapeutic treatment.

A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client? 1 Confronting the client about substance abuse 2 Avoiding calling attention to the client's drug abuse 3 Determining the amount and time of last use of the substance 4 Realizing that this client will need more pain medication than a nonabuser

3 Determining the amount and time of last use of the substance Determining the amount and last use of the substance is the priority. Nurses should base their treatment of withdrawal symptoms on the time and amount of last use. Confronting the client is not the nurse's responsibility at this time. The client must be helped to recognize that a problem with drugs exists, but this is not the priority. Because of cross-tolerance the client may need larger doses of analgesia for pain relief than a nonabuser would, but this is not the priority.

What should a nurse do first when managing interpersonal relationships with a client who has schizophrenia? 1 Allow the client to be alone when desired but provide quiet activities. 2 Insist that the client join group meetings and activities with other clients. 3 Establish a one-on-one relationship and then bring the client into group activities. 4 Encourage dependence by the client initially but set limits on the extent of this behavior.

3 Establish a one-on-one relationship and then bring the client into group activities. To improve social function in clients with schizophrenia, the nurse must first work to develop a trusting one-on-one relationship. Clients with schizophrenia will build trust through one-on-one interactions. Clients need interaction to increase trust; they will not seek interactions without encouragement. If forced, these individuals will be too fearful of the group to function in it or benefit by it. Dependency is not encouraged for any capable clients.

The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care? 1 Engages in many rituals 2 Independence of others 3 Exhibits lack of empathy for others 4 Possesses limited communication skills

3 Exhibits lack of empathy for others Self-motivation and self-satisfaction are of paramount concern to people with antisocial personality disorder, and they have little or no concern for others. Clients with obsessive-compulsive disorder, not antisocial personality disorder, engage in rituals. Individuals with antisocial personality disorder are extremely dependent on others; they count on others to extricate them from their problems. They are usually charming on the surface and can easily con people into doing what they want.

A client has the diagnosis of histrionic personality disorder. Which behavior should the nurse expect when assessing this client? 1 Boastful and egotistical 2 Rigid and perfectionistic 3 Extroverted and dramatic 4 Aggressive and manipulative

3 Extroverted and dramatic Clients with histrionic personality disorder draw attention to themselves, are vain, and demonstrate emotionality and attention-seeking behavior. Boastful and egotistical behaviors are typical of clients with the diagnosis of narcissistic personality disorder. Rigid and perfectionistic behaviors are typical of clients with the diagnosis of obsessive-compulsive personality disorder. Aggressive and manipulative behaviors are typical of clients with the diagnosis of antisocial personality disorder.

A client has been hospitalized for 3 weeks while receiving a tricyclic medication for severe depression. One day the client says to the nurse, "I'm really feeling better; my energy level is up." After the encounter an aide tells the nurse that the client has given away a favorite jacket. What should the nurse conclude that the client's statement indicates? 1 Improved mood 2 Improved socialization 3 Increased risk for suicide 4 Heightened need for independence

3 Increased risk for suicide When the energy level improves in the depressed client, the risk for suicide increases; also, the client has given away a personal belonging, which may indicate a plan to commit suicide. Elevated mood may be true, but the gift of a cherished personal belonging decreases the possibility that the client's statement simply reflects an improvement in mood. The client's socialization may be improved, but the gift of a valuable personal belonging decreases the possibility that the act simply reflects an improved level of socialization. Giving something away is unrelated to independence.

Which nursing intervention is most important for a client who has the diagnosis of antisocial personality disorder? 1 Teaching and modeling assertiveness 2 Using a gentle and reassuring approach 3 Providing clear boundaries and consequences 4 Presenting an empathetic and democratic approach

3 Providing clear boundaries and consequences Clients with antisocial personality disorder interact with others through manipulation, aggressiveness, and exploitation; therefore clear limits, with consistently enforced consequences for crossing set boundaries, must be set. These clients can be too assertive; teaching and modeling assertiveness is appropriate for a client with the diagnosis of dependent personality disorder. These clients need a firm, consistent approach with clear and realistic limits on inappropriate behavior; a gentle and reassuring approach should be used with clients who have the diagnosis of avoidant personality disorder. The nurse should provide a neutral, nonemotional approach with clear, realistic boundaries and consequences.

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? 1 Write down conversations to facilitate the recall of information. 2 Monopolize conversations about the anxiety being experienced. 3 Redirect the conversation with the nurse to physical symptoms. 4 Start a conversation asking the nurse to recommend palliative care.

3 Redirect the conversation with the nurse to physical symptoms. Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care.

What should be the nurse's first intervention in the care of a client with a generalized anxiety disorder? 1 Encouraging the client to verbalize feelings of anxiety 2 Having the client list the behaviors used to reduce anxiety 3 Removing as many stimuli from the client's environment as possible 4 Administering as-needed medications prescribed by the primary healthcare provider

3 Removing as many stimuli from the client's environment as possible Removing as many stimuli from the client's environment as possible helps reduce the client's anxiety by limiting the factors that must be confronted; decreasing stimuli usually decreases anxiety. Encouraging the client to verbalize feelings of anxiety will not decrease anxiety and may increase it. The anxiety level must be decreased before the client is asked to discuss coping strategies. Administering as-needed medications prescribed by the primary healthcare provider may or may not be necessary; it is not the first intervention before an assessment is completed.

At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we both mean the same thing." What technique is this an example of? 1 Reflecting feelings 2 Making observations 3 Seeking consensual validation 4 Attempting to place events in sequence

3 Seeking consensual validation Seeking consensual validation is a technique that prevents misunderstanding so the client and the nurse can work toward a common goal in the therapeutic relationship. Reflecting feelings, making observations, and trying to place events in sequence do not provide for clarification or understanding.

When talking with one of the day nurses, a client with the diagnosis of anorexia nervosa states that the day nurses give better care and are nicer than the night nurses. The client also asks a question that the day nurse knows was already answered by one of the night nurses. What conclusion should the nurse make about the client? 1 The client needs assistance in exploring and verbalizing feelings about the night nurses. 2 The client is trying to develop a bond of trust with a staff member that should be supported. 3 The client is trying to divide the staff, and the behavior should be reported to the other staff members. 4 The client has negative feelings about the night nurses, and the nurses should be informed of these feelings.

3 The client is trying to divide the staff, and the behavior should be reported to the other staff members. Clients with anorexia nervosa may use manipulation to divide the nursing staff; sharing this knowledge will be of benefit to the other health team members. The conclusion that the client needs assistance in exploring and verbalizing feelings about the night nurses is counterproductive, because it supports the client's manipulative behavior. The client is trying to manipulate the staff; this is not how trust is established. The conclusion that the client has negative feelings about the night nurses and the nurses should be informed of these feelings is counterproductive, because it supports the client's manipulative behavior.

Naltrexone is used to treat clients with substance abuse problems. In which situation does the nurse anticipate that naltrexone will be administered? 1 To treat opioid overdose 2 To block the systemic effects of cocaine 3 To decrease the recovering alcoholic's desire to drink alcohol 4 To prevent severe withdrawal symptoms from antianxiety agents

3 To decrease the recovering alcoholic's desire to drink alcohol Naltrexone is effective in reducing the risk of relapse among recovering alcoholics in conjunction with other types of therapy. Naloxone, not naltrexone, is used for opioid overdose. Naltrexone is not used to treat the effects of cocaine. Naltrexone is an opioid antagonist. It is not used for antianxiety agent withdrawal.

In addition to hydration during alcohol withdrawal delirium, parenteral administration of lorazepam is prescribed for a client. The nurse knows that this drug is given during detoxification primarily for what purpose? 1 To prevent injury when seizures occur 2 To enable the client to sleep better during periods of agitation 3 To reduce the anxiety tremor state and prevent more serious withdrawal symptoms 4 To quiet the client and encourage cooperation by promoting acceptance of the treatment plan

3 To reduce the anxiety tremor state and prevent more serious withdrawal symptoms Lorazepam potentiates the actions of gamma-aminobutyric acid, which reduces the anxiety and irritability associated with withdrawal. This drug helps reduce the risk of seizures but does not prevent physical injury if a seizure occurs. Although the drug may enable the client to sleep better during periods of agitation, this is not the primary objective of using the drug. The ability of the client to accept treatment depends on readiness to accept the reality of the problem.

A client with the diagnosis of bipolar disorder, manic episode, attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment? 1 Doing a needlepoint project 2 Joining a brief swimming competition 3 Walking around the facility with a nurse 4 Playing a board game with another client

3 Walking around the facility with a nurse Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive and whose attention span is limited. The sense of competition and added stimulation provided by a swimming competition may increase the client's anxiety. The client is too hyperactive to play a board game and may respond with distractibility or aggressiveness toward others.

The nurse is caring for a client with bulimia nervosa. Which outcome criteria are important to discuss with the client? Select all that apply. 1 Resuming menstruation 2 Achieving 85% of ideal body weight 3 Abstaining from binge-purge behaviors 4 Describing a realistic perception of body shape 5 Demonstrating three learned skills for managing stress

3 Abstaining from binge-purge behaviors 4 Describing a realistic perception of body shape 5 Demonstrating three learned skills for managing stress Abstaining from binge-purge behaviors is an appropriate goal for a client with bulimia nervosa. A realistic perception of body shape is an appropriate goal for clients with bulimia nervosa, because they have an obsessive and persistent concern with body shape and weight and experience a distortion of body image. Demonstration of three learned skills for managing stress is an appropriate goal for clients with bulimia nervosa, because they experience stress and anxiety and have limited impulse control. Although clients with bulimia may have menstrual dysfunction, amenorrhea is not expected. This outcome is appropriate for clients with anorexia nervosa. Clients with bulimia may be slightly overweight or slightly below weight for their height. Achievement of 85% of ideal body weight is not an appropriate goal for clients with bulimia nervosa.

A client is hospitalized with social anxiety disorder. The client has a history of exhibiting intense, irrational fear of being scrutinized by others. Which primary anxiolytic medications would be prescribed to the client? Select all that apply. 1 Sertraline 2 Paroxetine 3 Alprazolam 4 Venlafaxine 5 Clonazepam

3 Alprazolam 5 Clonazepam Manifestations of social anxiety disorder include stuttering, sweating, palpitations, dry throat, and muscle tension. Clients with this disorder exhibit intense, irrational fear of being scrutinized by others. Alprazolam and clonazepam are benzodiazepines that are well tolerated in clients, and the benefits are immediate. Sertraline and paroxetine are selective serotonin reuptake inhibitors that are also used in the treatment of social anxiety disorder, but they do not act quickly. Venlafaxine is used to treat posttraumatic stress disorder.

A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? Select all that apply. 1 Increasing high-fiber foods 2 Eating just three meals a day 3 Increasing food intake gradually 4 Limiting mealtime to half an hour 5 Providing privileges for goal achievement

3 Increasing food intake gradually 4 Limiting mealtime to half an hour 5 Providing privileges for goal achievement Food intake should be increased by approximately 200 calories weekly. A gradual increase allows the client to adapt emotionally and physically to the increased volume. Thirty minutes is sufficient time for eating. Extended mealtimes place excessive attention on eating and increase anxiety and conflict. Goals should be set (e.g., gaining 2 lb (0.9 kg) per week and eating 90% of each meal). Behaviors that result in achievement of goals should be rewarded. Goals provide structure, and rewards motivate additional positive behaviors while promoting self-esteem. Consumption of high-fiber foods does not have to be increased. A variety of foods and textures should be eaten. Small, frequent meals should be offered.

A client with schizophrenia who has type II (negative) symptoms is prescribed risperidone. Which outcomes indicate that the medication has minimized these symptoms? Select all that apply. 1 There is less agitation. 2 There are fewer delusions. 3 More interest is shown in unit activities. 4 The client reports that the hallucinations have stopped. 5 The client performs activities of daily living independently.

3 More interest is shown in unit activities. 5 The client performs activities of daily living independently. Apathy is a common type II (negative) symptom; flat affect and lack of socialization are also common. Therefore increased interest in unit activities indicates minimized symptoms. A lack of interest in performing daily self-care activities is a common type II (negative) symptom; performing activities of daily living independently represents a reduction in this symptom. Interest in unit activities is a type I (positive) symptom. Delusions and hallucinations are type I (positive) symptoms.

A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? Select all that apply. 1 Lability of affect 2 Specific food cravings 3 Neglect of personal hygiene 4 "I don't know" answers to questions 5 Apathetic response to the environment

3 Neglect of personal hygiene 4 "I don't know" answers to questions 5 Apathetic response to the environment Clients with depression are uninterested in their appearance because of low self-esteem. "I don't know" answers to questions require little thought or decision making, typical of depression. These clients' sense of futility leads to a lack of response to the environment. With depression there is little or no emotional involvement and therefore little alteration in affect. Clients with depression are uninterested in food of any kind.

A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response? 1 "How do you feel about the voices, and what do they mean to you?" 2 "You're the only one hearing the voices. Are you sure you hear them?" 3 "The health team members will observe your behavior. We won't leave you alone." 4 "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"

4 "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?" Acknowledging that client is hearing voices and that the voices are very real to the client validates the presence of the client's hallucinations without agreeing with them, which communicates acceptance and can form a foundation for trust; it may help the client return to reality. The nurse also needs to assess the content of the voices to determine the risk of self-injury or violence against others. The client's contact with reality is too tenuous to explore what the voices mean. Saying that the client is the only one hearing the voices and asking whether the client is sure the voices are being heard demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe the behavior and that the client won't be left alone is condescending and may impair future communication.

A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After assessing the client, what should the nurse ask? 1 "Exactly when did the weakness begin?" 2 "Is this similar to what you usually experience?" 3 "Would you like to leave the group for a while?" 4 "What emotion were you feeling before you felt the weakness?"

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

A client with a diagnosis of major depression refuses to participate in unit activities, claiming to be "just too tired." What is the best nursing approach? 1 Planning one rest period during each activity 2 Explaining why the staff believes that the activities are therapeutic 3 Encouraging the client to express negative feelings about the activities 4 Accepting the client's feelings about activities calmly while setting firm limits

4 Accepting the client's feelings about activities calmly while setting firm limits Fatigue and apathy are symptoms of depression and should be accepted; however, limits should be set to facilitate participation in unit activities. Planning one rest period during each activity allows the client to manipulate the environment. Explaining why the staff believes that the activities are therapeutic will not change the client's mind about them, and this response does not show an understanding of the client's needs. Encouraging the client to express negative feelings about the activities will reinforce negative feelings about participating in them.

A nurse is providing information about Alcoholics Anonymous (AA) meetings to a client with a history of alcohol abuse. What will be required when the client attends AA meetings? 1 Speaking aloud at weekly meetings 2 Maintaining controlled drinking after 6 months 3 Promising to attend at least 12 meetings yearly 4 Acknowledging an inability to control the alcoholism

4 Acknowledging an inability to control the alcoholism A major premise of AA is that to be successful in achieving sobriety, clients with an alcohol abuse problem must acknowledge their inability to control the use of alcohol. There are no rules of attendance or speaking at meetings, although both actions are strongly encouraged. Maintaining controlled drinking after 6 months is not part of the AA program; this group strongly supports total abstinence for life.

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? 1 Get the client's full name and address. 2 Call for assistance from the psychiatrist. 3 Know some myths and facts about sexual assault. 4 Be aware of any personal bias about sexual assault.

4 Be aware of any personal bias about sexual assault. If nurses are unaware of their biases about sexual assault, they will be unprepared to evaluate objectively and meet the client's needs. Getting the client's full name and address may interrupt communication; information can be solicited later. The nurse should be able to help this client without assistance. Although knowing some myths and facts about sexual assault may be important, it is not the priority.

A nurse is assigned to care for an adolescent who has been admitted to the psychiatric hospital with a diagnosis of anorexia nervosa. What should the nurse's initial intervention be? 1 Scheduling an endocrinology consult because of amenorrhea 2 Confronting those behaviors that reflect an inflated self-importance 3 Arranging for psychotherapy sessions to help develop a desire to accommodate others 4 Developing a contract to achieve a weekly weight gain, with consequences for nonachievement

4 Developing a contract to achieve a weekly weight gain, with consequences for nonachievement Treatment usually includes a contract for weight gain, signed by the client, whereby privileges are revoked if the weight is not gained; the diet and the amount of food eaten are not the focus of care. Menstruation usually ceases because of severe malnutrition, not because of endocrine pathology. These clients have a low self-esteem and usually do not feel important.

A 45-year-old client who recently completed alcohol detoxification reports plans to begin using disulfiram (Antabuse) as part of the alcoholism treatment regimen. What important client teaching does the nurse share regarding this drug? 1 Voluntary compliance with the disulfiram regimen is very high. 2 A single dose of oral disulfiram will be effective for up to 72 hours. 3 Disulfiram may be taken intramuscularly and will be effective for as long as 7 days. 4 Foods, medications, and any topical preparation containing alcohol should be avoided.

4 Foods, medications, and any topical preparation containing alcohol should be avoided. Disulfiram causes unpleasant physical effects when mixed with alcohol. Any substance that contains alcohol may trigger an adverse reaction. Voluntary compliance with the use of disulfiram is often very low because of the negative physical effects experienced by the individual if alcohol is ingested. For disulfiram to be effective, it must be taken orally every day. Disulfiram is not administered intramuscularly.

A client is receiving a monoamine oxidase inhibitor (MAOI). What does the nurse teach the client? 1 It is necessary to avoid the sun. 2 Drowsiness is an expected side effect of this medication. 3 The therapeutic and toxic levels of the drug are very close. 4 Many prescribed and over-the-counter drugs cannot be taken with this medication.

4 Many prescribed and over-the-counter drugs cannot be taken with this medication. MAOIs interact with many other medications to produce harmful side effects. Clients must be taught to check with the prescribing primary healthcare provider before taking any new medications. Photosensitivity has not been reported in clients who are taking MAOIs. Drowsiness is not an expected side effect, but it may occur as an adverse reaction. The therapeutic and toxic levels of the drug are not close for these medications.

A client is undergoing treatment for schizophrenia with antipsychotic drugs. During a client assessment, the primary healthcare provider noticed an increase in body temperature and unstable blood pressure. Which adverse effect of the antipsychotic drug caused this condition in the client? 1 Akathisia 2 Tardive dyskinesia 3 Extrapyramidal symptoms 4 Neuroleptic malignant syndrome

4 Neuroleptic malignant syndrome Neuroleptic malignant syndrome is the adverse effect caused by antipsychotic drugs. The symptoms are fever and unstable blood pressure. Akathisia is the one of the symptoms of pseudoparkinsonism. Tardive dyskinesia is one the adverse effects of antipsychotic drugs. The symptoms of this adverse effect are characterized by involuntary contractions of oral and facial muscles. Extrapyramidal symptoms is one the adverse effects of antipsychotic drugs. The symptoms of this adverse effect are involuntary motor symptoms.

A client with recurrent episodes of depression comes to the mental health clinic for a routine follow-up visit. The nurse suspects that the client is at increased risk for suicide. What is a contributing factor to the client's risk for suicide? 1 Psychomotor retardation 2 Decreased physical activity 3 Deliberate thoughtful behavior 4 Overwhelming feelings of guilt

4 Overwhelming feelings of guilt Overwhelming feelings of guilt contribute to the client's risk for suicide. The client may ruminate over past or current failings, and extreme guilt can assume psychotic proportions. Psychomotor retardation and decreased physical activity are clinical findings associated with depression and usually do not lead to suicide because the client does not have the energy for self-harm. Impulsive behaviors, not deliberate thoughtful behaviors, contribute to the client's risk for suicide.

A client is found to have generalized anxiety disorder. For what behavior should the nurse assess the client to determine the effectiveness of therapy? 1 Participating in activities 2 Learning how to avoid anxiety 3 Taking medications as prescribed 4 Recognizing when anxiety is developing

4 Recognizing when anxiety is developing Recognition of anxiety or symptoms of increasing anxiety is an indication that the client is improving. Avoidance of anxiety is not a good indication of improvement; there is no guarantee that anxiety can always be avoided. Participating in activities and taking medications as prescribed do not indicate improvement or recognition of feelings; the client may be doing what others expect.

A nurse is caring for a group of clients on the psychiatric unit. What clinical findings will alert the nurse that serotonin syndrome has developed in one of the clients? 1 Continuous involuntary movement of the tongue and jaw 2 Extremely high blood pressure with headache and flushing 3 Blurred vision, urine retention, dry mouth, and constipation 4 Restlessness, tachycardia, fever, diarrhea, and altered mental status

4 Restlessness, tachycardia, fever, diarrhea, and altered mental status Restlessness, tachycardia, fever, diarrhea, and altered mental status are related to serotonin syndrome, an excessive accumulation of serotonin that can lead to death if not identified and treated quickly. Continuous involuntary movement of the tongue and jaw is related to tardive dyskinesia, which results from long-term use of an antipsychotic medication. Extremely high blood pressure with headache and flushing indicate a possible hypertensive crisis from the intake of tyramine-containing foods by a client receiving a monoamine oxidase inhibitor antidepressant. Blurred vision, urine retention, dry mouth, and constipation are common anticholinergic side effects of tricyclic antidepressants and some antipsychotic medications.

The serum lithium blood level of a client with a mood disorder, manic episode, is 2.3 mEq/L (2.3 mmol/L). What does the nurse expect when assessing this client? 1 Elevation in mood 2 Nausea, thirst, and fine hand tremor 3 Decrease in manic signs and symptoms 4 Vomiting, diarrhea, and decreased coordination

4 Vomiting, diarrhea, and decreased coordination Vomiting, diarrhea, and decreased coordination are reflective of lithium toxicity. During the active phase of a manic episode, a lithium level of 2.3 mEq/L (2.3 mmol/L) is more than the therapeutic range of 0.8 to 1.4 mEq/L (0.8 to 1.4 mmol/L). An improvement in mood may occur when the therapeutic level is approached early in lithium therapy. Nausea, thirst, and fine hand tremor are common early side effects of lithium treatment. They are not related to lithium toxicity, which is indicated by a 2.3 mEq/L (2.3 mmol/L) lithium level. During the acute phase of mania, the therapeutic serum level of lithium should be between 0.8 and 1.4 mEq/L (0.8 to 1.4 mmol/L). The maintenance therapeutic serum level ranges from 0.4 to 1.0 mEq/L (0.4 to 1.0 mmol/L). A reduction in symptoms is expected when the therapeutic level of lithium is reached.

. A client with bulimia nervosa eats two sandwiches, two salads, and four desserts for lunch. What client behavior should the nurse anticipate after the meal is consumed? 1 Excessive exercise 2 Hoarding of more food for a later binge 3 Active socializing with small groups of clients 4 Withdrawing from the group to go to the bathroom

4 Withdrawing from the group to go to the bathroom Bulimia is characterized by the binge-purge cycle; most clients withdraw from others and vomit after an eating binge. Although some individuals with bulimia may exercise to excess, this is a more common finding with the diagnosis of anorexia nervosa. Although individuals with bulimia may hoard food, this behavior commonly occurs later, when limits are put on their intake. Most individuals with bulimia do not seek support or socialization after a binge, although they may socialize at other times.

The nurse assesses a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? Select all that apply. 1 Passivity 2 Fatigue 3 Anhedonia 4 Grandiosity 5 Talkativeness 6 Distractibility

4 Grandiosity 5 Talkativeness 6 Distractibility Grandiosity, manifested by extravagant, pompous, flamboyant beliefs about the self, frequently occurs during the manic phase of bipolar disorder. As mania increases, the client's rate of speech increases, and speech is delivered with urgency (pressured speech). Clients experiencing manic episodes have difficulty blocking out incoming stimuli, which results in distractibility and responses to irrelevant stimuli. Passiveness is exhibited when clients turn anger inward and show little emotion. It frequently occurs during the depressive stage of bipolar disorder. Fatigue is associated with the depressive stage of bipolar disorder. Anhedonia, an inability to feel pleasure, is associated with the depressive stage of bipolar disorder.

The personality characteristics of a client with an antisocial personality disorder make it difficult for family members to interact and maintain a healthy relationship. What are common characteristics of an antisocial personality? Select all that apply. 1 Aloof 2 Suspicious 3 Perfectionist 4 Irresponsible 5 Manipulative

4 Irresponsible 5 Manipulative People with antisocial personalities are often irresponsible, amoral, and dishonest and do not learn from negative experiences. People with antisocial personalities are often charming and calculating when exploiting others; they show no remorse for hurting others and do not develop insight into predictable consequences. Aloofness is associated with the schizoid personality. Suspiciousness is associated with the paranoid personality. Perfectionism is associated with the paranoid personality.

The healthcare provider prescribes lithium citrate liquid 450 mg twice a day. Lithium citrate is available as 300 mg/5 mL. How many milliliters of lithium solution will the nurse administer? Record your answer using one decimal place. ___ mL

7.5

The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? 1 "I didn't hear anyone talking; come with me to your room." 2 "What you heard was in your head; it was your imagination." 3 "Come to the dayroom and watch television; you'll feel better." 4 "God wouldn't tell you to lie there in the hall. God wants you to behave reasonably."

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

A nurse in a mental health facility is caring for a client with the diagnosis of borderline personality disorder. What should the nurse plan to do to maintain a therapeutic relationship? 1 Be firm, consistent, and understanding, because there is a need for structure. 2 Provide an informal environment, because the client seeks outlets for self-expression. 3 Use an authoritarian approach, because the client must learn to conform to the rules of society. 4 Ignore marked shifts in mood, suicidal threats, and temper displays, because they are short lived.

1 Be firm, consistent, and understanding, because there is a need for structure. Consistency, limit-setting, and supportive confrontation are essential nursing interventions to foster a secure, therapeutic environment. An informal environment is not therapeutic, because it supports impulsive behavior and impedes a change in behavior. The use of an authoritarian approach will increase anxiety, resulting in feelings of rejection and withdrawal. Ignoring the behavior is nontherapeutic and reinforces underlying fears of abandonment.

What therapy has the highest success rate for people with phobias? 1 Desensitization involving relaxation techniques 2 Insight therapy to determine the origin of the fear 3 Psychotherapy aimed at rearranging maladaptive thought processes 4 Psychoanalytic exploration of repressed conflicts of an earlier developmental phase

1 Desensitization involving relaxation techniques The most successful therapy for people with phobias consists of behavior modification techniques involving desensitization. Insight into the origin of the phobia will not necessarily help the client overcome the problem. Psychotherapy aimed at rearranging maladaptive thought processes may increase understanding of the phobia but may not help the client cope with the fear; there is no maladaptive thought process associated with phobias. Psychoanalysis may increase understanding of the phobia but may not help the client cope successfully with the unreasonable fear.

A client with the diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine drug. When the psychiatric daycare center plans a fishing trip, it will be important for the nurse to take which action? 1 Provide the client with sunscreen. 2 Caution the client to limit exertion during the trip. 3 Give the client an extra dose of medication to take after lunch. 4 Take the client's blood pressure before allowing participation in the outing.

1 Provide the client with sunscreen. Phenothiazines commonly cause a photosensitivity that can be controlled with sunscreen. Limiting activity is not a necessary precaution when phenothiazines are prescribed. The medication must be administered as prescribed. Participating in the outing should not negatively affect the client's blood pressure.

A college student is brought to the mental health clinic by parents with a diagnosis of borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply. 1 Impulsiveness 2 Lability of mood 3 Ritualistic behavior 4 Psychomotor retardation 5 Self-destructive behavior

1 Impulsiveness 2 Lability of mood 5 Self-destructive behavior Clients with borderline personality disorder often lead complex, chaotic lives because of their inability to control or limit impulses. Extremes of emotions, ranging from apathy and boredom to anger, may be displayed within short periods. Impulsive self-destructive acts such as reckless driving, spending money, and engaging in unsafe sex often result in negative consequences. Ritualistic behavior is associated with obsessive-compulsive disorders. Psychomotor retardation is associated with mood disorders such as depression.

A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place these interventions in priority order, from the least to the most restrictive. 1. Diversional activities 2. Limit-setting 3. Medication administration 4. Seclusion 5. Restraints

1,2,3,4,5 Diversional activities should be the first intervention attempted, because they do not involve any restriction on client activities and manic clients are easily distracted. Limit-setting should be the next intervention attempted, because it is minimally restrictive. Medication administration, although considered a chemical restraint, is less restrictive than physical restraints or seclusion. Seclusion is more restrictive than medication but less restrictive than restraints. Restraints are the most restrictive intervention in psychiatric nursing.

A client is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. The client's anxiety level is approaching a panic level, and the client's ritual is interfering with work and daily living. Which selective serotonin reuptake inhibitor (SSRI) does the nurse anticipate that the primary healthcare provider may prescribe? 1 Haloperidol 2 Fluvoxamine 3 Imipramine 4 Benztropine

2 Fluvoxamine Fluvoxamine inhibits central nervous system neuron uptake of serotonin but not of norepinephrine. Haloperidol is not an SSRI; it is an antipsychotic that blocks neurotransmission produced by dopamine at synapses. Imipramine is a tricyclic antidepressant, not an SSRI. Benztropine is an antiparkinsonian agent, not an SSRI.

A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam 7.5 mg intramuscularly stat is prescribed. Diazepam is available as 5 mg/mL. How many milliliters will the nurse administer? Record your answer using one decimal place. ___ mL

1.5