psych

On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement?

provide a well balanced liquid diet for the client

The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?

psychomotor agitation

A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take?

redirect the client by offering an activity such as playing card games

While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position?

reinforce reality to the client on the floor an remove him to a quiet space

A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

report any case of suspected child abuse

An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement?

report as suspected child abuse

The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?

reports feeling better and less depressed

An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens?

restlessness and confusion

A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements?

she is projecting her feelings onto the nurse

A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he is being treated for dissociative disorder. Which data are consistent with this diagnosis? (Select all that apply.)

sleepwalking unable to remember who he is exhibits multiple personalities

A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate?

take the clients vital signs and notify the HCP immediately

Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate?

tell me more about these accidents that your child has been having

The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority?

the child will be protected from further harm

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?

the usual activity pattern of each group member

A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make?

what has worked for you in the past

At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make?

yes I will be leading this group. what would you like to accomplish

A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best?

I know these treatments must seem like torture to you, but we want to help you recover

A schizophrenic client who is taking fluphenazine decanoate is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching?

I'm going to have lots of fun at the beach and plenty of time in the sun

A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?

a manic client who has started lithium carbonate treatment

Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

allow the group to handle the problem

A client believes that his health care provider is an FBI agent and that his apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to be prescribed for this client?

antipsychotic

On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorders?

anxiety disorders

A client mumbles out loud whether anyone is talking to her or not, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement?

ask the client how she has previously managed the voices

A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam. When developing the nursing care plan for this client, which intervention would be most important for the nurse to include?

assist client to focus on personal strengths

A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior?

cluster care to allow for brief rest periods during the day

A 25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make?

come with me to your room, and I will sit with you

A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression?

depressed clients may be unaware of guilt feelings and should be encouraged to increase self awareness

Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first?

determine if the client still needs constant observation

Which behavior indicates to the nurse that a client with paranoid ideas is improving?

discusses his feelings of anxiety with the nurse

What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam? (Select all that apply.)

do not combine this medication with alcohol this medication is typically used for short term treatment avoid driving or operating equipment while taking this drug

A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that someone is trying to steal his clothing. What is the correct action for the nurse to take based on the client's complaints?

enroll the client in an exercise class to promote positive activities

The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement?

greet the client by first name during each social interaction

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make?

how can I help you? tell me more about your problems

A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask?

how much alcohol do you consume daily

A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?

identification

A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic?

ill leave your tray here. I am available if you need anything else

The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression?

im not very pretty or likeable

Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.)

importance of adherence to medication regimen signs and symptoms of an exacerbation chronic grief associated with long term illness

The nurse cares for an adolescent with a history of violence who now exhibits signs of sublimation. Which behavior by the adolescent best represents sublimation?

joined a competitive boxing team

The nurse is caring for a client who is taking valproic acid. Which laboratory finding is most important to include in this client's record?

liver function test results

A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor?

low self esteem

A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important?

maintain a balanced diet and adequate exercise

A client who was admitted two days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement?

manipulation is being used to achieve the clients personal goals

A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression?

negative self image

During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization?

no matter what I do, I cannot make the voices go away

A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. Which response is best for the nurse to make?

others have had similar thoughts when under stress

When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.)

oxygen suction equipment crash cart

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take?

prior to giving the next dose, notify the healthcare provider of these symptoms

A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which intervention should the nurse include in this client's plan of care?

provide a structured environment with little stimuli