psych combined

A nurse is working with a patient that has frequent angry outbursts. Which of the following statements is most helpful when working with this patient?

"Anger is a normal feeling and you can use it to solve problems."

Knowing that relationships with others are significant to mental health, the nurse effectively assesses a patient's family relationships through which of the following?

"Describe your relationships with your family."

Knowing that relationships with others are significant to mental health, the nurse effectively assesses a client's family relationships through what? "How many people are in your family?" "Whom are you closest to in your family?" "Describe your relationships with your family." "Do you feel your family helps you?"

"Describe your relationships with your family." The nurse must assess the relationships in the client's life, the client's satisfaction with those relationships, or any loss of relationships. Open-ended questions and statements elicit more descriptive responses from the patient than direct questions. Asking the client to "Describe your relationships with your family" is open-ended, while each of the other listed questions elicits a yes or no answer.

A client will be taking disulfiram (Antabuse) after discharge from an alcohol treatment program. Which of the following statements would indicate that teaching has been effective?

"Drinking alcohol while taking Antabuse can cause dangerous symptoms."

The daughter of a patient with dementia has been the primary caregiver for 5 months. The daughter expresses to the nurse, "At times it is so overwhelming! I feel I do not have a life anymore!" Which of the following is the most helpful response by the nurse?

"Here is the number of a caregiver's support group. How do you think you would feel talking with others in the same situation?"

A 45-year-old physician is admitted to the psychiatric unit of a community hospital. The client is restless, loud, aggressive and resistive during the admission procedure and states "I will take my own blood pressure." The most therapeutic response by the nurse would be: * "Right now, doctor, you are just another client." "If you would rather, doctor. I'm sure you will do it ok." "I am sorry but I cannot allow that. I must take it." "If you do not cooperate, I will get the attendants to hold on."

"I am sorry but I cannot allow that. I must take it."

The nurse is discharging a client with a history of command hallucinations to harm self or other. The nurse provides instructions to the client about interventions for hallucinations and anxiety and determines that the client understands the instructions if the client states: * "I'll go to support group and talk so that I don't hurt anyone." "I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans not to hurt anyone." "My medication won't make me anxious." "I won't get anxious of hear things if I get enough sleep and eat well."

"I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans not to hurt anyone."

An 11-year-old child talks to the school nurse about a single episode of disruptive behavior in class. The child states, "I had a stomachache and felt like vomiting. I couldn't help it. I was just so mad at my dad." The most appropriate response by the nurse would be,

"I can see that you're angry. Let's look at better ways to express it."

A patient approaches the nurse and loudly states, "I'm not putting up with this anymore!" The most appropriate response by the nurse would be which of the following?

"I can see you are angry. Tell me what's going on."

A patient is being discharged from treatment for addiction to cocaine. Which of the following statements made by the patient would cause the most concern for the nurse?

"I can still hang out with my old friends. I am just not going to use."

The nurse employed in a mental hospital is greeted by a neighbor in a local grocery store. The neighbor says to the nurse. "How is Wanda doing? She is my best friend and is seen at your hospital every week." The appropriate nursing response is which of the following? * "If you want to know about her, you need to ask her yourself." "I cannot discuss any client situation with you." "I'm not suppose to discuss this, but because you are my neighbor, I can tell you that she is doing great!" "I'm not suppose to discuss this, but because you are my neighbor, I can tell you that she really has problems!"

"I cannot discuss any client situation with you."

A client who is delusional says to the nurse, "The police were sent to kill me." The nurse's best response is: * "I don't know anything about the police. Do you feel afraid that people are trying to hurt you?" "I don't believe this is true." "The police are not out to kill you." "What makes you think the police were sent to hurt you?"

"I don't know anything about the police. Do you feel afraid that people are trying to hurt you?"

The nurse is assessing the drinking history of a patient being admitted for alcohol abuse. Which of the following statements reflects the most probable patient statement at this time?

"I don't really have a problem with alcohol. I've just been having a streak of bad luck lately."

A married man expresses to the nurse that his wife's frequent nagging angers him. The nurse role plays assertive communication techniques with husband. Which of the following indicates the husband understands how to use assertive techniques effectively?

"I feel unappreciated when you criticize me."

The nurse is co-leading a family therapy group with a patient addicted to alcohol. Which statement made by the wife indicates the need for additional education regarding alcoholism as a family illness?

"I have to call in sick for my husband when he is too hung over to go to work."

A home health nurse is talking to the spouse of a client taking an antidepressant. The spouse says "Now that my husband is responding to the antidepressant, the suicidal risk is over and you can stop making these visits." After analyzing this statement, which of the following is the appropriate nursing response? * "I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions." "I need to continue with my visits. Your comment lacks knowledge that this disease runs in families." "I agree with you. Clients who want to kill themselves are only suicidal for a limited time. No can feel self-destructive forever. "I agree with you. The suicidal threats were really attention seeking. Continuing to visit would reinforce your husbands use of manipulation."

"I need to continue with my visits. Most suicides occur within 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions."

Which of the following questions is best to ask when assessing the client's judgment?

"If you found yourself downtown without money or a car, how would you get home?"

A patient calls the emergency department of the local hospital reporting that after 16 years of heavy drinking he is tired and wants to quit "cold turkey". The best response by the nurse would be:

"Is there a family member that can bring you in right away? It is not safe to stop drinking suddenly without medicine."

The mother of a 6-year-old boy with attention deficit hyperactivity disorder asks to speak to the nurse about her son's disruptive behavior. The nurse would be most therapeutic by saying which of the following?

"It must be difficult to handle your son at home."

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of the client's blood, the client begins to shout "You're all vampires. Let me out of here!" The appropriate nursing response is which of the following? * "I'll leave and come back later for your blood." "What makes you think that I am a vampire?" "It must be frightening to think that others want to hurt you." "I am not going to hurt you; I am going to help you."

"It must be frightening to think that others want to hurt you."

During a nurse-patient interaction, Elsa explains how she lost her job. The nurse responds therapeutically by saying: * "Do not worry, there will still be other opportunities." "Tell me more about your job." "What do you think is the reason for losing your job?" "It must have upset you so much."

"It must have upset you so much."

The caregiver of an Alzheimer's patient reports to the nurse that often the patient will suddenly become angry during meals and nothing seems to calm him down. The nurse teaches the caregiver to use distraction techniques. Which of the following responses would be best to teach as an example of this technique?

"Let's look at what is on television."

A 14-year-old girl is being treated for conduct disorder. She refuses to attend class today, stating that yesterday the other nurse told her she did not have to go to class if she did not want to. The best response by the nurse would be,

"Missing class is against the rules."

A client with moderate Alzheimer's disease is living with her grown daughter. Which of the following statements by the daughter would indicate the need for intervention by the nurse?

"Mother won't let anyone else do anything for her."

A nurse is working with a couple seeking counseling for marital discord. The history indicates the husband was treated for substance abuse 4 years ago and attends AA meetings occasionally. Which of the following statements made by the recovering husband should alert the nurse for the need for further education?

"She gets upset when I hang out with my old buddies on the weekends."

A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight?

"Sometimes I feel like the world would be better off if I were dead, but who doesn't feel like that from time to time?" Insight is characterized as an awareness of one's circumstances; it includes awareness of thoughts, feelings, and behaviors and ability in relation to the thoughts, feelings, and behaviors of others. Presuming that all people feel the world would benefit from their absence suggests a lack of insight. Anger at the perceived incompetence of care providers, apathy about one's bleak future, and expressions of despondency certainly warrant further assessment and treatment, but they do not necessarily indicate a lack of insight.

For the past 5 days, a client has been receiving antidepressant for treatment of a major depressive episode. This morning, the client refuses the medication, stating, "It doesn't help, so what's the use of taking it?" The response by the nurse that would best demonstrate an understanding of the action of this antidepressant would be: * "I'll talk to the physician about increasing the dosage, and that will help." "Sometimes it takes 2 to 3 weeks to seen an improvement." "It takes 6 to 8 weeks for this medication to have an effect." "You should have felt a response by now. I'll notify your physician."

"Sometimes it takes 2 to 3 weeks to seen an improvement."

An 8-year-old with attention deficit hyperactivity disorder is jumping off the bed onto a chair. Initially the best response by the nurse would be,

"Stop that right now."

The daughter of a woman with dementia asks the nurse if the patient will ever be able to live independently again. The most appropriate response by the nurse would be:

"Symptoms of dementia gradually get worse. Unfortunately she will not be independent again."

A client is readmitted to the substance abuse program for the second time in 6 months for alcohol abuse. On admission, he tells the nurse, "I am so ashamed." Which of the following would be the best response by the nurse?

"Tell me what has happened since your last admission."

The nurse is using limit-setting with a child diagnosed with conduct disorder. Which of the following statements reflects the most effective way for the nurse to set limits with the child?

"That is not allowed here. You will lose a privilege. You need to stop."

A client's nursing diagnosis of "risk for self-directed violence" has been identified because of her recent history of cutting and self-mutilation. Which of the following expected outcomes is most appropriate for this client's plan of care during inpatient treatment? "Staff will observe the client for signs of self-mutilation." "The client will refrain from cutting or self-mutilation." "The client will demonstrate better coping skills." "The client will demonstrate resolution of her psychiatric diagnosis."

"The client will refrain from cutting or self-mutilation." An expected outcome is a measurable, client-oriented goal, such as the goal of abstaining from self-harm. "Resolution of her psychiatric diagnosis" and "better coping skills" do not meet these criteria of attainability and measurability. An expected outcome should not be framed in terms of the care providers' actions or interventions.

A mother expresses concern to the nurse that the child's regularly scheduled vaccines may not be safe. The mother states that she has heard reports that they cause autism. The most appropriate response by the nurse is:

"There has been no research to establish a relationship between vaccines and autism."

A client lost control of his behavior, broke a window, and made verbal threats to staff and other clients. The client was placed in mechanical restraints. The nurse will explain the reason for restraints to the client by saying,

"This is a means of keeping you and others safe."

The wife of an alcoholic asks the nurse how to respond to him in a helpful way when he is disruptive in family life. Which of the following is the nurse's best response?

"Try to maintain a normal home environment for yourself and the children."

When dealing with the parents of a child diagnosed with pervasive developmental disorder, which of the following statements would be appropriate?

"Use time-out as a way to control aggressive behavior."

On the second day after admission, a suicidal client asks the nurse, "Why am I being observed around the clock and why is my freedom to move around the unit restricted?" The nurse's most appropriate reply would be: * "Why do you think we are observing you?" "We are concerned that you might try to harm yourself." "What makes you think that we are observing you?" "Your doctor has ordered it and is the one you should ask about it."

"We are concerned that you might try to harm yourself."

Which of the following statements would indicate that medication teaching for the parents of a 6-year-old child with attention deficit hyperactivity disorder (ADHD) has been effective?

"We'll be sure to record his weight on a weekly basis."

When teaching the parents of a child with attention deficit hyperactivity disorder (ADHD), which of the following statements by the parents would indicate the need for further teaching?

"We'll have him do his homework at the kitchen table with his brothers and sisters."

After an angry outburst, the patient is tearful and remorseful. The nurse can be most supportive to the patient through which of the following responses?

"What could you have done when you first started to feel angry?"

A nurse can best assess a patient's ability to use abstract thinking by asking the patient which of the following questions?

"What do I mean when I say, 'Don't sweat the small stuff?'"

After an angry outburst, a patient quickly appears more calm and rational. The nurse approaches the client. Which of the following is the most helpful response to the patient at this time?

"What happened that got you so upset?"

The nurse is performing a cultural assessment on a client admitted with depression. What question would obtain the most detailed assessment information? "What is your definition of health?" "Are you from another country?" "Do you seek help when you are ill?" "Do you believe in medicine men?"

"What is your definition of health?" The nurse is asking an appropriate assessment question with culture in determining a client's health beliefs. The nurse would not assume a client has certain beliefs, such as medicine men, and it is best also not to assume a person with a different ethnicity came from another country- instead the nurse can ask what cultural group a person belongs to. Asking about seeking help will not elicit the best response to health beliefs and behaviors- it is best to ask how illness is defined and what a patient would do to get better if ill to determine this information.

A technique that enhances a communication is illustrated by one of the following statements? * "It is for your own good" "I would like to spend time with you" "I am sure he only meant to help you" "Why do you feel this way?"

"Why do you feel this way?"

A patient with conduct disorder starts yelling at another patient and calling the patient insulting names. Which of the following is the most appropriate response by the nurse?

"Yelling at others is unacceptable. You need to let staff know you're upset."

During a special meeting to discuss the unexpected suicide of a young female client while on a weekend pass, the nurse overhears another client moan softly, "I'm next. Oh, my God, I'm next. They couldn't prevent hers and they can't protect me." It would be most therapeutic for the nurse to respond by saying: * "The other client was a lot sicker than you are." "It's different. The other client was home; you are here." "There is no need to worry. All passes will be canceled for a while?" "You are afraid you will hurt yourself?"

"You are afraid you will hurt yourself?"

During a group discussion regarding the unexpected suicide of a young female client while on a weekend pass, one of the other clients stands up and shouts, "Oh, I know what you're all thinking; you think that I should have known that she is going to kill herself. You think I helped her plan this." The most therapeutic response by the group leader would be: * "Oh, no. We all know you liked her." "Helping another person to plan a suicide would not be healthy." "It will help if you tell us the truth." "You feel we're blaming you for her death?"

"You feel we're blaming you for her death?"

The nurse is interviewing a client who has a diagnosis of panic disorder. Which statement by the nurse indicates the use of summarizing? "You may need to find ways to relax." "You have had several stressful events occur." "I can see that your hands are shaking." "Your stress level seems really high right now."

"You have had several stressful events occur." The nurse is summarizing by stating that several stressful events have occurred. Noting symptoms such as shaking hands relates to objective data. Discussing the stress level is stating the consequence of these events that have occurred versus summarizing the reasons. The nurse statement regarding the need to relax is a solution to the discussion on stress and events causing this instead of summarizing what the client has said.

The nurse is working with a client who has hallucinations and delusions. The client tells the nurse she cannot take a shower because she is waiting for her husband to take her home. Which of the following responses by the nurse is best in this situation?

"You have plenty of time to shower before it's time to go home."

The nurse sits with an elderly, depressed client twice a day, although there is little verbal communication. One afternoon, the client asks, "Do you think they'll ever let me out of here?". The nurse's best reply would be * "Why don't you ask your doctor?" "Why, do you think you are ready to leave?" "You have the feeling that you might not leave?" "Everyone says you're doing just fine."

"You have the feeling that you might not leave?"

A regressed, emotionally disturbed client who has been watching the nurse for a few days suddenly walks up and shouts, "You think you're so damned perfect and good. I think you stink!" The most appropriate response for the nurse to make would be: * "I can't be all that bad, can I." "You seem angry with me." Boy, you're in a bad mood." Stink? I don't understand."

"You seem angry with me."

A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. The best response by the nurse would be,

"You seem angry. Tell me more about how you're feeling."

The patient asks the nurse, "What will happen if I drink while taking Antabuse?" The most accurate response by the nurse would be which of the following?

"You will experience a severe reaction including a throbbing headache and vomiting."

The client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." The therapeutic response by the nurse is: * = "I think we should talk more about your anger with your family." "Well, it sounds like you're being pretty pessimistic. After all, years ago, people died of pneumonia." "Have you shared your feelings with your family?" "You're feeling angry that your family continues to hope for you to be cured?"

"You're feeling angry that your family continues to hope for you to be cured?"

The community health nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse illustrates a therapeutic communication technique for this client? * "Sometimes, I have trouble sleeping too." "Sleeping?" "Go on." "You're having difficulty sleeping?"

"You're having difficulty sleeping?"

A client with a diagnosis of major depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The therapeutic response to the client is: * "I don't see you as a failure." "You've been feeling like a failure for a while?" "Feeling like this is all part of being ill." "You have everything to live for."

"You've been feeling like a failure for a while?"

The parents of an autistic child ask the nurse, "Will my child ever be normal?" The most appropriate response by the nurse would be:

"Your child will probably always have some autistic traits."

The nurse can best reassure an elderly, depressed client who is concerned about many fears that are upsetting and frightening and expresses a feeling of having committed the "unpardonable sin" by stating: * "Your ideas are part of your illness and they will change as you improve." "You know that you are not a bad person." "Your family loves you very much." "You know, those ideas of yours are in your imagination."

"Your ideas are part of your illness and they will change as you improve."

What is characteristic of the environment of a client in seclusion? Select all that apply.

-No furniture except a mattress and a blanket -No hanging devices -Walls are usually padded -No windows A seclusion room has not furniture except a mattress and a blanket. The walls are usually padded. The room is environmentally safe, with no hanging devices, electrical outlets, or windows from which the client could jump. A patient should be under constant observation when secluded.

Milieu therapy is a stable and coherent social organization to facilitate an individual's treatment. Which concept would the nurse most likely include as a key concept? Select all that apply.

-containment -validation -structured interaction -open communication The key concepts of milieu therapy include containment, validation, structured interaction, and open communication. Milieu therapy is the responsibility of the nurse in collaboration with the patient and other health care providers.

What are the first and second most common hallucinations experienced?

1 - Auditory 2 - Visual

What seven questions should the nurse ask a client who has suicidal ideas?

1. Are you thinking about killing yourself? 2. Do you have a plan? 3. How do you plan to kill yourself? 4. How would you carry out this plan? Do you have access to what you need to carry out your plan? 5. Where would you kill yourself? 6. When do you plan to kill yourself? 7. What time of day do you plan on killing yourself?

Assessment of sensorium and intellectual processes includes which of the following?

1. Concentration 2. Memory 3. Orientation

What are the ten aspects of the psychosocial assessment?

1. History (age, developmental stage, cultural considerations, spiritual beliefs, previous history) 2. General Appearance and Motor Behavior (hygiene/grooming, dress, posture, eye contact, any unusual movements/mannerisms, quality and clarity of speech) 3. Mood and Affect (expressed emotions/facial expressions) 4. Thought Process and Content (content, process, clarity of ideas, self-harm or suicidal thoughts or urges) 5. Sensorium and Intellectual Processes (Orientation, confusion, memory) 6. Abnormal Sensory Experiences or Misperceptions (concentration, abstract thinking abilities) 7. Judgement and Insight (judgement, decision-making ability, insight) 8. Self-Concept (personal view of self, description of physical self, personal quality and attributes) 9. Roles and Relationships (current roles, satisfaction with roles, success at roles, significant relationships, support systems) 10. Physiologic and Self-Care considerations (eating habits, sleep patterns, health problems, compliance with meds, ability to perform ADLs)

List the 10 major clinical scales measured by the MMPI-2.

1. Hypochondriasis 2. Depression 3. Hysteria 4. Antisocial personality features 5. Comfort with sexual orientation 6. Paranoia 7. Anxiety 8. Schizophrenia 9. Mania 10. Social introversion

Assessment of suicidal risk includes which of the following?

1. Intent to die 2. Method 3. Plan 4. Reason

5 objective personality assessments listed in textbook

1. Minnesota Multiphasic Personality Inventory (MMPI-2) 2. Milton Clinical Multiaxial Inventory 3. Psychological Screening Inventory 4. Beck Depression Inventory 5. Tenessee Self-Concept Scale

3 projective personality assessments listed in textbook

1. Rorschach Test 2. Thematic Apperception Test 3. Sentence Completion Test

What are some ways in which a nurse can assess a client's ability to concentrate?

1. Spell "world" backward 2. Serial sevens (100, minus 7, minus 7, minus 7 etc) 3. Say the days of the week backward. 4. Give three instructions at one time, then have the client complete the actions. Example: stand up, place your left hand on your head, and stand on one foot.

Identify five questions that the nurse would choose to ask this client initially. Give a rationale for the chosen questions.

1. What is the problem as the client sees it (to gain the client's perception of the situation)? 2. Has the client ever felt this way before (to determine if this is a new occurrence, or a recurrent one)? 3. Does the client have thoughts of harming herself or others (to determine safety)? 4. Has the client been drinking alcohol, using drugs, or taking medication (to assess client's ability to think clearly or if there is impairment)? 5. What kind of help does the client need (to see what kind of help the client wants, e.g., someone to listen, help to solve a specific problem, or as a referral)?

A client receiving lithium carbonate complains of watery stools and difficulty walking. The nurse would expect the serum lithium level to be which of the following? * 1 meq/l 1.8 meq/l 1.3 meq/l 0.7 meq/l

1.8 meq/l

In which year did the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issue a sentinel event alert concerning "intimidating and disruptive behavior" that undermine a culture of safety and lead to errors, decreased patient satisfaction, preventable adverse outcomes, increased health care cost, and loss of qualified personnel?

2008

Which of the following clients would have an increased risk for delirium?

3-year-old child with a temperature of 103.2 °F

At what GAF range would a client be considered a danger to self?

41-50 = suicidal ideation 21 - 30 = suicidal preoccupation 11-20 = suicide attempts without clear expectation of death 1-10 = suicide attempt with clear expectation of death

C

A client is admitted to the psychiatric unit and states, ìI am president of the largest corporation in the world. Everyone comes to me for advice.î The client is exhibiting which of the following? A) Flight of ideas B) Thought broadcasting C) Delusion D) Loose associations

A

A client is being evaluated for dementia. The nurse knows that a client who is able to complete very few tasks is most likely to have A) a greater cognitive deficit. B) A less precise mental status exam. C) more potential for agitation. D) no bearing on mental status.

Which of the following is an accurate definition of a nursing diagnosis?

A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes The North American Nursing Diagnosis Association (NANDA) defines nursing diagnosis as a "clinical judgment about individual, family, or community responses to actual or potential health problems/life processes."

A client tells the nurse, "That man on television is responsible for my being sick." The nurse recognizes that this is an example of: * A hallucination A delusion An illusion Autistic thinking

A delusion

D

A delusion represents a problem in which of the following areas? A) Memory B) Motivation C) Orientation D) Thinking

Mental illness is: * Not treatable A disturbance in the persons thoughts feelings and behavior Always hereditary A state of emotional balance

A disturbance in the persons thoughts feelings and behavior

The client asks the nurse about milieu therapy. The nurse responds, knowing that the primary focus of milieu therapy can be described as which of the following? * A behavioral approach to changing behavior A living, learning, or working environment A form of behavior modification therapy A cognitive approach to changing behavior

A living, learning, or working environment

C

A nurse assesses that a depressed patient is lethargic during the day and does not actively participate in unit activities. The notes from the night shift document that the patient did not sleep well. The most probable interpretation of these data is A) the patient's medications are ineffective. B) the patient is being kept awake at night due to noise on the unit. C) the patient's depressed mood is impairing restful sleep patterns. D) the patient is resisting treatment recommendations to participate in unit activities

B

A nurse can best assess a patient's ability to use abstract thinking by asking the patient which of the following questions? A) ìWhat would you do if you found a wallet containing $100 on the sidewalk?î B) ìWhat do I mean when I say, 'Don't sweat the small stuff?'î C) ìWhat are you going to do next time you hear voices?î D) ìCan you begin with the number 100 and subtract 7, and then subtract 7 again?î

C

A nurse suspects that a patient is abusing alcohol while taking prescribed medications. The nurse plans to educate the patient on the dangers of mixing medicine with alcohol. Which of the following would be the most effective way for the nurse to approach this subject with the patient? A) Firmly inform the patient of the dangers of mixing medications with alcohol. B) Recommend a higher level of care, so the patient can be more closely supervised. C) Emphasize the importance of truthful information using a nonjudgmental approach D) Recognize the patient's right to self-determination and avoid addressing the subject.

C

A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient? A) Stopping abruptly in the middle of expressing himself B) Jumping from one idea to another C) Wandering off the topic and never answering the question D) Excessive and fast talking about an array of ideas

A

A patient reported to the nurse that on his way to the clinic, a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the patient stated, ìI pulled over, of course.î Which of the following was the nurse trying to assess? A) The client's judgment B) The client's insight C) The client's concentration D) The client's self-concept

D

A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect? A) Blunt affect B) Restricted affect C) Broad affect D) Flat affect

Rationalization is exemplified in one of the following situations: * An applicant for a job develops fever on the day of her personal interview A student says: "I did not get good grades because the teacher does not like me." A patient says "I don't like to think about my problems" An unfaithful husband gives a gift to his wife after a heated argument

A student says: "I did not get good grades because the teacher does not like me."

The client who believes everyone is out to get him is experiencing a(n): a. delusion b. hallucination c. idea of reference d. loose association

A.

In her plan of care, nurse Nanno, includes a short-term goal which is one of the following: * Develops problem solving skill Takes the initiative of interacting with other patients Talks with the nurse regularly in a week's time Able to participate in schedule activities

Able to participate in schedule activities

Ability to make associations or interpretations about a situation or comment

Abstract thinking

The nurse is assessing which of the following when he asks the client to interpret a common proverb? Concentration Abstract thinking Concrete thinking Memory

Abstract thinking To evaluate abstract thinking, the nurse can ask the client to interpret a common proverb such as "a stitch in time saves nine." Concrete thinking occurs when a client gives literal translations. The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. The nurse assesses the client's ability to concentrate by asking the client to perform certain tasks such as "Spell the word world backward."

What does the saying "A rolling stone gathers no moss" mean to you?

Abstract thinking ability

A nurse employed in a mental health unit of a hospital is the leader of a group psychotherapy session. The nurse's role in the termination stage of group development is to: * Encourage accomplishment of the group's work Encourage problem-solving Acknowledge the contribution of each group member Encourage members to become acquainted with one another

Acknowledge the contribution of each group member

The nursing instructor asks the nursing student to identify priorities of care for an assigned client. The student correctly identifies the client needs that are the priority by telling the nursing instructor that: * Completing care in a reasonable time frame is the priority Time constraints related to the client's needs are the priority Actual or life-threatening concerns are the priority Obtaining needed supplies to care for the client is the priority

Actual or life-threatening concerns are the priority

A client's outward expression of emotional state

Affect

Which of the following if verbalized by a student nurse needs further education about antipsychotic medications? * Improve thought processes and the behavior of the client with psychotic symptoms Affect dopamine receptors in the brain, thereby increasing the psychotic symptoms The effects of antipsychotic medications will be potentiated when given with other medications acting on CNS Atypical antipsychotics are more effective for the negative symptoms of schizophrenia, such as withdrawal and apathy.

Affect dopamine receptors in the brain, thereby increasing the psychotic symptoms

A client with dementia is unable to recognize ordinary objects, such as a pen or notebook. The nurse recognizes this symptom as

Agnosia

A client with a history of heavy alcohol use, whose last drink was 24 hours ago, is seen in the emergency department. The client is oriented but is tremulous, weak, and sweaty and has some gastrointestinal (GI) symptoms. The nurse recognizes these symptoms as typical of which of the following?

Alcohol withdrawal syndrome

Anger management is likely to be included in the care of patients with which of the following psychiatric diagnoses? (Select all that apply)

Alzheimer's dementia, Schizophrenia, Acute alcohol intoxication

What a culture considers acceptable strongly influences the expression of anger. Which culture-bound syndrome is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects?

Amok

The nurse is developing interventions to promote socialization in a client with moderate dementia. Which of the following would provide a safe and secure environment for the client?

An activity with the nurse

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all the doctors fault. I have done everything that the doctor has asked me to do!" The nurse interprets the client's statements as: * A need to notify the hospital lawyer An expression of guilt on the part of the client An ineffective coping mechanism An expected coping mechanism

An expected coping mechanism

The nurse gives an inaccurate dose of a medication to a client. Following assessments of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administered the inaccurate medication dose understands that: * The error will result in suspension An incident report needs to be a completed and is a method of promoting quality care and risk management The incident will be reported to the board of nursing The incident will be documented in the personnel file

An incident report needs to be a completed and is a method of promoting quality care and risk management

An example of maladaptive use of defense mechanism is: * A short man excels in public speaking An individual resorts to drinking alcohol when under stress to diffuse tension A patient participates in the nurse's ward activities A former drug addict helps in the rehabilitation of drug users

An individual resorts to drinking alcohol when under stress to diffuse tension

If clients do not abide by their diet restrictions while taking a monoamine oxidase inhibitor (MAOIs), it is likely that they will develop: * An occipital headache General rash Severe muscle spasms Sudden, severe hypotension

An occipital headache

Three-year-old Jayvee belongs to what stage of development? * Anal and sensory motor Anal and preoperational Phallic and preoperational Phallic and sensory motor

Anal and preoperational

Data _____ involves thinking about the overall assessment rather than bits of information.

Analysis

Which behavior is characteristic of panic during a crisis? A. Being physically immobile B. Sobbing for no apparent reason C. Difficulties with falling asleep D. Startling to loud noises and touch

Answer: A Being unable to physically move is a psychomotor characteristic of extreme panic during a crisis. Sobbing, difficulties with sleep, and startling are associated with lower levels of anxiety.

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), which behaviors describe an individual with a cluster A personality disorder? A. Odd and eccentric B. Anxious and fearful C. Dramatic and erratic D. Hostile and impulsive

Answer: A Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These clients are odd and eccentric and use strange speech and have impaired relationships. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. These clients are anxious, fearful, tense, and rigid. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. These clients are dramatic, erratic, labile, impulsive, hostile, and manipulative.

According to Peplau's model of the nurse-client relationship, in which phase will most of the client's problem solving occur? A. Working phase B. Preorientation phase C. Orientation phase D. Termination phase

Answer: A During the working phase, goals are met, problems are resolved, and changes in behavior occur. In the preorientation phase, the nurse prepares for the orientation phase. During the orientation phase, trust is the primary focus, goals and contracts are set, and problems are identified. During the termination phase, the nurse and client review accomplishments, reinforce the use of new behaviors, and close the relationship.

Which condition would be a contraindication to electroconvulsive therapy (ECT)? A. Brain tumor B. Type 1 diabetes C. Hypothyroid disorder D. Urinary tract infection

Answer: A ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroidism, or urinary tract infection.

Which primary feeling would the nurse anticipate that clients with bulimia nervosa experience after an episode of bingeing? A. Guilt B. Paranoia C. Euphoria D. Satisfaction

Answer: A Guilt is a primary feeling clients experience after a bingeing episode. A sense of being out of control accompanies the consumption of large amounts of food, resulting in guilt, depression, and disgust with one's self. Paranoia is associated with schizophrenia and paranoid personality disorder, not with bulimia nervosa. After bingeing, a person with bulimia nervosa usually feels guilt rather than euphoria or satisfaction because these clients are aware that the eating pattern is abnormal.

Which intervention is most important when helping clients resolve a crisis situation? A. Encouraging socialization B. Meeting dependency needs C. Supporting coping behaviors D. Suggesting a therapy group

Answer: A In a crisis, the individual often just needs support to regroup and reestablish the ability to cope. Socialization is part of recovery; this is not done during the initial stage of a crisis. Meeting dependency needs is not possible or realistic. People who are experiencing crisis may have difficulty working in a therapy group. After stabilization occurs, an individual may benefit from sharing common experiences with others.

Which principle guides the nurse's role in the maintenance or promotion of the health of older adults? A. There is a strong correlation between successful retirement and good health. B. Thoughts of impending death are common and depressing to most older adults. C. Some of the physiological changes that occur as a result of aging are reversible. D. Older adults can better accept the dependent state that chronic illness often causes.

Answer: A Individuals who can reflect on life and accept it for what it was and who are able to adjust and enjoy the changes retirement brings are less likely to experience health problems, especially stress-related health problems. Most emotionally healthy older adults do not focus on death. The changes of aging are usually not reversible. Dependency often is more threatening to this age group.

While caring for an older adult client, which symptom would require an immediate reassessment of the client's needs and plan of care? A. Memory loss or confusion B. Neglect of self-care C. Increased daily fatigue D. Withdrawal from usual activities

Answer: A Memory loss or confusion would require an immediate reassessment. All are common signs of depression due to the aging process; however, memory loss or confusion requires immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention. Although neglect of self-care can occur, it is not the immediate need. Although increased daily fatigue is important, it does not require immediate follow-up. It is common for clients with depression to withdraw from usual activities, so it does not need immediate reassessment.

Which initial response would the nurse give to a husband who is upset that his wife's alcohol withdrawal delirium has persisted for a second day? A. "I see that you're worried. We're using medication to ease your wife's discomfort." B. "This is expected. I suggest that you go home because there's nothing you can do to help." C. "If you're afraid that she will die, I assure you, very few alcoholics die during detoxification." D. "If you are concerned that she is uncomfortable, I'm sure that she's not in pain."

Answer: A Recognizing the spouse's feelings and explaining therapy help decrease his anxiety. Saying that there is nothing he can do discourages verbalization of concerns and promotes feelings of isolation and helplessness. Talking about death is inappropriate and increases fears. Pain is the client's subjective experience and the nurse would avoid giving false reassurance.

Which medication would the nurse expect to be added to the plan of care of a schizophrenic client exhibiting repetitive tongue smacking and restlessness? Select all that apply. One, some, or all responses may be correct. A. Clozapine B. Venlafaxine C. Haloperidol D. Fluphenazine E. Atomoxetine F. Carbamazepine

Answer: A Repetitive tongue smacking and restlessness are examples of extrapyramidal symptoms, which are common in clients taking first-generation antipsychotics. Clients with these symptoms may be switched to a second-generation antipsychotic, such as clozapine. Venlafaxine is a serotonin norepinephrine reuptake inhibitor (SNRI) typically given for depression. First-generation antipsychotics like haloperidol and fluphenazine block dopamine. This can lead to extrapyramidal symptoms such as acute dystonic reactions, parkinsonism, akathisia, and tardive dyskinesia. Atomoxetine is a norepinephrine reuptake inhibitor (NRI) approved to treat attention-deficit hyperactivity disorder (ADHD) in children 6 years of age and older. Carbamazepine is an anticonvulsant medication used to treat bipolar disorder.

Which primary objective of nursing interventions would the nurse maintain for clients with dementia, delirium, and other neurocognitive disorders? A. Safety within the environment B. Enhancement of psychological faculties C. Participation in educational activities D. Face-to-face contact with other clients

Answer: A Safety within the environment is the primary objective of nursing interventions. Clients with neurocognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other neurocognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. The primary objective is not to participate in education activities or have face-to-face contact with other clients. People with dementia, delirium, and other neurocognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.

The CAGE questionnaire is used to screen the client's use of which substance? A. Alcohol B. Barbiturates C. Hallucinogens D. Multiple drugs

Answer: A The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words (Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

Which quality is the most important tool the nurse brings to the therapeutic nurse-client relationship? A. The self and a desire to help B. Knowledge of psychopathology C. Advanced communication skills D. Years of experience in psychiatric nursing

Answer: A The nurse brings an understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model and contribute to quality of care, but these are secondary to the offering of self and the fundamentals of good communication.

The nurse manager notices that a previously effective nurse appears to be distracted, forgets to document, and rarely completes the workload. Which response would the nurse manager use? A. "Your workflow is usually great, but now you seem distracted. What's going on?" B. "Why are you are so distracted and forgetful? I need to know what's going on." C. "Go ahead and take a break and then come to my office so that we can talk." D. "I've noticed that your performance has slipped. Are you using drugs or alcohol?"

Answer: A The nurse manager starts with an understanding and supportive approach to help the individual self-identify ("What's going on?") and address the problem. "Why" questions are usually avoided, and this particular why question sounds accusatory. Taking a break after the discussion would be more helpful to the nurse if intense emotional content is disclosed. Changes in performance can be associated with substance abuse, but at this point there is insufficient evidence.

Which prescribed treatment would a nurse anticipate for a client with severe, persistent, intractable depression and suicidal ideation? A. Electroconvulsive therapy B. Short-term psychoanalysis C. Nondirective psychotherapy D. High doses of anxiolytic medications

Answer: A The nurse would anticipate electroconvulsive therapy. Electroconvulsive therapy, which interrupts established patterns of behavior, helps relieve symptoms and limits suicide attempts in clients with severe, intractable depression that do not respond to antidepressant medication. The client's depressed mood limits participation in psychoanalysis, which is usually long term; feelings precipitated by therapy may lead to suicidal acting out. Psychotherapy should be directed, not nondirective, toward helping the client learn new coping mechanisms and better ways of coping with problems; the depressed client needs direction to accomplish this. Nondirective psychotherapy would be ineffective. Antianxiety medications (anxiolytic medications) are usually not prescribed for clients with depression.

Which action would the nurse take for a client with bipolar disorder, manic episode? A. Assign the client to a private room. B. Suggest that the client play cards with several other clients. C. Encourage the development of insight through introspection. D. Have the client sit at the communal dining table during meals.

Answer: A The nurse would assign the client to a private room. During the acute phase of mania, care would be focused on maintaining the safety of the client and others and decreasing the client's energy expenditure. A private room protects the other clients and provides privacy for the client. The client is too hyperactive to engage in group activities, like playing cards. Also, manic clients can be overly competitive, which may disturb the other clients. Activities at this time would be solitary or one-on-one with the nurse. Manic clients have flight of ideas (rapid racing thoughts) and are easily distracted. Introspection and the development of insight cannot occur during this phase of the illness. The hyperactive client will not have the self-control to sit long enough to eat a communal meal. The nurse would provide finger foods and other portable foods (e.g., sandwich, fruit, milkshake) and encourage the intake of food with short declarative statements that direct the client to eat (e.g., "Finish your sandwich" or "Eat this banana").

Which consistent approach would the nurse use for a client with an antisocial personality disorder? A. Warm and firm without being punitive B. Indifferent and detached but nonjudgmental C. Conditionally acquiescent to client demands D. Clearly communicative of personal disapproval

Answer: A The nurse would be warm and firm without being punitive. The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. Acting indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. Being conditionally acquiescent to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

Which response would the nurse make to a client with an obsessive-compulsive disorder who on the day of a job interview begins to display compulsive behavior? A. "Going for your interview must be upsetting you. Describe what you're feeling now." B. "It's important for you to overcome your anxiety. You should keep that appointment." C. "Your actions indicate that you want to delay the interview. Do you really want the job?" D. "This interview seems to upset you. Do you think you should look for another kind of job?"

Answer: A The nurse would say, "Going for your interview must be upsetting you. Describe what you're feeling now." The client's behaviors are a defense against anxiety resulting from having to make decisions, which triggers old fears; the client needs support. Noting that it is important for the client to overcome the anxiety and encouraging the client to keep the appointment denies the client's overwhelming anxiety and shows a lack of realistic support. Asking whether the client really wants the job is judgmental; an increase in anxiety does not necessarily mean that the client does not want to attain the goal. The client should be encouraged to work through symptoms, not to avoid risk by looking for another kind of job.

Which action for nutritional needs would the nurse take for a depressed client who has been sitting alone in a chair most of the day and displays no interest in eating? A. Stay with the client during meals. B. Take the client to the dining room. C. Bring the client a tray of finger foods. D. Talk with the client about the importance of nutrition.

Answer: A The nurse would stay with the client during meals. Active support is demonstrated when the nurse sits with the client during meals. Even if taken to the dining room, a depressed client may lack the physical or emotional energy to eat. Finger foods are more effectively given to clients experiencing mania. Discussing the importance of nutrition is too passive an intervention for a depressed client and usually will not stimulate the client to eat.

Which action by the nurse would decrease the risk of injury for a child with oppositional defiant disorder? A. Redirect anger in other ways. B. Assess problem-solving skills. C. Explore home support systems. D. Determine the presence of substance abuse.

Answer: A The nurse would work with the child to learn how to take control of, take responsibility for, and redirect their angry outbursts. Problem-solving skills and presence of substance abuse would be assessed in children with conduct disorders. Home support systems would be explored for children with intermittent explosive disorders.

An older adult says, "I regret so many of the choices I've made during my life." According to Erikson's psychosocial stages of development, which developmental conflict has the client failed to accomplish? A. Ego integrity versus despair B. Identity versus role confusion C. Generativity versus stagnation D. Autonomy versus shame and doubt

Answer: A The sense of ego integrity comes from satisfaction with life and acceptance of what has been and what is. Despair reflects guilt or remorse over what might have been. During puberty adolescents attempt to find themselves and integrate their own values with those of society; an inability to solve conflict results in confusion and hinders mastery of future roles. During early and middle adulthood the individual is concerned with the ability to produce and to care for that which is produced or created; failure during this stage leads to self-absorption or stagnation. Autonomy, the ability to control the body and environment, is developed during the toddler period; doubt may result when the child is made to feel ashamed or embarrassed.

Which characteristic of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior? A. Sets limits B. Has variety C. Is group oriented D. Allows freedom of expression

Answer: A The therapeutic milieu characteristic would be to set limits. Because clients with socially aggressive behavior have poor control, these individuals require a therapeutic environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others, because the client may be unable to control impulses.

A woman accompanied by three young children says that she is seeking help in leaving her husband. He has beaten her for years and has recently started hitting the children. Which action would the nurse take first? A. Arrange for a staff member to watch the children so the mother and nurse can talk. B. Call a facility where the mother and her children will be safe until the crisis is resolved. C. Assess for ambivalence about the decision to leave before making permanent plans. D. Suggest that the husband and wife make an appointment for couples counseling.

Answer: A This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, an action plan can be developed. A safe facility, the client's ambivalence, and couples counseling might be discussed after assessment of the situation.

Which statement demonstrates that a psychiatric nurse has successfully fostered a therapeutic nurse-client relationship? A. "My clients and I are partners in the planning that helps meet their physical and mental health needs." B. "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." C. "Mental health is achieved and maintained when the nurses and the clients exhibit respect and caring for each other." D. "Without a mutually satisfying relationship between nurse and client, achieving mental and physical wellness is very difficult."

Answer: A Today's nurse-client relationship is a partnership that includes the nurse's clinical competence and the client's right to self-determination in decision-making. The development of a true therapeutic relationship is a goal, but when that is not achievable, nursing care is still be provided. Mutual respect and caring are basic elements, but many other factors also have an effect on mental health A truly therapeutic nurse-client relationship provides satisfaction for both nurse and client. If that is not achievable, nursing care is provided to help the client maximize potential in physical and mental health.

According to Erikson's psychosocial stages of development, mastery of which task increases a child's ability to cope with separation or pending separation from significant others? A. Trust B. Identity C. Initiative D. Autonomy

Answer: A Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense of self; this results in identity diffusion and confusion. Without initiative, the individual will experience the development of guilt and feelings of inadequacy. Without autonomy, the individual has little self-confidence, develops a deep sense of shame and doubt, and learns to expect defeat.

Which response is therapeutic for a client who says, "The world is filled with terrible people. Why couldn't one of them get HIV [human immunodeficiency virus] instead of me"? A. "It seems unfair that you should have this disease." B. "I'm sure you really don't wish this on someone else." C. "Maybe you should speak with your religious leader." D. "You can get treatment; HIV is considered a chronic illness."

Answer: A The nurse reflects feelings of unfairness and this encourages the client to express feelings. The nurse avoids judgmental responses (don't wish this) that may create a rift in the nurse-client relationship. Suggesting that the client speak with a religious leader may precipitate guilt feelings or offense. People with newly diagnosed chronic illnesses grieve for their loss of health and should be assisted through the stages of grief.

A client who has alcoholism becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms is the client using? Select all that apply. One, some, or all responses may be correct. A. Projection B. Suppression C. Sublimation D. Identification E. Rationalization

Answer: A & E Clients with alcoholism commonly use projection and rationalization to make reality more acceptable. Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. Rationalization is making acceptable excuses for undesirable behavior. Suppression, sublimation, and identification are not commonly used by clients with an alcohol problem. Suppression keeps uncomfortable thoughts, feelings, and wishes in the subconscious. Sublimation is the rechanneling of anxiety into constructive activities. Identification is the unconscious wish to be like another person.

Which factors would the nurse find in the client history of a young college student with borderline personality disorder? Select all that apply. One, some, or all responses may be correct. A. Impulsiveness B. Lability of mood C. Ritualistic behavior D. Psychomotor retardation E. Self-destructive behavior

Answer: A, B, E Impulsiveness, lability of mood, and self-destructive behavior are all characteristics of a borderline personality disorder. 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.

Which substance is considered addictive in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)? Select all that apply. One, some, or all responses may be correct. A. Alcohol B. Caffeine C. Cannabis D. Gambling E. Hallucinogens F. Antianxiety medications

Answer: All of them Alcohol, caffeine, cannabis, hallucinogens, and antianxiety medications are all considered substances of abuse in the DSM-5. Tobacco, opioids, inhalants, sedatives, hypnotics, and stimulants are also listed. Behaviors are gradually being recognized as addictive. For example, gambling was officially declared a disorder in 2013.

Which type of group is Alcoholics Anonymous (AA)? A. Social group B. Self-help group C. Resocialization group D. Psychotherapeutic group

Answer: B AA is a self-help group of people who meet to attain and maintain sobriety. A social group centers on building interpersonal relationships through participation in mutual activities. A resocialization group centers on increasing social skills that may be diminished or lacking. A psychotherapeutic group treats mental and emotional disorders with the use of psychological techniques and always has a member of the health care profession as its leader.

At which point in the daily routine do clients who experience alterations in perception tend to have more problems with vivid hallucinations? A. Before meals B. After going to bed C. During group activities D. While watching television

Answer: B After going to bed, auditory hallucinations are most troublesome because environmental stimuli are diminished and there are few competing distractions. Meals, group activities, and television provide relatively high and competing environmental stimuli.

The client can no longer recognize familiar objects such as his glasses and toothbrush. Which term describes these assessment findings? A. Apraxia B. Agnosia C. Aphasia D. Amnesia

Answer: B Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the body. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or properly putting on clothing. Aphasia is the term for the loss of language ability; loss is usually progressive. Amnesia is the term for the impairment of memory both recent and remote.

Which description is correct for Alzheimer disease? A. Emerges in the fourth decade of life B. Is a slow, relentless deterioration of the mind C. Is functional in origin and occurs in the later years D. Is diagnosed through laboratory and psychological tests

Answer: B Alzheimer disease is a slow and relentless deterioration of the mind; clients become progressively worse over time. The disease usually appears in people 60 years of age and older. Alzheimer disease is an organic, not a functional, disorder. Diagnostic tools, such as computed tomography scan or positron emission tomography, are used to rule out conditions (e.g., neoplasms), and psychological tests such as the Mini-Mental State Examination are used to determine cognitive decline; however, there are no tests that give a definite confirmation of Alzheimer disease.

In the acute phase of bipolar disorder, manic episode, which biopsychosocial need is the priority? A. Psychological B. Physical C. Intellectual D. Relational

Answer: B During a manic episode, the excessive hyperactivity increases the risk for cardiac collapse, dehydration, nutritional deficiencies, and sleep pattern disruption. The client also has increased risk for physical injury secondary to poor judgment and impulsiveness. The other needs are also important, but during the acute manic phase, it is difficult for the client and the health care team to work on topics that require focus and concentration.

Which speech pattern is a disturbed client displaying when she or he starts to repeat phrases that others have just said? A. Alogia B. Echolalia C. Neologism D. Symbolic speech

Answer: B Echolalia is repetition of another person's remarks, words, or statements. It occurs when individuals are fearful of saying their own words and echo the words of others. Alogia is limited speech. Neologism is when new words are coined or old words take on private symbolic meanings. Symbolic speech is use of symbols to replace direct communication.

When the nurse revises the care plan because the goals have not been met, which phase of the nursing process is being applied? A. Planning B. Evaluation C. Assessment D. Implementation

Answer: B Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.

Which intervention would the nurse use when 2 female clients are found together in bed having sexual relations? A. Ask the health care provider to transfer one of the clients to another unit. B. Adopt a matter-of-fact, nonjudgmental attitude and set limits on the behavior for several days. C. Separate them whenever possible throughout the day and always at night. D. Limit their privileges because their behavior is undesirable.

Answer: B Everyone has the right to his or her sexual orientation and preferences, but limits must be set for behavior in a psychiatric unit. Helping clients deal with their sexuality is therapeutic; if the staff always takes control by transferring clients or separating them, the opportunity to learn socially acceptable behavior is lost. Punishing clients is never therapeutic.

Which characteristic distinguishes post-traumatic stress disorders from other anxiety disorders? A. Lack of interest in family and others B. Reliving the trauma in dreams and flashbacks C. Avoidance of situations that resemble the stress D. Blunted affect when discussing the traumatic situation

Answer: B Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes post-traumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations that resemble the stress is more common with phobic disorders. Blunted affect that occurs during discussion of a traumatic situation is more characteristic of acute stress disorder.

Which intervention would the nurse include when planning continuing care for a moderately depressed client? A. Encourage the client to determine four leisure-time activities. B. Offer the client the opportunity to decide on wearing a green or blue shirt. C. Relieve the client of the responsibility of making any decisions. D. Allow the client time to be alone to decide in which activities to engage.

Answer: B For a moderately depressed client, the nurse would offer the client the opportunity to make a decision to wear a green or blue shirt. Allowing the client to make decisions that can be handled helps improve confidence. The client is depressed, and asking the client to determine four leisure-time activities can result in total inactivity. Relieving the client of the responsibility of making any decisions will demoralize a client who is only moderately depressed. Allowing time for the client to be alone to decide in which activities to engage would be overwhelming for a moderately depressed client; this decision allows too many options.

Which type of sexual disorder describes a client who has a sexual obsession with shoes? Select all that apply. One, some, or all responses may be correct. A. Sexual sadism B. Fetishistic C. Pedophilic D. Voyeuristic E. Frotteuristic F. Exhibitionistic

Answer: B Having a fetish is to become sexually aroused by something that would not be typically arousing. A fetishistic disorder is characterized by a sexual focus on objects (such as shoes, gloves, pantyhose, and stockings) that are intimately associated with the human body. Sadism is achievement of sexual satisfaction from the physical or psychological suffering (including humiliation) of a victim. Pedophilic disorder is a predominant or exclusive sexual interest toward prepubescent children. Voyeurism is characterized by seeking sexual arousal through the viewing (usually secret) of other people engaged in intimate situations. Rubbing or touching a non-consenting person is frotteuristic disorder. Exhibitionistic disorder involves the intentional display of the genitals in a public place.

For a hyperactive, manic client who exhibits flight of ideas, which rationale explains why the client is not eating? A. Feels undeserving of the food B. Is too busy to take time to eat C. Wishes to avoid others in the dining area D. Believes that the food is poisoned

Answer: B Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

Which intervention would the nurse use when the roommate reports that the client is masturbating at night and demands another room? A. Move the roommate who made the report to another room. B. Provide the client who is masturbating with periods of private time. C. Tell the roommate that the client has the right to engage in sexual activity. D. Encourage the client who is masturbating to discontinue the behavior.

Answer: B Masturbating is a healthy human sexual behavior. The client should be provided with private time. Moving the roommate to another room could be ineffective because this may happen with the client's future roommate. The client has the right to meet physical needs, but other clients also have rights that should be respected.

Which technique would the nurse recommend to a client who reports racing thoughts that are difficult to control in periods of stress? A. Humor B. Meditation C. Guided imagery D. Progressive muscle relaxation

Answer: B Meditation is a practice that helps quiet the mind and could be especially helpful for this client. It helps reduce the internal dialogue that can cause stress. Humor, although a good technique, does not specifically address racing thoughts. Guided imagery and muscle relaxation are helpful for producing relaxation in the body but may not address racing thoughts as well as meditation does.

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease? A. Physical contact will increase dependency needs. B. Routines provide stability for clients with neurocognitive disorders. C. Regressive behavior should be interrupted immediately. D. Procedures do not have to be explained to clients with neurocognitive disorders.

Answer: B Routines provide stability for clients with neurocognitive disorders. Rituals and routines in activities of daily living provide a framework and structure for clients with Alzheimer disease, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency, and touch may have to be used judiciously depending upon the stage of Alzheimer disease. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood by clients with Alzheimer disease.

Which of these questions is included on the CAGE screening test for alcoholism? A. "Do you feel that you are a normal drinker?" B. "Have you ever felt bad or guilty about your drinking?" C. "Are you always able to stop drinking when you want to?" D. "How often did you have a drink containing alcohol in the past year?"

Answer: B The CAGE screening test for alcoholism contains four questions corresponding to the letters CAGE: Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (as an " Eye-opener") to steady your nerves or get rid of a hangover? "Do you feel that you are a normal drinker?" and "Are you always able to stop drinking when you want to?" are two of the 26 questions on the Michigan Alcohol Screening Test (MAST). "How often did you have a drink containing alcohol in the past year?" is one of the 10 questions on the Alcohol Use Disorders Identification Test (AUDIT).

An individual is found unconscious and is admitted to the hospital with heroin overdose. Which nursing action is the priority? A. Monitoring level of consciousness B. Establishing a patent airway C. Monitoring for heroin withdrawal D. Establishing a therapeutic relationship

Answer: B The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Monitoring level of consciousness would be the next priority. Symptoms of heroin withdrawal will occur 6 to 8 hours after the last dose if the client has a physical addiction. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.

Based on Erikson's psychosocial stages of development, which task must a 30-year-old client work through? A. Integrity versus despair B. Intimacy versus isolation C. Industry versus inferiority D. Identity versus role confusion

Answer: B The major task of the young adult is to develop close, sharing relationships that may include a sexual partnership; the person develops a sense of belonging and avoids isolation (intimacy versus isolation). During the integrity-versus-despair stage, the adjusted older adult can look back with satisfaction and acceptance of life and resolve the inevitability of death; failure at these tasks results in despair. The middle school-aged child gains a sense of competence and self-assurance as social interactions and academic pursuits are mastered; failure in these tasks leads to feelings of inferiority. During adolescence the individual develops a sense of self, self-esteem, and emotional stability; failure to establish self-identity results in a lack of self-confidence and difficulty with occupational choices.

Which intervention would the nurse use for a client with schizophrenia who is experiencing hallucinations? A. Advocate for client's admission to institutional care. B. Acknowledge that the client's experience is real for him. C. Prepare the client for electroconvulsive therapy. D. Advise the family to act normally around the client.

Answer: B The nurse accepts the client and the client's fears to facilitate effective communication. Today mental health therapy is directed toward returning the client to the community as rapidly as possible. Electroconvulsive therapy is not the treatment of choice for clients with schizophrenia. Family's behavior and interaction with the client should be assessed first. Based on that assessment, the nurse may decide to teach the family how to respond when the client is actively hallucinating.

Which question to help reduce anxiety would the nurse ask a client who is pacing the floor and appears extremely anxious? A. "Are you feeling upset right now?" B. "Shall we walk together for a while?" C. "Are you the type to work out?" D. "Shall we sit and talk about your feelings?"

Answer: B The nurse would ask, "Shall we walk together for a while?" The nurse's presence may provide the client with support and feelings of control and allow the client to use large muscle groups to release some of the anxiety. "Are you feeling upset right now?" is premature. The client may just be extremely anxious. Although working out may help release excess energy from the anxiety, asking the client if he or she is "the type to work out" can be demeaning. The client is too distraught to sit; to be therapeutic, the nurse would be where the client is.

Which action would the nurse take for a client with borderline personality disorder? A. Provide an unstructured environment to promote self-expression. B. Be firm, consistent, and understanding while focusing on specific target behaviors. C. Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. D. Record but ignore marked shifts in mood, suicidal threats, and temper displays because these are attention-seeking behaviors.

Answer: B The nurse would be firm, consistent, and understanding while focusing on specific target behaviors. Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with borderline personality disorder. To be therapeutic, the environment needs structure, and the staff must help the client set short-term goals for behavioral changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings of rejection and withdrawal. Ignoring the client's behavior is nontherapeutic and may reinforce underlying fears of abandonment.

Which type of delusion would the nurse chart about a client who says, "I've figured out how foreign agents have infiltrated the news media. Now they want to shut me up"? A. Nihilistic B. Persecution C. Control D. Grandeur

Answer: B The nurse would chart about delusions of persecution. Thoughts of being pursued by powerful agents because of one's special attributes or powers are fixed false beliefs and are referred to as delusions of persecution. There is no evidence to indicate that there are nihilistic delusions of total or partial nonexistence. There is also no evidence to support that external forces are controlling the client (delusions of control) or that the client has false beliefs of being a famous figure (delusions of grandeur).

Which activity would the nurse include in the plan of care for a client with vascular neurocognitive disorder? A. Reeducation program B. Supportive care interventions C. Introduction of new leisure-time activities D. Involvement in group therapy sessions

Answer: B The nurse would include supportive care interventions in the plan of care. Damaged brain cells do not regenerate. Care is directed toward preventing further damage and providing protection and support for vascular neurocognitive disorders. The deterioration of the brain cells makes plans for a reeducation program unrealistic. A client with this disorder may not be able to grasp, understand, or enjoy new leisure activities. It is beyond the scope of the client's ability to function in a group therapy session.

Which action would the nurse take when caring for a client who is experiencing a paranoid delusion? A. Touch the client's arm gently to convey concern. B. Maintain eye contact when talking with the client. C. Attempt to disprove the client's delusional thoughts. D. Speak softly when talking with others near the client.

Answer: B The nurse would maintain eye contact when talking with the client. Eye contact focuses the client's attention on the nurse; it also conveys caring and tells the client that the nurse considers the client important. The nurse would respect the client's personal space; touching the client, particularly without warning, may reinforce suspicious thoughts or precipitate agitation. Attempting to disprove the client's delusional thoughts is useless, because a delusion is real to the client. Whispering or laughing in the presence of a paranoid delusional client may reinforce the delusional state and further agitate the client.

In comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? A. Memory impairment B. Abrupt onset of symptoms C. Difficulty making decisions D. Inability to use words to communicate

Answer: B The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Memory impairment and difficulty making decisions may or may not be a symptom of vascular dementia; it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment and difficulty with decision-making, but not abruptly. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

Which communication pattern is defined as confabulation? A. The flow of thoughts is interrupted. B. Imagination is used to fill in memory gaps. C. Speech flits from one topic to another. D. Statements are too loose to understand.

Answer: B Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting from one topic to another with no apparent meaning is the definition of flight of ideas. In associative looseness, the connections between statements are so loose that only the speaker understands them.

A client says, "Sky, flower, angry, green, opposite, blanket." Which term describes this type of communication? A. Echolalia B. Word salad C. Confabulation D. Flight of ideas

Answer: B Word salad is an incoherent mixture of words. Echolalia is a pathological repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic.

Which functions are registered nurses (RNs) legally permitted to perform in a mental health hospital? Select all that apply. One, some, or all responses may be correct. A. Psychotherapy B. Health promotion C. Case management D. Prescribing medication E. Treating human responses

Answer: B, C, & E Health promotion, case management, and treating human responses are all within the legal scope of RN practice. RNs may use counseling interventions but may not perform psychotherapy; the members of the nursing team permitted to perform psychotherapy are psychiatric/mental health clinical nurse specialists and psychiatric/mental health nurse practitioners. Only those who are legally licensed to prescribe medications, such as psychiatric nurse practitioners, may do so.

Which signs and symptoms would the nurse observe in a client experiencing alcohol withdrawal? Select all that apply. One, some, or all responses may be correct. A. Fatigue B. Anxiety C. Runny nose D. Diaphoresis E. Psychomotor agitation

Answer: B, D, & E Anxiety, diaphoresis, and psychomotor agitation all occur with alcohol withdrawl. Anxiety is commonly associated with withdrawal from alcohol. When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system, resulting in excited motor activity (psychomotor agitation). Fatigue is associated with withdrawal from caffeine or stimulants. A runny nose and tearing of the eyes are associated with withdrawal from opioids.

Which intervention would the nurse use to prevent injury to others when caring for a client with intermittent explosive disorder? Select all that apply. One, some, or all responses may be correct. A. Administer antipsychotics. B. Set limits and expectations. C. Use seclusion and time out. D. Provide structure and boundaries. E. Ignore attention-seeking behaviors.

Answer: B, D, & E When caring for clients with intermittent explosive disorder, interventions to promote safety and prevent injury to others include setting limits and expectations, providing structure and boundaries, and ignoring attention-seeking behavior. Antipsychotics and seclusion are used only as last-resort measures.

Which clinical manifestations would the nurse observe in an older client with major depressive disorder? Select all that apply. One, some, or all responses may be correct. A. Loss of memory B. Decreased appetite C. Neglect of personal hygiene D. "I don't know" answers to questions E. "I can't remember" answers to questions

Answer: BCDE The nurse would observe decreased appetite, neglect of personal hygiene, "I don't know" answers, and "I can't remember" answers. Clients with depression usually have decreased appetite. Neglect of personal hygiene is associated with depression because of low self-esteem. People who are depressed do not have physical or emotional energy; "I don't know" and "I can't remember" answers require little thought or decision-making. Depression does not cause loss of memory.

Which approach is best to use with a client who is angry and agitated? A. Confront the client about the behavior. B. Turn on the television to distract the client. C. Maintain a calm, consistent approach with the client. D. Explain to the client why the behavior is unacceptable.

Answer: C Consistency allows the client to predict the nurse's behavior and a calming approach helps decrease agitation. Confronting the client may escalate anger and agitation. Environmental stimulants should be decreased, not increased. An agitated client cannot attend to logical explanations and perceived criticisms should be avoided.

A client had a first-trimester abortion and has been unable to function for 3 months. Which type of grief is the client experiencing? A. Complex bereavement B. Anticipatory C. Disenfranchised D. Complicated

Answer: C Disenfranchised grief is grief over a loss that is not a socially recognized relationship. Grief after an abortion or death of a pet are examples of disenfranchised grief. Complex bereavement is a prolonged (longer than 12 months) and dysfunctional grieving. In anticipatory grief, the loss is expected or predictable so there is an opportunity to work through a part of the grief process before death. Complicated grieving occurs when there is a failure to progress through the grief process. There is preoccupation about the deceased, accompanied by depression, anger, and feelings of emptiness.

Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech? A. Touch B. Silence C. Focusing D. Summarizing

Answer: C Focusing is used when a client rambles or jumps from topic to topic; the intended meaning is easier to understand if the client focuses on one specific aspect. Touch invades the client's space and could increase anxiety, which increases pressured speech. Use of silence allows the client to continue rambling. Until the concern is identified and explored, summarizing is impossible.

The nurse advises a client with anxiety to focus on a positive scene. Which relaxation technique is the nurse using? A. Meditation B. Biofeedback C. Guided imagery D. Progressive muscle relaxation

Answer: C Guided imagery is the process of using pleasant images to help reduce stress and anxiety levels. Biofeedback uses precise measurements of specific indicators to help users learn to control them. Meditation is a discipline that trains the mind to produce calm and insight into one's life. It involves concentrating on a specific object or sound, such as breathing or a flickering candle, to quiet the mind. Progressive muscle relaxation is the deliberate tensing and relaxing of specific muscles to elicit the relaxation response.

Which nursing intervention is the most therapeutic to help a late-middle-age individual cope with the emotional aspects of aging? A. Focusing on the individual's past experiences B. Scheduling the individual to attend lectures on aging C. Assisting the individual with plans for the future D. Encouraging the individual to focus on her or his career

Answer: C Helping an individual maintain an interest in the future is therapeutic. It is forward looking and fosters a positive attitude. Focusing on the individual's past experiences is appropriate for an older adult, not a late-middle-age adult. Lectures may or may not include emotional aspects of aging; also, the client should express an interest in attending lectures. Encouraging the individual to focus on her or his career does not address concerns about the future.

Which factor would precipitate a client's use of confabulation? A. Ideas of grandeur B. Need for attention C. Marked memory loss D. Difficulty in accepting the diagnosis

Answer: C Marked memory loss precipitates a client's use of confabulation. A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not precipitate use of confabulation. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. The individual uses confabulation as an attempt to mask memory loss, not because of difficulty in accepting the diagnosis.

Which disorder is defined as a preoccupation with the fear of having a serious disease? A. Conversion disorder B. Somatization disorder C. Hypochondriac disorder D. Body dysmorphic disorder

Answer: C Preoccupation with fears of getting or having a serious disease is called hypochondriasis. The condition usually exists for 6 months or longer, persists despite negative medical tests and reassurance, and results in social or occupational impairment. Conversion disorder is characterized by the presence of 1 or more symptoms related to a neurological problem that has no organic cause. Somatization disorder is characterized by the reporting of many physical problems by the client, usually beginning before age 30; physical problems may include pain, gastrointestinal symptoms, sexual or reproductive problems, and at least 1 symptom that suggests a neurological disorder. Body dysmorphic disorder is characterized by preoccupation with some imagined defect in appearance that causes marked distress and significant impairment in social and occupational function.

The nurse says, "Let's see whether we both mean the same thing." Which communication technique is the nurse using? A. Reflecting feelings B. Making observations C. Seeking consensual validation D. Placing events in sequence

Answer: C 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 and making observations are therapeutic techniques, but the nurse must make a best-guess interpretation about the client's feelings and actions. Placing events in sequence helps the nurse and client organize information. Reflection, observations, and sequencing still require consensual validation.

When discussing standards for involuntary admission to a mental health facility, which factor is related to safety? A. Mental illness B. Severe disability C. Currently cutting D. Needs treatment

Answer: C The client who is a danger to others or to himself or herself is a safety factor that would necessitate involuntary admission to a mental health facility. This would include the client who is cutting. Having a mental illness, a severe disability, and an inability to know that treatment is required are reasons for involuntary admission but are not safety factors.

Which defense mechanism is a client displaying when the client can no longer remember why an event was stressful, even though it happened just 3 days ago? A. Denial B. Regression C. Repression D. Dissociation

Answer: C The client's inability to recall is an example of repression, which is the unconscious and involuntary forgetting of painful events, ideas, and conflicts. Denial is an unconscious refusal to admit an unacceptable situation. Regression is a return to an earlier, more comfortable developmental level. Dissociation is the separation and detachment of emotional affect and significance from an idea, situation, or incident.

The nurse is working with a client who is crying and very upset. The client states, "I don't want to talk about it; it is too painful." Which question would the nurse ask to obtain the most information about the client's safety? A. "Is there anyone I can notify of your condition?" B. "Have you ever thought about going to a safe house?" C. "Do you feel that your life is in danger where you live?" D. "Do you belong to any churches in the area that could help?"

Answer: C The nurse would ask about safe living conditions to determine if the client feels his or her life is in danger in the home. The questions regarding asking about notifying someone of the client's condition and about church membership will assess situational support systems. Asking about going to a safe house would be appropriate if the client is found to be in actual danger.

Which approach would the nurse take for a client with hallucinations who suddenly rises and shouts, "Stop saying that. Who do you think you are"? A. Explaining to the client that ignoring the voices will make them disappear B. Taking the client to the client's room for a quiet place to think away from other clients C. Telling the client that the voices are not heard by the nurse, then offering to listen to music together D. Pointing out to the client the inappropriateness of the behavior in a nonthreatening, nonjudgmental manner

Answer: C The nurse would tell the client that the nurse does not hear the voices and then offer to listen to music together. Telling the client that the nurse doesn't hear the voices and offering to listen to music together presents the reality of the situation and helps distract the client during a threatening hallucination. Telling the client to simply ignore the voices is not therapeutic. It will be difficult for the client to do this. Taking the client to the client's room encourages withdrawal and isolation and will not stop the hallucination. Pointing out the inappropriateness of the client's behavior will have little effect on it and will not stop the hallucination.

Which defense mechanism are the parents displaying when have a bitter argument immediately after being told that their child has acute myelogenous leukemia? A. Denial B. Projection C. Displacement D. Compensation

Answer: C The parents are focusing their feelings about their child's prognosis on someone or something else—in this case, each other. Denial is ignoring, avoiding, or refusing to recognize painful realities. Projection is the attribution of one's own feelings to another person. Compensation is making up for a perceived deficiency by emphasizing another feature perceived as an asset.

Which behavior is most commonly used by an individual with a phobic disorder? A. Rumination B. Desensitization C. Avoidance D. Confrontation

Answer: C The person transfers anxieties to activities or objects, usually inanimate objects, which are then avoided to decrease anxiety. Rumination (continuously rethinking about an issue) is more common in depression. Desensitization is a therapy that is used to treat phobias by systematically exposing the individual to the phobic object using a series of small steps. People with phobias fear confrontation with the phobic object and are less likely to attempt this without the help of a therapist.

Which primary symptom would the nurse assess for in a boy who has encopresis? A. Practicing self-mutilation B. Practicing self-induced vomiting C. Passing feces either voluntarily or involuntarily into inappropriate places D. Passing urine either voluntarily or involuntarily into inappropriate places

Answer: C The primary symptom the nurse would observe in encopresis is passing feces either voluntarily or involuntarily into inappropriate places. Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-mutilation; self-mutilation occurs in borderline personality disorder. Encopresis does not involve self-induced vomiting; self-induced vomiting occurs with eating disorders. The passage of urine into inappropriate places is called enuresis.

A woman with five children and multiple facial injuries says, "My husband is an alcoholic, and he just beat me up." Which intervention would the nurse use? A. Report her statements and injuries to the police. B. Refer her to a community legal aid program. C. Inquire about her and the children's safety. D. Discuss taking the children and leaving the husband.

Answer: C The safety of the victim and the children must be assessed, because research shows that children of an alcoholic parent are commonly abused. If the nurse suspects child abuse, a report must be made to child protective services. State laws determine whether the police must be contacted. Referring to legal aid and discussions of leaving are premature; these actions can precipitate abuse if the husband finds out.

Which portion of the nervous system is primarily responsible for the clinical manifestations that occur during a crisis? A. Central nervous system B. Peripheral nervous system C. Sympathetic nervous system D. Parasympathetic nervous system

Answer: C The sympathetic nervous system reacts to stress by releasing epinephrine, which prepares the body to fight or flee by increasing the heart rate, constricting peripheral vessels, and increasing oxygen supply to muscles. Although the central nervous system (brain) responds to stress, it is the sympathetic nervous system that is primarily affected. The peripheral nervous system includes the sympathetic and parasympathetic nervous systems; however, the sympathetic nervous system is primarily affected, and the parasympathetic nervous system does not play a role in the fight-or-flight reaction. The parasympathetic nervous system has the opposite effects of the sympathetic nervous system.

An older client who has been taking lorazepam for several years is scheduled for a procedure that requires the client to be awake for the duration. The client has a history of violence and hypotension. Which antipsychotic medication is appropriate to administer to the client during the procedure? Select all that apply. One, some, or all responses may be correct. A. Loxapine B. Risperidone C. Haloperidol D. Perphenazine E. Olanzapine IM F. Chlorpromazine

Answer: C, D Haloperidol and perphenazine are the most appropriate medications. Loxapine is available only through a restricted program and would not be suitable for this client. Risperidone can cause hypotension with reflex tachycardia and carries a risk of stroke among older adult clients. Olanzapine IM should be avoided with lorazepam and also raises the risk of stroke in older adults. Chlorpromazine is very sedating.

The nurse manager is educating a group of nurses regarding older adults and the risk for suicide. Which factors would be included in this presentation? Select all that apply. One, some, or all responses may be correct. A. Spiritual beliefs B. Presence of family C. Loss of independence D. Chronic health conditions E. Access to many medications

Answer: C, D, & E Older adults, especially men over the age of 65, are at increased risk for committing suicide. Risk factors include loss of independence, presence of chronic health conditions, and access to large amounts of medications. Positive factors that decrease the risk for self-harm include spiritual beliefs and presence of family in the life of the older adult.

Which intervention would provide comfort to the client experiencing alcohol toxicity? A. Dim the lights. B. Use distraction. C. Offer activities. D. Stay with the client.

Answer: D Agitation and anxiety are common in clients experiencing alcohol toxicity. Staying with the client as much as possible will help decrease their anxiety and provide the opportunity to reorient them as needed. Dimming the lights may place the client at risk for injury due to their impaired judgment and lack of coordination. Distraction and activities are not appropriate nursing interventions at this time.

A young college student smiles and angrily says, "If my girlfriend's pregnancy test is positive, I'll drop out of school, marry her, and get a full-time job." Which term would the nurse use to document the client's verbal and nonverbal behaviors? A. Double-bind message B. Mixed message C. False reassurance D. Incongruent message

Answer: D Although the client's facial expression suggests happiness, the client's tone of voice gives the message of anger; the behaviors are incongruent. A double-bind message occurs when a person in power uses 2 or more contradictory statements or behaviors; the receiver is trapped in a no-win situation. The student is giving a mixed message, but for documentation purposes, incongruent is the preferred term and in this case is more precise. False reassurance occurs when a speaker tells a distressed person that everything will be okay, when the outcomes are not guaranteed.

An older client is able to perform activities of daily living, but he has vague physical complaints and has experienced multiple deaths of friends and family and has lost his social roles. Which question is the most therapeutic? A. "Can you cope with being alone?" B. "Have you considered assisted living?" C. "What is the main problem today?" D. "How do you feel about your life now?"

Answer: D An open-ended question is the most therapeutic invitation to encourage the client to discuss hopes and frustrations without being threatening or probing. Closed questions (Can you cope? Have you considered?) provide little information and are not the best choice for clients who need encouragement to verbalize feelings and needs. Focusing on one main problem suggests that the client must limit his communication.

Before discharging an anxious client, which information about anxiety would the nurse teach the family? A. Anxiety is a totally unique feeling and experience. B. Apprehension is generalized to the total environment. C. Fears results from conscious actions, thoughts, and wishes. D. Anxiety is a pattern of emotional and behavioral responses to stress.

Answer: D Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. Apprehension is usually related to a specific aspect of the environment rather than the total environment. Fears are not intentionally or consciously generated.

According to Erikson's psychosocial stages of development, in which stage would toilet training be achieved? A. Trust versus mistrust B. Initiative versus guilt C. Industry versus inferiority D. Autonomy versus shame

Answer: D Children between the ages of 18 months and 3 years attempt to develop independence; control over the self; and mastery of toileting, dressing, and feeding. Infants between birth and 1 year attempt to meet basic oral and sensory needs and develop a sense of trust in themselves and others. Children between the ages of 3 and 6 years develop a sense of purpose; they accept responsibility, learn to be cooperative, and are enthusiastic about helping others. Children between the ages of 7 and 11 years develop a sense of competence; through learning and mastery of skills, they develop self-assurance.

An older adult seems to make up stories to fill in for memory lapses. Which behavior is the client displaying? A. Lying B. Denying C. Fantasizing D. Confabulating

Answer: D Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead. Denying is a refusal to believe or accept reality and is used as a protective defense mechanism. Fantasizing is a more-or-less connected series of mental images, such as those that occur in daydreams, that usually involve some unfulfilled desire.

Which term describes the disturbance in mood and affect seen in clients who are depressed? A. Euphoric B. Labile C. Expansive D. Dysphoric

Answer: D Dysphoric describes feelings of hopelessness and sadness, which are symptomatic of depression. Euphoric is a feeling of elation and joyfulness; this is often seen in the early manic phase of bipolar disorder. A labile mood describes a rapid change in mood, for example, clients with dementia may be easily upset and then happy. An expansive (talkative, exaggerated friendliness) mood is usually associated with the manic phase of bipolar disorder.

Which action would the nurse therapist take when the father of an autistic child states that the family members wish to share their religious beliefs with the therapist? A. Ask the father if religious beliefs relate to the child's autism. B. Include the mutual discussion of religious beliefs. C. Invite the family's religious leader to a therapy session. D. Encourage discussion of their religion in the sessions.

Answer: D If religious beliefs are a family concern, the nurse should encourage discussion of their thoughts and feelings; this would include the relationship of religious beliefs to the child's autism if this topic is important to the family. The role of the nurse is to facilitate and listen, not to participate in a mutual discussion about religious beliefs. The religious leader is not part of the family unit and should be invited only if this is requested by the family.

Which characteristic uniquely associated with psychophysiological disorders would differentiate them from somatic symptom disorders? A. Emotional cause B. Feeling of illness C. Restriction of activities D. Underlying pathophysiology

Answer: D Psychophysiological disorders have an underlying pathophysiology or actual physical cause, whereas somatic symptom disorders usually do not. The psychophysiological response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatic symptom disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.

The nurse hears a child who was not invited to a sleepover say, "I have better things to do than go to that sleepover." Which defense mechanism would the nurse conclude the child is using? A. Denial B. Projection C. Regression D. Rationalization

Answer: D Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation; the child is not avoiding the reality of the sleepover. Projection is blaming others for one's shortcomings; the child is not blaming others for not being invited to the sleepover. Regression is returning to an earlier more familiar mode of behavior; the child is not regressing.

During the assessment interview, which response would the nurse make to a bipolar client who is depressed, avoids eye contact, responds in a very low voice, and is tearful? A. "You'll get better faster if you let us help you." B. "Hold my hand. I know that you're frightened. I won't let anyone harm you." C. "I'm your nurse. I'll take you to the dayroom as soon as I get some information." D. "I know this is difficult, but as soon as we're finished I'll take you to your room."

Answer: D Saying, "I know this is difficult, but as soon as we're finished I'll take you to your room," is the correct response. This response recognizes the client's feelings and explains what is expected. "You'll get better faster if you let us help you," is threatening and constitutes false reassurance; it puts the responsibility on the client and does not permit expression of feelings. "Hold my hand. I know that you're frightened. I won't let anyone harm you," may lead the client to think that the environment is unsafe, which may increase insecurity and anxiety. Although saying "I'm your nurse" is correct, saying, "I'll take you to the dayroom as soon as I get some information," is not. Being with other people in a strange situation will add more stress to the new and already frightening experience of hospitalization.

Which nursing intervention would be helpful in meeting the needs of an older adult with Alzheimer disease? A. Providing nutritious foods that are high in carbohydrates and protein B. Offering opportunities for choices in the daily schedule to stimulate interest C. Developing a consistent plan with a fixed time schedule to fulfill emotional needs D. Simplifying the environment as much as possible by limiting the need for decisions

Answer: D Simplifying the environment as much as possible by limiting the need for decisions is the nursing intervention that would be helpful for a client with Alzheimer disease. Clients with this disorder need a simple environment. Because of brain cell destruction, they are unable to make choices or decisions. A well-balanced diet is important throughout life, not just during senescence; a diet high in carbohydrates and protein may be lacking in other nutrients such as fat. The client with dementia may be incapable of making choices; providing alternative choices will increase anxiety. Emotional needs must be met on a continuous basis, not just at fixed times.

Which defense mechanism would be exhibited when a client with alcohol use disorder states, "I function better when I'm drinking than when I'm sober"? A. Sublimation B. Suppression C. Compensation D. Rationalization

Answer: D The client is using rationalization. The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.

Which intervention is the most important for a young female client who was raped 3 days ago and continually talks about the trauma of being sexually assaulted? A. Getting her involved with a rape therapy group B. Remaining available and supportive to limit destructive anger C. Exploring her feelings about men to promote future relationships D. Providing a safe environment that permits the ventilation of feelings

Answer: D The client needs to be able to express her current feelings in a safe environment. It is too soon after the assault to discuss this topic in a group. Although the nurse should be available and supportive, feelings of anger are usually not the initial response. It is too soon after the assault to discuss her feelings about men and future relationships.

Which action would the school nurse take for a child who tells the nurse, "My father has been getting into bed with me at night and touching me"? A. Ask the child to describe the touching. B. Talk to the teacher about any inappropriate behavior. C. Contact the father to come to the school immediately. D. Report the child's conversation to child protective services.

Answer: D The nurse is legally responsible for reporting suspected child abuse to the appropriate child protection agency. The agency must assess the situation and intervene if necessary to protect the child. Asking the child to describe the touching may worsen the psychological trauma; the nurse would listen and demonstrate concern. The nurse does not need any more data from the teacher to have a reasonable suspicion of child abuse; the situation must be reported. Contacting the father may result in more abuse or in the child not reporting future abuse.

A newly admitted client quietly listens to the nurse's explanation of the mental health unit and then says, "So this is where they keep the crazies." Which response would the nurse use? A. "These people are emotionally ill; we never use words like crazy or nuts." B. "Some people feel that way. Let's talk about mental health." C. "Would you like me to explain the philosophy of psychiatric care?" D. "Do you feel that a person has to be crazy to need mental health services?"

Answer: D The nurse reflects the specific fear of being "crazy" and invites discussion about the client's misconceptions of mental health services. The focus should remain on the client, not on others (these people or some people). Explaining the philosophy of care is an example of intellectualization, which is defense mechanism that incorporates facts and avoids emotional content.

The client says, "I don't see how talking to you can possibly help." Which response would the nurse use? A. "I can see how you might feel that way now, but I hope you'll change your mind." B. "You'll never know whether or not it's helpful unless you're willing to give it a try." C. "The one-on-one relationship has proved helpful for others, and you should give it a try." D. "I hope I can help you express and better understand your thoughts and feelings."

Answer: D The nurse uses an optimistic response (I hope) that clarifies the purpose of the relationship (to express and understand). By making an inaccurate reflection (I can see how you might feel), the nurse comes across as being unsure if talking will help. Platitudes (you'll never know, unless you give it a try) are not helpful. Placing the focus on others (proved helpful for others) diminishes the client.

Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal? A. Infuse intravenous fluids. B. Monitor the level of anxiety. C. Obtain frequent vital signs. D. Administer chlordiazepoxide

Answer: D The nurse would administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures and autonomic hyperactivity. Administering intravenous fluids maintains hydration. Monitoring anxiety levels does not affect client safety. Obtaining frequent vital signs allows the nurse to assess for autonomic hyperactivity but does not directly affect client safety.

Which response would the nurse make to the husband who told his suicidal wife that he would bring their 26-month-old daughter to visit and asks if that would be possible. Which is the best response by the nurse? A. "Probably so, but you'd better check with her primary health care provider first." B. "Of course! Children of all ages are welcome to visit relatives." C. "It could be very upsetting for your child to see her mother so depressed." D. "Tell me what your wife said when you offered to bring your child for a visit."

Answer: D The nurse would determine whether the spouse has discussed the child visiting with the client before commenting further. The responses, "Probably so, but you'd better check with her primary health care provider first," and "Of course! Children of all ages are welcome to visit relatives," assume that the client has consented to the visit; this assumption may be incorrect. The response, "It may be very upsetting for your child to see her mother so depressed," makes an assumption that requires more data and discussion to validate.

Which intervention would the nurse include when developing a plan of care for an older client with dementia? A. Explain to the client the details of the regimen. B. Demonstrate interest in the client's various likes and dislikes. C. Be firm when dealing with the client's attitudes and behaviors. D. Provide consistency in carrying out nursing activities for the client.

Answer: D The nurse would include providing consistency in carrying out nursing activities for the client. Familiarity with situations and continuity add to the client's sense of security and foster trust in the relationship. Detailed explanations will be forgotten; instructions should be simple and to the point and given when needed for clients with dementia. Although demonstrating interest in the client's likes and dislikes helps individualize care, in a client with dementia likes and dislikes may be hard to remember. Being firm when dealing with the client's attitudes and behaviors may increase anxiety in the client with dementia; some degree of flexibility by the nurse helps decrease outburst from clients with dementia.

Which conclusion would the school nurse make about a female teenager who has anorexia nervosa and states that she thinks she is pregnant even though she has had intercourse only once, more than a year ago? A. Is using magical thinking B. Is submitting to peer pressure C. Is lying about the last time she had intercourse D. Is lacking knowledge that the disease can cause amenorrhea

Answer: D The nurse would make the conclusion that the client is lacking knowledge that the disease can cause amenorrhea. The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data are available to support the fact that the client is using magical thinking, which is characterized by the belief that thinking or wishing something can cause it to occur; in light of the client's diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this type of concern. Although the nurse might question the timeline again, the client's nutritional status would be explored first.

Which strategy would the nurses use to minimize aggressive behaviors from the client with a neurocognitive disorder? A. Limit the time staff and the client spend together. B. Follow an outline of consequences for uncooperative behavior. C. Use the client's preferences as a reward or a punishment. D. Identify nursing staff members whom the client prefers.

Answer: D The strategy is to identify nursing staff members whom the client prefers. The type of care needed by the client requires trust in the caregiver, which develops more rapidly when there is a cooperative relationship and client input is accepted. Limiting staff time may place the client in jeopardy. The staff should not be put in the position of punishing the client; the client with neurocognitive disorder cannot be held responsible for uncooperative behavior. Clients with neurocognitive disorder will not remember and learn from a reward system.

Which behavior would indicate that a client with a long history of alcohol use disorder is ready for treatment? A. Drinking only socially B. Avoiding drinking for a week C. Being hospitalized for detoxification D. Verbalizing an honest desire for help

Answer: D Verbalizing an honest desire for help indicates readiness for treatment. When clients with alcohol problems voice a desire for help, it usually signifies that they are ready for treatment, because they are admitting they have a problem. Drinking only socially does not indicate a readiness for treatment because adherence to an alcohol treatment program requires abstinence. A week is too short a time to signal readiness for treatment. Hospitalization alone is not an indication that the client is really ready for treatment; many factors can influence admission.

Which response is best to give a client who has schizophrenia, when he interjects random and nonsensical sentences that have nothing to do with the main conversational topics? A. "You aren't making any sense; let's talk about something else." B. "Why don't you take a rest? We can talk again later this afternoon." C. "I'd like to understand what you're saying, but you're too confused now." D. "I'd like to understand what you're saying, but I'm having trouble following you."

Answer: D When the nurse conveys a desire to understand, this increases the client's feeling of self-esteem. Nurse also states reality and the reality is that as a listener, the conversation is hard to follow, and the intended meaning is not being received. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic. The other responses serve to block or stop communication, and they suggest that the nurse doesn't want to speak to the client unless he makes sense.

Which behavior is the nurse displaying while caring for a depressed 75-year-old woman who reminds her of her grandmother when she spends extra time and attention and brings home-baked cookies? A. Affiliation B. Displacement C. Compensation D. Countertransference

Answer: D With countertransference, the professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts. Affiliation is turning to others for support and help when stressed or conflicted. Displacement is the discharge of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings. Compensation is attempting to balance deficiencies in one area by excelling in another area.

Which personality disorder would the nurse suspect in a client telling a rambling, lengthy, unclear, and overly detailed story about their dog, who they say is the president? Select all that apply. One, some, or all responses may be correct. A. Schizoid B. Paranoid C. Histrionic D. Borderline E. Narcissistic F. Schizotypal

Answer: F People with schizotypal personality disorder demonstrate symptoms that are strikingly strange and unusual, such as magical thinking, odd beliefs, strange speech patterns, and inappropriate affect. A client telling an odd and rambling story about their dog being the president would be demonstrating behavior consistent with schizotypal personality disorder. People with schizoid personality disorder display a lack of interest in social relationships. Paranoid personality disorder is characterized by a longstanding distrust and suspicion of others based on the belief (unsupported by evidence) that others want to exploit, harm, or deceive the person. People with histrionic personality disorder are excitable and dramatic yet often high functioning. Borderline personality disorder is characterized by severe impairments in functioning caused by patterns of marked instability in emotional control or regulation, impulsivity, identity or self-image distortions, unstable mood, and unstable interpersonal relationships. Narcissistic personality disorder is characterized by feelings of entitlement, an exaggerated belief in one's own importance, and a lack of empathy.

A 26-year-old client receiving inpatient care tells the nurse, " I'm a police informant but I'm being threatened by organized crime members. I can't sleep at all." The client has also been observed pacing frequently with tremulous hands and pressured speech. Which issue would the nurse most likely identify as the client's nursing diagnosis?

Anxiety Anxiety is a NANDA-approved nursing diagnosis and one that is strongly supported by the client's behavior and condition. Delusions, schizophrenia, and persecution are not nursing diagnoses.

DSM-IV - Axis III

Any medical or neurological problems that may be relevant to current or past psych problems Example: SOB R/T asthma may be confused with a panic attack or may precipitate one

DSM-IV - Axis II

Any personality disorder that may be shaping the current response to the Axis I problem; developmental disorders such as mental retardation which may predispose person to axis I problem. Example: someone with mental retardation may not have the coping skills to deal with a major life event and is more likely to experience a major depressive episode

Which of the following terms is used to describe deterioration in language function?

Aphasia

Affect

Appearance of observable emotions

When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what?

Appetite and sleep Biologic data are essential for analyzing an individual's physical responses to stress, coping efforts, and adaptation. Nurses should pay particular attention to alterations in vegetative functions (e.g., appetite and eating patterns, sleep, energy level, and sexual activity).

An unconscious patient is admitted to the emergency department after a motor vehicle accident. The patient's blood alcohol level upon admission was 1.7. The patient's family soon arrives, reporting that this is an uncle that is visiting from out of town. They cannot give much more history other than that he is a "social drinker". After being transported to the unit, the patient starts sweating and has elevated vital signs. It is most important for the nurse to continue gathering history from the family regarding which of the following?

Are there other indications that the patient may be a heavy drinker?

How would the nurse assess the client's self-concept?

Ask the client to describe themselves and what characteristics about themselves they would change.

What would a good way to determine how a client's culture influences their values and beliefs?

Ask them, "what beliefs and health practices are important to you? How do you view yourself in the context of society and in relationships?" These questions should be modified to the client's level of understanding.

Which of the following is the first step in the nursing process? * Assessment Planning Diagnosis Implementation

Assessment

General appearance and motor behavior

Assessment data about the clients speech patterns are catergorized in which of the following areas?

Repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair or tapping one's foot

Automatisms

In Freud's theory, age 1-3 belong to the anal stage while in Piaget's theory age 2-7, belongs to the preoperational stage. * Autonomy Initiative Trust Industry

Autonomy

List what each of the five axis of the DSM identifies

Axis I - Clinical Disorders Axis II - Personality disorders and conditions of mental retardation Axis III - General medical conditions Axis IV - Psychosocial and environmental problems Axis V - Global assessment of functioning

Which of the following is an example of an open-ended question? a. Who is the current President of the U.S.? b. What concerns you most about your health? c. What is your address? d. Have you lost any weight recently?

B.

When the nurse is assessing whether or not the client's ideas are logical and make sense, the nurse is examining which of the following? a. Thought content b. Thought process c. Memory d. Sensorium

B. Thought process refers to how the client thinks, whereas thought content refers to what the client actually says. Thought content may be used to determine thought process, but it is the content that is ultimately being assessed.

Assessment data about the client's speech patterns are categorized in which of the following areas? a. History b. General Appearance and Motor Behavior c. Sensorium and Intellectual Processes d. Self-Concept

B. Also included in this category is hygiene, grooming, dress, posture, eye contact, and unusual movements or mannerisms.

Objective personality test that involves 21 items rated on a scale of 0 - 3 to indicate the level of depression

Beck Depression Inventory (BDI)

When interviewing the family members of a client being treated for substance abuse problems, which of the following behaviors would alert the nurse to the possibility of codependency?

Blaming themselves for the family's problems

Showing little facial expression; slow-to-respond facial expression

Blunted Affect

The nurse is assisting a child with ADHD to complete his ADLs. The best approach for nurse to use with this child I which of the following?

Break tasks into small steps

Displaying a full range of emotional expressions

Broad Affect

What type of therapeutic communication techniques allows the client to take the opportunity to set the direction of the conversation? * Broad openings General Leads Encouraging comparison Restating

Broad openings

How might a nurse assess a client's judgement?

By asking hypothetical questions, like "if you found a stamped addressed envelope on the ground, what would you do with it?" or "if you saw a man hitch-hiking with an ax, what would you do?"

How does a nurse assess memory, both recent and remote?

By asking questions with verifiable answers. Example: What is your social security number? Who is the current president?

How might a nurse assess a client's intellectual abilities?

By having them compare two objects; i.e. "What do a banana and a pear have in common?" or "What is similar about a door and a window?"

What is one common way a nurse may assess a client's ability to use abstract thinking?

By using a common saying (i.e. 90% of inspiration is perspiration; a friend to all is a friend to none; all's fair in love and war, etc) After the nurse relays the saying to the client, she asks the client to interpret what the saying means.

The client's belief that a news broadcast has special meaning for him is an example of: a. abstract thinking b. flight of ideas c. ideas of reference d. thought broadcasting

C.

To assess the client's ability to concentrate, the nurse would instruct the client to do which of the following? a. Explain what "a rolling stone gathers no moss" means b. Name the last three presidents c. Repeat the days of the week backward d. Tell what a typical day is like

C. Other ways to do this include spelling "world" backward or counting backward from 100 by sevens.

An angry patient has just thrown a chair across the room and is racing to pick up another chair to throw. The most appropriate action by the nurse would be which of the following?

Call for an emergency response from trained personnel

When interacting with a client in the day room, the nurse determines that a violent outburst is imminent. Which of the following should the nurse do first?

Call for assistance.

The nurse is working in an intensive care unit and observes that some clients do not respond to injections of diazepam (Valium) when the injections are given by a particular nurse. This nurse returns from lunch exhibiting slurred speech and euphoria. Which of the following is the best action for the nurse to take?

Call the manager and report the observations.

In a mentally health care clinic, a nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? * Call the police Lock the co-worker in the medication room until help is obtained Call the security Call the nursing supervisor

Call the nursing supervisor

A client eventually answers a question but only after giving excessive unnecessary detail

Circumstantial Thinking

You ask your client to tell you more about why she stated she is angry at her best friend. This is her response: "So, last Tuesday, I was out shopping. I found the perfect pair of shoes. It fit just right, and it was the perfect color and it went perfectly with my favorite blue and pink dress with the little pink sweater. I love that dress, I wear it out all the time. I got home and tried on the dress with the shoes and it matched, and I was so excited! I decided to wear it to the club that weekend. Saturday night rolled around and I got all dressed up. I even went and got my hair done, because the club we were going to was REALLY fancy and I had to look the part. I got some new jewelry, too. It matched my favorite dress too. We got to the club and we were dancing and having such a good time. My favorite song was on, and we were out on the dancefloor, and my best friend had a glass of red wine in her hand. She spille

Circumstantial Thinking

During the admission assessment, the nurse asks the client, "How are you feeling?" The client responds, "I feel, I kneel, do you steal?" The nurse recognizes this response as which of the following?

Clang association

During a one-to-one interaction with a nurse, the client states "I'm worried about going home." The nurse responds, "Tell me more about this." This response is an example of: * Reflecting Refocusing Focusing Clarifying

Clarifying

The client receiving antidepressant drug arrives at the mental health clinic. Which of the following observation indicate that the client is following the medication plan correctly? * Client reports not going to work for this past week Client reports sleeping more than 12 hours per day Client arrives at the clinic neat and appropriate in appearance Client complaints of not being able to "do anything" anymore

Client arrives at the clinic neat and appropriate in appearance

The nurse decides to place an aggressive and violent client in mechanical restraints. The nurse bases this decision on which of the following?

Client's safety

An important aspect of teaching any client receiving monoamine oxidase inhibitors (MAOIs) should be that: * Drowsiness is an expected side effect of this medication It is necessary for these clients to wear a hat outdoors and avoid the sun Clients taking this type of medication have special dietary restrictions The therapeutic level and the toxic level of these drugs are very close

Clients taking this type of medication have special dietary restrictions

Which of the following is believed to be a risk factor specific to the development of delirium?

Co-occurring general medical condition

The nurse plans to assess a patient's self-concept in the admission assessment knowing that self-concept influences which of the following? (Select all that apply)

Cognitive processing, Frequently experienced emotions, Coping strategies

The nurse plans to assess a patient's self-concept in the admission assessment knowing that self-concept influences which of the following? (Select all that apply)

Cognitive processing, Frequently experienced emotions, Coping strategies

What type of environment should a psychosocial assessment be completed in?

Comfortable, private and safe for both the nurse and the client. Should be a quiet place with as few distractions as possible. If the nurse's safety even has the possibility of being threatened, the interview should be conducted in a place that ensures help is nearby, or a third party may need to be in the room.

The nurse asks a patient to list the days of the week in reverse order. The nurse is assessing which of the following?

Concentration.

A client continually gives literal translations, for example: Nurse: "An apple a day keeps the doctor away." Client: "If you have an apple, the doctor will leave you alone.

Concrete thinking. If the client were capable of abstract thinking, the response would be similar to this: "Eating apples keeps you healthy so you don't need to go to the doctor."

A child is expelled from school for repeated fighting and vandalizing school property. The school nurse and counselor meet with the parents to explain that the child may benefit from counseling as the child is experiencing signs of which disorder?

Conduct Disorder

A nurse reports for work looking unkempt and disheveled. Her movements are uncoordinated and her breath smells like mouthwash. Another nurse suspects this nurse is intoxicated. What should the nurse do first?

Confront the nurse about her behavior and relieve her of her responsibilities.

Another term for the superego is: * Conscience Narcissism Ideal self Self

Conscience

The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician and the medication is due to be administered. Which action should the nurse take? * Hold the medication until the physician can be contacted Contact the nursing supervisor Administer the dose prescribed Administer the recommended dose until the physician can be located.

Contact the nursing supervisor

Lithium carbonate is the drug of choice for: * Agitated phase of paranoid states Acute agitation of schizophrenia Modification of the depressive phase of major depressions Control of manic episodes of bipolar disorders

Control of manic episodes of bipolar disorders

A patient is observed pacing the hall with clenched fists, and swearing at others. The nurse intervenes immediately to prevent the patient from escalating to which phase of the aggressing cycle?

Crisis

Which of the following is an example of a closed-ended question? a. How have you been feeling lately? b. How is your relationship with your wife? c. Have you had any health problems recently? d. Where are you employed?

D.

A patient in treatment for drug abuse makes the statement, "I am a winner. You all are the losers because you can't beat this on your own." The nurse interprets this statement as reflecting which characteristic common to people addicted to drugs?

Defending against a negative self-concept

You introduce yourself to a new client who arrives for their first interview. They respond with, "Hello, I am a famous actor...you might have heard of me. I've won three Oscars. Would you like an autograph?" What type of thought process might the client be exhibiting?

Delusion

The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient?

Delusional thinking

The nurse can distinguish delirium from dementia by knowing which of the following?

Dementia has a gradual onset and is progressive in course.

The nurse is encouraging a group of patients with dementia to join in upper body range of motion exercises using light dumbbells. Which technique will most likely result in the greatest amount of participation?

Demonstrate the exercises while patients simultaneously perform them

A client admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting "Let me out. There's nothing wrong with me. I don't belong here." The nurse analyzes this behavior as: * Rationalization Regression Projection Denial

Denial

A client who has just been sexually assaulted is quiet and calm. The nurse analyzes this behavior as indicating which defense mechanism? * Projection Rationalization Intellectualization Denial

Denial

Upon admission, Lara says to the nurse, "Why am I here? I am not sick, I don't have any health problem." This statement exemplifies a common defense mechanism used by anorectic patient known as one of the following: * Suppression Regression Conversion Denial

Denial

What type of non-therapeutic communication denounce the client's behavior or ideas? * Testing Disapproving Rejecting Defending

Disapproving

Which of the following would best assess a client's judgment?

Discussing hypothetical situations

Which of the following would best assess a client's judgment? Interpreting proverbs Counting by serial sevens Spelling words backward Discussing hypothetical situations

Discussing hypothetical situations The client's problem-solving and decision-making abilities can be elicited by discussing solutions to hypothetical situations.

At the change of shift report the nurse learns that a patient in the intensive care unit has developed signs of delirium over the past 8 hours. Which of the following behaviors documented in the nursing notes is the most probable indication of delirium?

Disoriented to person

The supervisor reprimands the nurse in charge of the nursing unit because she has not adhered to the unit budget. Later that afternoon, she accuses the nursing staff of wasting supplies. This behavior is an example of: * Displacement Suppression Denial Rationalization

Displacement

What are some ways in which a nurse might assess a client's relationships, satisfaction with those relationships, or loss of relationship?

Do you feel close to your family? Are you in a romantic relationship? Are there any needs you feel are not being met by the important people in your life? Has anyone been hurting you or abusing you? Have you ever been abused? Tell me what happened with your wife/husband. Do you feel safe at home? Is there anyone in your life who does not make you feel safe?

Which of the following is most important to maintain therapeutic boundaries when working with aggressive patients?

Don't personalize a patient's anger

A

During the admission assessment, the nurse asks the client, ìHow are you feeling?î The client responds, ìI was able to purchase gas for 7 cents a gallon less than yesterday, which saved me a total of 84 cents. My car has a 12-gallon gas tank. Usually I am able to put in 11.7 gallons. I am very happy to have saved so much money.î The nurse recognizes this response as which of the following? A) Circumstantial thinking B) Echolalia C) Flight of ideas D) Neologisms

C

During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the client's A) admitting diagnosis. B) communication skills. C) perception of the problem. D) personal needs.

The legal term for our responsibility as healthcare providers to alert a potential target of our client's plans to cause them harm; legal requirement to breach confidentiality

Duty to Warn

A nurse asks an assigned client, "How are you doing today?" The client responds with "doing today, doing today, doing today." This is an example of which of the following speech pattern disturbances?

Echolalia

The ability to tolerate frustration is an example of one of the functions of the: * Unconscious Ego Superego Id

Ego

A nurse suspects that a patient is abusing alcohol while taking prescribed medications. The plan is to educate the patient on the dangers of mixing medicine with alcohol. The most effective way for the nurse to approach this subject with the patient includes which of the following?

Emphasize the importance of truthful information using a non-judgmental approach

A client states, "I don't want to eat anything because I am afraid that my food is poisoned." Which intervention is best for the nurse to perform to encourage the client to eat? Tell the client to take vitamins on a daily basis. Discuss the importance of proper nutrition with the client. Encourage the client to help with meal preparation. Ask the client about favorite foods to add for meals.

Encourage the client to help with meal preparation. The client who demonstrates paranoia about food being poisoned should be encouraged to help with food preparation so that there is certainty about food being not poisoned. Discussing nutrition, taking vitamins and adding favorite foods will not address the feeling of paranoia the client has about the food being poisoned.

Many clients have difficulty expressing anger. Which of the following interventions would assist the client with the appropriate expression of anger?

Encourage verbalization

The nurse observes two clients in the day room arguing. One client runs into the corner and huddles while the other follows and continues with verbal abuse. The nurse's most appropriate action would be to

Engage the attention of the client who is still yelling and ask what is happening

A 22-year-old client who has been diagnosed with paranoid personality disorder has been receiving treatment. The final stage of the nursing process in the care of this client should focus on what? Engaging the client's friends and family Encouraging the client to develop coping skills and life skills Evaluating the effectiveness of the treatment Selecting specific interventions

Evaluating the effectiveness of the treatment The evaluation phase is the final phase of the nursing process, and it focuses on the client's status, progress toward goal achievement, and ongoing reevaluation of the care plan.

The psychiatric mental health nurse is preparing to perform an assessment on a new client. Which action should be performed first by the nurse? Obtain legal consent from client. Establish rapport with the client. Explain the purpose of the assessment. Examine own biases and values.

Examine own biases and values. Before beginning the interview, the nurse should examine his/her own biases and values. In trying to interpret assessment data, it is important for the nurse to be objective and being aware of these biases and values will help to improve this. Next, the nurse will obtain legal consent and then explain the purpose of the interview and establish rapport with the client.

The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid?

Explaining the consequences the client will face if control is lost

A parent of an autistic child asks the nurse if there is anything that can be done to control the child's tantrums. The nurse should inform the parents that which of the following options may be appropriate?

Explore the use of antipsychotic medications to control tantrums

A client is unable to communicate verbally. The nurse would accurately document this disorder as which of the following?

Expressive language disorder

True or false: A confused person cannot be oriented x 4.

False A confused person cannot make sense of their surroundings or figure things out even though they may be fully oriented.

A child with ADHD complains to his parents that he doesn't like the side effects of his medicine, Adderall. The parents ask the nurse for suggestions to reduce the medication's negative side effects. The nurse can best help the parents with which of the following instructions?

Feed the child nighttime snacks

Showing no facial expressions

Flat Affect

A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect?

Flat affect

A client is showing no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which term when documenting the client's affect? Flat affect Absent affect Restricted affect Broad affect

Flat affect Common terms used in assessing affect include blunted affect: showing little or a slow-to-respond facial expression; broad affect: displaying a full range of emotional expressions; flat affect: showing no facial expression; inappropriate affect: displaying a facial expression that is incongruent with mood or situation, often silly or giddy regardless of circumstances; restricted affect: displaying one type of expression, usually serious or somber. A flat affect is not synonymous with having an "absent" affect.

Your client arrives for her first interview. You say, "So, Lucy, tell me a little about you." Her response is made up of rapid, fragmented speech: "My dog is gray and purple is my favorite color of blanket but sleep is not fun, fun things are like running fast, that's how I go to the park, it has swings in the sun, and the sun is pretty like birds and flowers..." What kind of thought content is your client be exhibiting?

Flight of Ideas

What type of questions should be used for clients who have marked difficulties with thought process and content?

Focused questions requiring short answers

Assessment data about the client's speech patterns are categorized in which of the following areas?

General appearance and motor behavior

The nurse is administering Haloperidol (Haldol) to a client who is scheduled to be discharged. Prior to discharge, which of the following should the nurse teach the client? * Get adequate sunlight Avoid foods rich in potassium Continue driving as usual Get up slowly when changing positions

Get up slowly when changing positions

How should the nurse approach the crying client? What should the nurse say and do?

Give positive feedback for coming to the clinic to get help. 1. Tell her it is all right to cry. 2. Tell the client that the nurse will sit with her until she's ready to talk. 3. Validate the client's feelings (i.e., "I can see you're very upset").

The client identifies anger management as a problem. What is the next step in planning therapeutic interactions?

Give the client permission to be angry.

A numeric scale, 1 through 100, used by mental health clinicians and physicians to rate subjectively the social, occupational and psychological functioning of adults; score is often given as a range

Global Assessment of Functioning (GAF)

A client with alcohol dependence is admitted to the hospital with pancreatitis. Which of the following interventions should be included in the client's plan of care?

Glucometer checks bid

The adult son of a patient with dementia asks the nurse how he should respond when his mother repeatedly says she has had a busy day at work. The mother has not worked in over 20 years. The best guidance the nurse can give is which of the following?

Go along with her thought of it having been a busy day, but do not refer to her work

A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." The client is exhibiting which of the following?

Grandiosity

A client is being evaluated for dementia. The nurse knows that when completing a mental status exam, the fewer tasks the client completes accurately, the

Greater the cognitive deficit

A client is being evaluated for dementia. The nurse knows that when completing a mental status exam, the fewer tasks the client completes accurately, the..

Greater the cognitive deficit

The family is most important in the emotional development of the individual because it: * Gives rewards and punishment Reflects the mores of a larger society Helps one to learn identify and roles Provides support for the young

Helps one to learn identify and roles

The mother of a 15-year-old boy tells the nurse that her son is becoming more assertive in conflict situations and wants to get a job. She asks if it is healthy for a 15-year-old to be so independent. Which of the following is valid information for the nurse to give the mother?

His behaviors reflect normal growth and development.

The nurse is assessing suicide potential in a patient who has expressed hopelessness. In what order does the nurse question the patient about suicidal thoughts?

How would you carry out this plan? Do you have a plan to kill yourself? Are you thinking of killing yourself? How do you plan to kill yourself?

The nurse is assessing suicide potential in a patient who has expressed hopelessness. In what order does the nurse question the patient about suicidal thoughts?

How would you carry out this plan?, Do you have a plan to kill yourself?, Are you thinking of killing yourself?, How do you plan to kill yourself?

The client has an elevated serum thyroxine concentration. This finding indicates which disease processes?

Hyperthyroidism An elevated serum thyroxine concentration is indicative of hyperthyroidism. Hypothyroidism, anemia, and muscle tissue injury are not typically associated with an elevated thyroxine concentration.

The client has an elevated serum thyroxine concentration. This finding indicates which disease processes? Muscle tissue injury Hypothyroidism Hyperthyroidism Anemia

Hyperthyroidism An elevated serum thyroxine concentration is indicative of hyperthyroidism. Hypothyroidism, anemia, and muscle tissue injury are not typically associated with an elevated thyroxine concentration

The superego is that part of the self which says: * I should not want that I can wait for what I want I want what I want I like what I want

I should not want that

You are meeting with a client, and she begins to tell you about her experience listening to the radio on her drive in this morning. "The disc jockey started talking about relationships, and I just knew she was talking about MY relationship..." What type of thought process is this client exhibiting?

Ideas of Reference

The client tells the nurse, "That new TV anchor is telling the world about me." This is an example of

Ideas of reference

When the nurse asks the client, Are you thinking about killing yourself?" The nurse is questioning which component of a suicide assessment?

Ideation

When should the nurse use direct, closed-ended questions?

If the client cannot organize their thoughts or has difficulty answering open-ended questions

A client with three children (11, 9, and 6 years of age) seeks preventive treatment at a mental health clinic. She states, "I'm here before I go crazy! The kids don't listen. I yell at them and then, rather than argue constantly, I give in. I'm at my wit's end. I just don't know what to do anymore. Some mom, huh? My mom and dad were very permissive with me, but I was more cooperative and willing to behave." Which nursing diagnosis would be most appropriate?

Impaired Parenting related to a lack of knowledge about parenting skills as evidenced by statements about feelings of ineffectiveness The nurse chooses the appropriate diagnosis from the North American Nursing Diagnosis Association (NANDA) list by examining definitions, considering related and risk factors, and choosing a diagnostic concept that fits the assessment data. Although health seeking behaviors, situational low self-esteem, and ineffective coping may be appropriate, the related to factors and evidence listed do not support these diagnosis. The data reflect a problem with parenting skills based on the client's statements about yelling at the children, giving in, and not knowing what to do.

C

In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as A) flight of ideas. B) lack of insight. C) labile mood. D) tangential thinking.

When a client talks about the recent loss of a family member while laughing or smiling, this type of affect would be labeled as which of the following? Blunted Inappropriate Flat Restricted

Inappropriate An inappropriate affect is displaying a facial expression that is incongruent with the mood or situation. A blunted affect is showing little or a slow-to-respond facial expression. A restricted affect is displaying one type of expression, usually serious or somber. A flat affect is exhibited by no facial expression.

Displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances

Inappropriate Affect

Which of the following is not true about nurse-client relationship? * The goal of the nurse-client relationship is to assist the client to develop problem solving and coping mechanisms Inappropriate limits and boundaries define and facilitate a therapeutic nurse-client relationship The nurse respects the client's confidentiality and limits discussion of the client to members of the treatment team The client should be cared for in a holistic manner

Inappropriate limits and boundaries define and facilitate a therapeutic nurse-client relationship

word salad

Incoherent mixture of words, phrases, and sentences

A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what? Flat Blunted Incongruent Labile

Incongruent The correct answer is incongruent affect or lack of harmony between one's voice and movements with one's speech or verbalized thoughts. Blunted affect is a severe reduction or limitation in the intensity of one's affective responses to a situation. Flat affect describes absence or near absence of any signs of affective responses. Labile affect is the abnormal fluctuation of one's expressions.

The grown daughter of a woman with Alzheimer's disease reports to the nurse that she is trying to keep her mother's condition from worsening by asking her questions whenever they are together. The nurse recognizes that this activity is likely to do which of the following?

Increase frustration

A child with attention deficit hyperactivity disorder is taking methylphenidate (Ritalin) in divided doses. If the child takes the first dose at 8 a.m., the school nurse might expect to see which of the following behaviors at noon?

Increased impulsivity or hyperactive behavior

When monoamine oxidase inhibitors (MAOIs) are prescribed, the client should be cautioned against: * Prolonged exposure to the sun Engaging in active physical exercise Ingesting wine and aged cheese The use of medications with an elixir base

Ingesting wine and aged cheese

The nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire. In spite of the client's efforts, the neighbor died. Which action does the nurse engage in with the client during a working phase of the nurse-client relationship? * Exploring the client's potential for self-harm Exploring the client's ability to function Inquiring about and examining the client's feelings that may block adaptive coping Inquiring about the client's perception or appraisal of the neighbor's death

Inquiring about and examining the client's feelings that may block adaptive coping

Understanding one's own part in the current situation

Insight

What led you to come to the clinic?

Insight

The ability to understand the true nature of one's situation and accept some responsibility for the situation, i.e. "I got arrested because I stole money that was not mine," rather than "I got arrested because Suzy called the cops on me."

Insight - the second example, where the client blames the arrest on their friend rather than on the fact that they themselves broke the law, is that of "poor insight"

What impact might a psychotic state have on a client's psychosocial assessment?

Insufficient attention span Unable to comprehend questions Parts of assessment may be incomplete or vague as a result.

The nurse asks the client, "What is similar about a cow and a horse?" and "What do a bus and an airplane have in common?" These questions would best assess which of the following areas?

Intellectual function

thought blocking

Interruption of a thought process before it is carried through to completion

Erikson described the psychosocial tasks of the developing person in his theoretical model. The primary developmental tasks of the young adult (age 18 to 25) is: * Generativity vs. Stagnation Industry vs. Inferiority Intimacy vs. Isolation Trust vs. Mistrust

Intimacy vs. Isolation

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry effect. The most appropriate interpretation of the behavior is that the: * Needs to be referred to the psychiatrist as soon as possible Is displaying typical behaviors that can occur during termination Needs to be admitted to the hospital Requires further treatment and is not ready to be discharged

Is displaying typical behaviors that can occur during termination

Nursing as an interpersonal process: * Is the core of psychiatric nursing Is best carried out in the hospital setting Forms the basis of nursing interventions only Is the only key to successful practice of psychiatric nursing

Is the core of psychiatric nursing

Why is the use of open-ended questions the optimal way to begin an interview?

It allows the client to begin as they feel comfortable, and gives the nurse an idea of the client's perception of the situation. Use questions like: "Why are you here today?" "Tell me what has been happening to you." "How can we help you?"

The nurse is co-leading a family therapy group for patients and families of drug addicted individuals. The family of a cocaine addict is angry and can't understand why the patient can't just stop using. The nurse guides the group to discuss their understanding of the nature of addiction. The nurse evaluates an accurate understanding in which of the following statement? (Select all that apply)

It is a medical illness that is progressive, Relapses and remissions are part of the illness

Interpretation of environment

Judgement

The ability to interpret one's environment and situation correctly and to adapt one's behaviors and decisions accordingly; i.e. knowing when it is safe to cross the street

Judgement

If you were lost downtown, what would you do?

Judgment

D

Knowing that relationships with others are significant to mental health, the nurse effectively assesses a patient's family relationships through which of the following? A) ìDo you feel your family helps you?î B) ìHow many people are in your family?î C) ìWhom are you closest to in your family?î D) ìDescribe your relationships with your family.î

A rapidly changing mood; the client exhibits unpredictable and rapid mood swings that can quickly go from depressed and crying to euphoria with no apparent stimuli

Labile Mood

In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as

Labile mood

In the space of five minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as ...

Labile mood Moods that shift rapidly, displaying a range of emotions, are termed labile.

In the space of five minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as ... Lack of insight Tangential thinking Labile mood Flight of ideas

Labile mood Moods that shift rapidly, displaying a range of emotions, are termed labile.

DSM-IV - Axis V

Level of function at time of assessment. Coded on a scale of 0-100 with 100 being perfect functioning (which is basically unattainable). Anything over 61 indicates the client is functioning at least pretty well. Anything over 81 indicates the client is functioning well, and has no more than "everyday" problems or concerns.

Who is the first American Psychiatric nurse? * Eugen Bleuler Hildegard Peplau Linda Richards June Mellow

Linda Richards

The nurse has completed the psychosocial assessment. Which of the following is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care?

Look for patterns reflected in the overall assessment

You are interviewing a client for the first time. As he begins talking, you become unsure how he is relating his thoughts. He says things like, "I went to the market today and my mother was always very kind to me. A have a blue car, it gets really good gas mileage. Can you believe the price of ground beef these days?" What type of thought content is your client exhibiting?

Loose Associations

Throughout the assessment, the client displays disorganized thinking, jumping from one idea to another with no clear relationship between the thoughts. The nurse would assess the client as having which of the following?

Loose associations

Objective Personality test that involves 567 true/false items; provides score on 20 primary scales

MMPI-2

Teaching for parents of children with pervasive developmental disorder should include which of the following?

Maintaining a structure in the child's daily activities to minimize disruption

The nurse in the mental health unit reviews the therapeutic and non-therapeutic communication techniques with an NEUST nursing student. Which of the following are therapeutic communication techniques? Select all that apply: * Giving advice Maintaining neutral responses Asking the client "Why?" Listening Providing acknowledgement and feedback Restating

Maintaining neutral responses Listening Providing acknowledgement and feedback Restating

DSM-IV - Axis IV

Major psychological stressors the individual has faced recently Examples: divorce, death of a loved one, job loss etc

The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? * Developing realistic solutions Planning short-term goals Making appropriate referrals Identifying expected outcomes

Making appropriate referrals

The most effective intervention for clients with delirium is which of the following?

Managing environmental stimuli

For a psychiatric client's expected outcomes to be appropriate they must be ...

Measurable and realistic Expected outcomes must be measurable and realistic.

For a psychiatric client's expected outcomes to be appropriate they must be ... Mutually agreed upon by client and care team Measurable and realistic Flexible and abstract Closely aligned with the psychiatric diagnosis

Measurable and realistic Expected outcomes must be measurable and realistic.

What exam is often used to screen for dementia due to its ability to assess cognitive function?

Mental Status Exam

When assessing a patient's mental health status, the nurses includes which of the following as a major focus of the assessment?

Mental capacity

What examination is used to determine whether a client is experiencing abnormalities in thinking and reasoning ability, feelings, or behavior? Health examination Mental status examination Psychosocial examination Psychoses examination

Mental status examination The mental status examination (MSE) helps identify whether clients are experiencing abnormalities in thinking and reasoning, feelings, or behavior. It is part of the "tool kit" for gathering objective and observational data.

A nurse is exploring treatment options with a patient addicted to heroin. The nurse would include which of the following information regarding the use of methadone?

Methadone will prevent the craving for heroin

The nurse must determine whether the depressed or hopeless client has suicidal ideation or a lethal plan. When the nurse asks the client, "How do you plan to kill yourself?" the nurse is questioning which component of a suicide assessment?

Method

Objective personality test that involves 175 true/false items; provides scores on various personality traits and personality disorders

Milton Clinical Multiaxial Inventory (MCMI)

A client is admitted for a drug overdose with a central nervous system (CNS) depressant. The priority nursing action when planning care for this client would be to

Monitor respiratory function

A client's pervasive and enduring emotional state

Mood

In general, how are you feeling?

Mood

The nurse is caring for a client with Alzheimer's disease. The nurse observes that the client's pacing and mumbling to himself increase at mealtime and shift change. Which of the following interventions should the nurse implement first?

Move the client to a quieter area during these times.

The nurse knows that a therapeutic relationship is possible only when: * Emotional difficulties are identified Mutual trust is achieved Patient is motivated to change Patient's self-esteem is enlarged

Mutual trust is achieved

Invented words that have meaning only for the client

Neologisms

The client was admitted involuntarily to the mental health unit because episodes of extremely violent behavior. The client is demanding to be discharged from the hospital and the nurse does not allow the client to leave. Which of the following represents the legal ramifications associated with the nurse's behavior? * No charge will be made against the nurse because the nurses' actions are reasonable The nurse will be charged with slander The nurse will be charged with imprisonment The nurse will be charged with assault

No charge will be made against the nurse because the nurses' actions are reasonable

It is important for the nurse to use _____ tone and language when asking questions in order to get the most honest responses.

Nonjudgemental

Questions about drug or alcohol use require ______ phrasing, because a truthful response is necessary in determining a plan of care.

Nonjudgemental

The nurse is teaching a client who is being started on Imipramine hydrochloride (Tofranil) as an antidepressant. The nurse informs the client that the maximum desired effects may: * Not occur for 2 to 3 weeks of administration Not occur until 2 months of administration Start during the second week of administration Start during the first week of administration

Not occur for 2 to 3 weeks of administration

Personality test constructed of true/false or multiple choice questions

Objective Personality Tests

After three weeks of therapy, the patient's blood lithium level is 2.2 meq/. The nurse should: * Observes the patients for signs of toxicity Asks the doctor to explain it is normal Instructs the patient to avoid fluids Gives the medication before meals

Observes the patients for signs of toxicity

The nursing instructor provides a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right? * Performing a procedure without consent Telling the client that he or she cannot leave the hospital Threatening to give a client a medication Observing care provided to the client without the client's permission

Observing care provided to the client without the client's permission

The nurse is assessing a patient's risk factors for developing a substance abuse disorder. Which of the following family characteristics would the nurse identify as a significant risk factor?

One parent that is an alcoholic

When initiating an assessment, the nurse should use which type of questioning? Open-ended questions "Why" questioning Focus on several symptoms Closed-ended questions

Open-ended questions The nurse should use open-ended questions when gathering assessment data from the client. Doing so allows the client to begin as he or she feels comfortable and also gives the nurse an idea about the client's perception of his or her situation.

Can you tell me today's date? (time)

Orientation

Can you tell me where you are? (place)

Orientation

Can you tell me your name? (person)

Orientation

What five aspects of cognition are assessed in a mini-mental status exam?

Orientation Registration Attention & Calculation Recall Language

Sensorium and intellectual processes

Orientation, concentration, memory

Which of the following terms describes the repeating of one's own words or sounds?

Palilalia

Which of the following is the most appropriate topic during the orientation phase of nurse and patient relationship? * Identification of more effective methods of dealing with stress Exploration of the patient's inadequate coping skills Patient's perception of the reason of her being hospitalized Establishment of regular schedule for meeting

Patient's perception of the reason of her being hospitalized

During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the client's

Perception of the problem

During the assessment, the nurse asks the client to describe the client's problems. The purpose of this question is to obtain information about what? Communication skills Personal needs Admitting diagnosis Perception of the problem

Perception of the problem The question will elicit information about the client's view or perspective of the problem. The nurse must know the admitting diagnosis, but this is not obtained from the client. Communication is necessary for the client to describe these perceptions, but this question is not primarily asked to assess communication skills. Similarly, the client may address his or her personal needs in a response, but this is not the nurse's main purpose for asking this assessment question.

A client who is stuck on a topic and seems unable to move to another idea is said to be exhibiting what?

Perseveration

Which of the following disorders involves problems with forming sounds associated with speech?

Phonologic disorder

A child has been ingesting dirt and leaves. The nurse would be alert to which of the following disorders?

Pica

The nursing supervisor in an extended care facility is managing the environment to best help the patients with dementia. Which of the following should the nurse include in planning the living environment?

Plan for the same caregivers to provide care to individuals as much as possible

A child has been displaying behaviors associated with conduct disorder. The nurse should further assess for common risk factors seen in children with conduct disorder. (Select all that apply)

Poor family functioning, Family history of substance abuse, Possible child abuse, Poverty conditions

During this period the Filipinos believed in a world that was equally material and spiritual. * Spanish Rule American Era Pre-Spanish Regime Japanese Occupation

Pre-Spanish Regime

DSM-IV - Axis I

Principal disorder that needs immediate attention Example: an exacerbation of schizophrenia or a major depressive episode. Usually what brings the client through the office door.

The client with a history of explosive outbursts becomes angry and states, "I am really getting angry." The nurse sees this as

Progress

Personality tests that are unstructured; usually conducted by interview method

Projective Personality Tests

The nurse is meeting with a family of a patient with conduct disorder. The nurse discusses changes the parents can make to help their child change problematic behaviors. Which parenting technique would the nurse encourage the parents to use?

Provide consistent consequences for behaviors

When planning care for a client newly diagnosed with Alzheimer's disease, the nurse should focus on

Providing a safe, structured environment

Objective personality test that involves 103 true/false items; used to screen for the need for psychological help

Psychological Screening Inventory (PSI)

Overall slowed movements

Psychomotor Retardation

Involves the collection, organization and analysis of information about the client, as well as a mental status exam. Purpose is to construct a picture of the client's current emotional state, mental capacity and behavioral function.

Psychosocial Assessment

What three aspects of speech should the nurse assess?

Quantity Quality Any abnormalities such as nonstop talking, rhyming or perseveration

The nurse is caring for a patient with cognitive impairment. To determine whether the patient is suffering from delirium or dementia, the nurse reviews the symptoms and course of each disorder. Which of the following terms describe delirium?

Rapid Onset, Slurred Speech, Hallucinations

A patient is being discharged on disulfiram (Antabuse). The patient should receive which of the following instructions related to the use of Antabuse?

Read products labels carefully to avoid all products containing alcohol

A nurse is educating a group of elderly community members about cognitive disorders. Which of the following would the nurse include as a measure most likely to prevent Alzheimer's disease and other dementias?

Reading

Projection, rationalization and denial by hallucinations and delusions are examples of a disturbance in: * Reality testing Association Logic The thought processes

Reality testing

The nurse is performing a health history with a patient exhibiting signs of delirium. The nurse asks the patient and family members about possible causes of the delirious state. Which of the following would the nurse likely attribute as underlying causes for the patient's delirium? (Select all that apply)

Recent alcohol use, Dehydration, Lack of spontaneity, Exposure to paint or gasoline, Sleep disturbances

The nurse is assessing a client with early signs of dementia. The nurse asks the client what he ate for breakfast that morning. The purpose of this question is to determine which of the following?

Recent memory

When the language of a client in the manic phase of a bipolar disorder becomes vulgar and profane, the nurse should: * Ignore it, since the client is using it only to get attention. Recognize the language as part of the illness, but set limits on it. State: "We do not like that kind of talk around here." State: "When you can talk in an acceptable way, we will talk to you."

Recognize the language as part of the illness, but set limits on it.

One of the first steps that a nurse should take to deal effectively with aggressive patients is which of the following?

Reflect on abilities to handle own feelings of anger

What type of therapeutic communication techniques direct client actions, thoughts and feelings back to the client? * Reflecting Presenting Reality Consensual Validation Focusing

Reflecting

When upset, the patient curls in to a fetal position in bed. The nurse judges the patient to be exhibiting: * Substitution Fixation Symbolization Regression

Regression

What type of non-therapeutic communication refuse to consider or show contempt for the client's ideas or behaviors? * Probing Testing Rejecting Using Denial

Rejecting

While the nurse is talking with a client, a female client comes up and yells, "I hate you. You're talking about me again, "and throws a glass of juice at the nurse. The best nursing approach would be to: * Remove the client to an isolation room because she needs to have limits placed on her behavior Ignore both the behavior and the client, clean up the juice, and talk to her when she is better Verbalize feelings of annoyance as an example to the client that it is more acceptable to verbalize feelings than to act out Understand her behavior and say, "You hate me? Tell me about that."

Remove the client to an isolation room because she needs to have limits placed on her behavior

To assess the client's ability to concentrate, the nurse would instruct the client to do which of the following?

Repeat the days of the week backward.

A nurse suspects a co-worker is signing out narcotics for patients and is using them herself. Which action should be taken by the nurse who has these suspicions?

Report the observations to the supervisor

The nurse is teaching a patient to recognize early signs of anger and aggression. The nurse explores ways that the patient can recognize which of the following?

Restlessness and irritability

Displaying one type of expression; usually serious or somber

Restricted Affect

Projective personality assessment; 10 stimulus cards of inkblots; client describes perceptions of inkblots; narrative interpretation discusses areas such as coping styles, interpersonal attitudes and characteristics of ideation

Rorschach Test

What is the number one concern during assessment?

Safety

A community health nurse is planning a substance abuse prevention program. Which group would be the best target audience for the nurse to plan a program?

School age children in an after school program

Global Assessment of Functioning (GAF)

Scores on Axis V of DSM IV -TR a. done by clinicians to estimate overall psychological health and illness using a 100 point scale b. generally scores of 0-40 reflect patients requiring hospitalization c. scores of 71-80 are considered minimal psychopath

The hospitalized client has begun taking Bupropion (Wellbutrin) as an antidepressant agent. The nurse monitors this client for which adverse effect indicating that the client is taking an excessive amount of medication? * Seizure activity Dizziness when getting upright Constipation Increased weight

Seizure activity

Which of the following is a generally accepted criterion of mental health? * Self-acceptance Absence of anxiety Ability to control others Happiness

Self-acceptance

How would you describe yourself as a person?

Self-concept

The way one views oneself in terms of personal worth and dignity

Self-concept

Factors contributing to mental illness can also be viewed within individual, interpersonal, and social/cultural categories. Which of the following includes individual factors? * Ineffective communication, inadequate social support, and loss of emotional control Negative view in the world, racism, and sexism Homelessness, discrimination, and violence Sense of disharmony in life, loss of meaning in one's life, and intolerance of life's uncertainties

Sense of disharmony in life, loss of meaning in one's life, and intolerance of life's uncertainties

Projective personality assessment; client completes a sentence from beginnings such as "I often wish..." "Most people..." and "When I was young..."

Sentence Completion Test

The nurse encourages the patient with dementia to meet nutritional needs. Which of the following is the best approach to assist in meeting adequate dietary intake?

Serve meals in small, bite-size pieces

The nurse is assessing a 16 month old-child during a well-baby check-up. Deficiencies in the following areas may indicate early signs of autistic disorder? (Select all that apply)

Social interaction, Motor skills, Speech patterns

Who is the first chief nurse of the mental hospital? * Jesus Bagan Lara Magda Carolina Go Vera Llamanzares Sotera V. Capellan Nenita Yasay-Davadilla

Sotera V. Capellan

Neurochemical influences on substance abuse patterns point to which of the following explanations as the probable cause of substance abuse?

Stimulation of dopamine pathways in the brain

A client admitted for suicidal ideation progresses satisfactorily an dis to be discharged from the unit within a day or two. The client denies suicidal tendencies and the staff is pleased with the client's progress. One day the door to the unit is accidently left unlocked. Fifteen minutes later the client is gone and is found hanging in the bathroom. In this situation: * The lifting of the depression demonstrated the client's recovery, so supervision was unnecessary Suicidal clients should be observed until all symptoms of depression disappear Determined clients almost always succeed at suicide, even with constant supervision The client's actions should have been anticipated by the nurse

Suicidal clients should be observed until all symptoms of depression disappear

During an assessment, which would be the most important question topic?

Suicidal ideation The client's safety is a priority. Asking clients clearly and directly about suicidal ideation is essential.

During an assessment, which would be the most important question topic? History Roles and relationships Suicidal ideation Motor behavior

Suicidal ideation The client's safety is a priority. Asking clients clearly and directly about suicidal ideation is essential.

What type of therapeutic communication techniques developed a concise resume of what has transpired? * Suggesting Collaboration Seeking Information Summarizing Silence

Summarizing

The nurse is caring for a client with a phobia who is being treated for the condition. The client is introduced to short periods of exposure to the phobic object while in a relaxed state. The nurse understands that this form of behavior modification can be described as: * Systematic desensitization Milieu therapy Aversion therapy Self-control therapy

Systematic desensitization

A patient with dementia is starting pharmacotherapy to slow the progression of cognitive decline. The patient has a history of moderate but steady alcohol use over the past 45 years. Which of the following medications should the nurse question as least suitable for this patient?

Tacrine (Cognex)

You are meeting with a client who has been suffering depression after the loss of her sister. You ask her how she has been coping since you last met. She replies, "fine, I guess..." So you delve deeper, and ask what she has been doing to cope. Her response is this: "Well retail therapy is always a good thing... hey, have you been to Kohl's lately? They're having this great sale on dresses. I found a beautiful green one that just looked amazing on me. So I had to buy it, and I'm so glad I did." She never truly answers your question. What type of thought process is this client exhibiting?

Tangential thinking

The nurse notes that a client diagnosed with schizophrenia is moving her mouth, protruding her tongue, and grimacing as she watches television. The nurse determines that the client is experiencing: * Hypertensive crisis Tardive dyskinesia Neuroleptic malignant syndrome Torticollis

Tardive dyskinesia

The nurse understands that when working with a child with a mental health problem, the family must be included in the care. One of the best ways the nurse can advocate for the child patient is which of the following?

Teach the parents age appropriate expectations of the child

If the client decided to leave the clinic before the assessment formally began, what would the nurse need to do?

Tell the client that the nurse needs to know if the client is safe (from suicidal ideas or self-harm urges). If the client is safe, she can leave the clinic. If she is not safe, the nurse must ask her to stay or must call emergency services (911) if necessary.

A patient is clenching his fists and yelling at another patient on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time?

Tell the patient to stop and take a time out

Objective personality test that involves 100 true/false items; provides information on 14 scales related to self-concept

Tennessee Self-Concept Scale (TSCS)

Unresolved feelings related to loss most likely may be recognized during which phase of the therapeutic nurse-client relationship? * Trusting Orientation Working Termination

Termination

What phases of therapeutic nurse-client relationship identify responses related to separation such as anger, distancing from the relationship, a return of symptoms and dependency? * Orientation Phase Working Phase Pre-interaction Phase Termination Phase

Termination Phase

This assessment should be completed within three days of admission, and includes a list of thirty items such as the client's appearance, affect, mood, memory, and perceptions, and rates each item on a scale of zero (never) to four (always)

The Nurses' Observation Scale for Inpatient Evaluation (NOSIE)

A parent is concerned that his child might suffer from Attention Deficit Hyperactivity Disorder (ADHD). Which of the following behaviors reported by the parent would further support diagnosis?

The child interrupts others

What, if any, assumptions might the nurse make about this client and her situation?

The client is in crisis. The client is seeking help/treatment. The client is not currently stable.

A nurse is viewing laboratory values for a client on psychotropic drugs who has elevated BUN (blood urea nitrogen) and serum creatinine levels. Why should the nurse be concerned regarding these laboratory values? The client may need an increased dose of medication. The client may be at risk for toxicity from the medication. The client may need to have the medication more frequently. The client may not be able to metabolize the medication.

The client may be at risk for toxicity from the medication. Elevated BUN and creatinine levels can be an indication of a problem with the kidneys that would affect excretion of the medication. If the client is unable to excrete the medication, there is a risk for drug toxicity. Therefore, the client would not need more medication with an increased dose or frequency. The client would have elevated liver enzymes that could affect metabolism of the drug instead of these laboratory values.

A

The client spoke of a current event in the national news and described it as it relates to the client. Then the client spoke of a historical event and described it as it relates to the client. Which of the following questions might the nurse ask to determine if the client is experiencing ideas of reference? A) ìWhere were you when this happened?î B) ìWhy do you think that?î C) ìAre you sure?î D) ìThat is unbelievable!î

A

The client tells the nurse, ìThat new TV anchor is telling the world about me.î This is an example of A) ideas of reference. B) persecutory delusions. C) thought broadcasting. D) thought insertion.

A 33-year-old female client with a diagnosis of bipolar I disorder has a history of having reckless, frequent, and anonymous sexual encounters during manic periods. As a result, she has recently tested positive for a chlamydial infection. What is the most appropriate outcome for this client?

The client will demonstrate three positive coping strategies when feeling the impulse to seek new sexual encounters. Outcome must be measurable and specific in order to be clinically useful. The demonstration of coping skills meets these criteria. Complying with treatment may be necessary but does not address the core diagnosis. Showing "better self-control" and controlling mood are less measurable outcomes.

The nurse employed in a mental health unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse anticipates which of the following? * The client's family will resist treatment measures The client will be angry and will refuse care The client will participate in the planning of the care and treatment plan The client will resist treatment measures

The client will participate in the planning of the care and treatment plan

Why is the client's health status an important aspect of the psychosocial assessment?

The client's physical state can impact their emotional state as a result of pain, fatigue, etc. Medication or rest may be necessary to complete the assessment.

In planning the care of a client who has been admitted to the hospital after a suicide attempt, an expected outcome should relate directly to what? The client's refraining from suicide attempts The client's compliance with therapy The client's coping skills The client's mood and affect

The client's refraining from suicide attempts The outcome statement should be directly related to the nursing diagnosis. In the case of client who has attempted suicide, an expected outcome should be the absence of further attempts.

Why is cultural awareness so important in a psychosocial interview?

The culture can influence what the client considers their role in society to be, and can also effect what they believe is acceptable social or personal behavior.

A client's frequent night awakenings, early morning rising, and daytime drowsiness have prompted the nurse to add a diagnosis of "disturbed sleep pattern" to the client's plan of care. What information should immediately follow this diagnosis? Previous attempts at alleviating the diagnosis The DSM-IV-TR diagnosis that corresponds to the nursing diagnosis The client's preferred intervention for the diagnosis The evidence supporting the diagnosis

The evidence supporting the diagnosis A nursing diagnosis should be followed by the cues and judgments that underlie the diagnosis. This is normally accomplished by following the diagnosis with statements such as "evidenced by," "related to," and "demonstrated by."

The nurse is talking with the friend of a client with alcoholism. The friend tells the nurse that his relationship with the client was codependent and enabling. Which of the following is an example of codependent behavior?

The friend called the client every night to make sure he got home safely and went looking for him if he was not at home.

A client has escalating behavior issues and is threatening to leave the unit. Which factor is most important for the nurse in selection of a type of restraint for this client? Ankle restraints are best to be used to keep a client from escaping from the unit. A client can be restrained in the bed with a tightly tucked sheet to limit movement. Medications administered can also be considered a type of restraint for a client. The least restrictive method of restraint should be used to keep the client safe.

The least restrictive method of restraint should be used to keep the client safe. While all of these are important concepts related to restraints, the one that is the most important in considering the least restrictive method of restraint in order to keep the patient safe. Deescalation techniques should always be tried first as least restrictive. Ankle restraints, chemical restraints, and tucked in sheets would not be used before deescalation techniques since they are all methods of restraints.

When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore? The proximity of the networks to the client The length and quality of relationships Challenges faced with social networks The number of networks

The length and quality of relationships Social assessment also includes identification of the person's social network. The nurse should elicit the information about the size and extent of the network, both relatives and nonrelatives, and the length and quality of the relationships.

A

The nurse asks a patient to list the days of the week in reverse order. The nurse is assessing which of the following? A) Concentration B) Memory C) Orientation D) Abstract thinking

A

The nurse asks the client, ìWhat is similar about a cow and a horse?î and ìWhat do a bus and an airplane have in common?î These questions would best assess which of the following areas? A) Intellectual function B) Insight C) Judgment D) Memory

D

The nurse best assesses a patient's memory by asking which of the following questions? A) ìDo you have any problems with memory?î B) ìWhat did you have for lunch yesterday?î C) ìDo you know where you are?î D) ìWho is the current president?î

A patient with dementia gets angry and begins to yell at the nurse during mealtime. The nurse leaves the patient's side for 5-10 minutes and then returns. Which of the following best explains the nurses' behavior?

The nurse gave the patient a chance to calm down before resuming the meal

B

The nurse has completed the psychosocial assessment. Which of the following is the best approach toward analysis of the data to identify nursing diagnoses and develop an appropriate plan of care? A) Focus on each piece of information obtained from the patient. B) Look for patterns reflected in the overall assessment. C) Consider only the abnormal findings in the assessment. D) Present all data obtained in the treatment team meeting.

CBDA

The nurse is assessing suicide potential in a patient who has expressed hopelessness. In what order does the nurse question the patient about suicidal thoughts? A. ìHow would you carry out this plan?î B. ìDo you have a plan to kill yourself?î C. ìAre you thinking of killing yourself?î D. ìHow do you plan to kill yourself?î

A patient is readmitted to the detox unit for the 4th time in 3 years. The nurse states in the morning report, "Not again! Why should we keep trying to help this guy? He obviously doesn't want it." This statement reflects which of the following?

The nurse lacks the self awareness to work effectively with this addicted patient

ACD

The nurse plans to assess a patient's self-concept in the admission assessment knowing that self-concept influences which of the following? Select all that apply. A) Body image B) Cognitive processing C) Frequently experienced emotions D) Coping strategies E) Responsiveness to medications

A

The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient? A) Delusional thinking B) Ideas of reference C) Word salad D) Hallucination

The nurse is discussing the principles of 12-step programs for recovery with a patient. Which of the following is consistent with the principles of 12-step programs?

The patient will need to abstain from all substances for successful recovery

A nurse working in an assisted living facility is holding an in-service for the nursing assistants. The nurse reviews common behaviors associates with cognitive deterioration associated with dementia. The nurse would evaluate the assistants' correct understanding if which of the following were expressed during a post-test?

The patients may not recognize family when they come to visit

The nurse reviews results of the Minnesota Multiphasic Personality Inventory (MMPI) recorded in a patient record. While considering the usefulness of this data, the nurse is mindful that the MMPI has which limitation?

The results of the MMPI could be culturally biased

Projective personality assessment: 20 stimulus cards with pictures; client tells a story about the picture; narrative interpretation discusses themes about mood state, conflict, and quality of personal relationships

Thematic Apperception Test (TAT)

Hildegard Peplau is best known for her writing about: * Humane treatment Community-based care Therapeutic nurse-client relationship Psychopharmacology

Therapeutic nurse-client relationship

A client has been admitted to the inpatient unit after using inhalants recently. Which of the following is an antidote to treat inhalant toxicity?

There is no antidote

A delusion represents a problem in which of the following areas?

Thinking

A client is responding to your question, but suddenly stops mid-sentence. You wait, and wait, but they never complete their sentence. What type of thought content is the client exhibiting?

Thought Blocking

You're conducting an initial assessment on a client. You ask him why he is here today, and he stares back at you. You wait for a response. Finally he says, "You know." You ask, "what do I know?" The client responds, "you know everything. Everyone knows everything. Everyone can hear what I'm thinking." What type of thought process is this?

Thought Broadcasting

What the client is thinking; what the client says

Thought Content

During an interview, your client becomes agitated. She covers her ears and yells, "stop trying to put ideas in my head!" What type of thought process may she be exhibiting?

Thought Insertion

How the client is thinking; can be inferred from speech and speech patterns

Thought Process

You are interviewing a client, and he seems quiet and withdrawn. You say, "Tell me what you are thinking." He responds with, "I can't. They took my thoughts. Every last one of them." What type of thought process is he exhibiting?

Thought Withdrawal

When the nurse is assessing whether or not the client's ideas are logical and make sense, the nurse is examining which of the following?

Thought process

Which aspect of the mental status exam refers to information about how the client's thoughts connect to one another? Mood Orientation Behavior Thought process

Thought process Thought process refers to data about how thoughts connect to one another. One of the most basic assessments of cognitive function is the client's orientation to person, place, and time.

C

Throughout the assessment, the client displays disorganized thinking, jumping from one idea to another with no clear relationship between the thoughts. The nurse would assess the client as having which of the following? A) Tangential thinking B) Ideas of reference C) Loose associations D) Word salad

A young female client, age 16, is admitted to the psychiatric service with the diagnosis of anorexia nervosa. She has lost 20 pounds in 6 weeks. She is very thin but excessively concerned about being overweight, her daily intake is 10 cups of coffee. The most important initial nursing intervention would be to: * Try to establish a relationship of trust Explain the value of good nutrition Explore the reasons why she does not eat Compliment her on her lovely figure

Try to establish a relationship of trust

The nurse has been working with the family of a small child with oppositional defiant disorder. The nurse is feeling very frustrated because the parents refuse to implement effective parenting skills that the nurse has taught. What is the best action for the nurse at this time?

Try to remember that the parents are trying to the best of their ability to carry out the suggestions

A new nurse has been working with Alzheimer's patients for almost 6 months. During a staff meeting the nurse expresses frustration because the same instructions have to be giving to patients on a daily basis. The nurse states, "I feel like all my work doesn't do them any good." The nurse's supervisor should encourage the nurse to do which of the following?

Try to stay supportive and meet the patients' needs at the current moment

A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. The best approach by the nurse would be to

Use brief statements and questions to obtain information

The parents of a child with ADHD express to the nurse, "We get so frustrated when our son never minds us." The nurse discusses which of the following as possible helpful parenting strategies? (Select all that apply)

Use time-out for behavior control, Give verbal reprimands for negative behavior, Use a point system for positive and negative behavior

A client admitted to the mental health unit is experiencing disturbed thought processes and believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat? * Offering opinions about the necessity of adequate nutrition Using open-ended questions and silence Identifying the reasons that the client may not want to eat Focusing on self-disclosure regarding food preferences

Using open-ended questions and silence

The nurse caring for an elderly woman with dementia has asked the woman's children to bring old photo albums when they visit. Which of the following best describes the usefulness of viewing photos when caring for the dementia patient?

Viewing photos will help stimulate remote memory

A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient?

Wandering off the topic and never answering the question

Maintenance of posture or position over time even when it is awkward or uncomfortable

Waxy Flexiblity

hygiene and grooming appropriate dress posture eye contact unusual speech or mannerisms

What are you looking for in the assessment of motor behavior?

Which of the following is an example of an open-ended question?

What concerns you most about your health?

If a client makes remarks that are angry or hostile in regards to another person, what assessment questions must the nurse ask?

What thoughts have you had about hurting them? What is your plan? What do you want to do to them?

ABC

When assessing a patient's mental health status, which of the following describe the purpose of the psychosocial assessment? Select all that apply. A) To assess the client's current emotional state B) To assess the client's mental capacity C) To assess the client's behavioral function D) To assess the client's plan of care E) To assess the client's physical health status

D

When the nurse asks the client to restate the following in his or her own words, which sensorium and intellectual process is the nurse attempting to identify? The nurse states, ìA stitch in time saves nine.î A) The client's orientation B) The client's memory C) The client's ability to concentrate D) The client's ability to use abstract thinking

Thought Process

When the nurse is assessing whether or not the clients ideas are logical and make sense, the nurse is examining which of the following? thought content thought process memory sensorium

Which of the following is an example of a closed-ended question?

Where are you employed?

ACDE

Which of the following are components of the assessment of thought process and content? Select all that apply. A) What the client is thinking B) Abstract thinking abilities C) How the client is thinking D) Clarity of ideas E) Self-harm or suicide urges

ABCD

Which of the following are the types of roles that are usually included when assessing roles and relationships? Select all that apply. A) Family B) Hobbies C) Occupation D) Activities E) Race F) Ethnicity

C

Which of the following factors influencing assessment is under the nurse's control? A) Client participation and feedback B) Client's health status C) Nurse's attitude and approach D) Client's ability to understand

B

Which of the following is the most compelling reason for the nurse to discuss matters of sexuality and suicide? A) It is required by the law by the federal government and in most states in the union. B) It is the nurse's professional responsibility to keep safety needs first and foremost. C) This is commonly required documentation for every encounter with every client. D) It allows the nurse to gain valuable experience in these kind of difficult discussions.

B

Which of the following questions is best to ask when assessing the client's judgment? A) ìCan you describe your usual daily activities for me?î B) ìIf you found yourself downtown without money or a car, how would you get home?î C) ìOn a scale of 1 to 10, how stressed would you rate yourself?î D) ìWhat problem would you like to work on while you're hospitalized?î

B

Which of the following would best assess a client's judgment? A) Counting by serial sevens B) Discussing hypothetical situations C) Interpreting proverbs D) Spelling words backward

The nurse best assesses a patient's memory by asking which of the following questions?

Who is the current president?

Upon meeting your client for the first time, you notice her speech is slightly unintelligible. You ask why she is here, and her response is this: "The sheep languished blue trains suffer windows books dogs hands run desk making dinner sunglasses." What type of thought content is this?

Word Salad

What phases of therapeutic nurse-client relationship identifies themes and patterns of behavior that promotes insights into problem-solving and coping mechanisms? * Pre-interaction Phase Termination Phase Working Phase Orientation Phase

Working Phase

Defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity. * Department of Health Hildegard Peplau World Health Organization Linda Richards

World Health Organization

A hospitalized client is started on Phenelzine Sulfate (Nardil) for the treatment of depression. The nurse instructs the client to avoid consuming which foods while taking this medication? Select all that apply * Yogurt Crackers Aged cheese Tossed salad

Yogurt Aged cheese

The client who believes everyone is out to get him or her is experiencing a(n) a.delusion. b.hallucination. c.idea of reference. d.loose association.

a

Assessment of sensorium and intellectual processes includes which of the following? a.Concentration b.Emotional feelings c.Memory d.Judgment e.Orientation f.Thought process

a c e

Assessment of suicidal risk includes which of the following? a.Intent to die b.Judgment c.Insight d.Method e.Plan f.Reason

a d e f

When planning patient teaching for a patient who has been receiving lithium for the past 2 weeks for treatment of bipolar disorder. The nurse understands that the patient needs to know that: * serum lithium levels will be monitored once a month a double dose can be taken when there is a missed dose a low-sodium diet must be maintained it is alright to drink coffee when taking lithium

a low-sodium diet must be maintained

A nurse is completing a mental health assessment. When the nurse asks a client to interpret a proverb, the nurse is assessing: insight concentration abstract reasoning memory

abstract reasoning To test abstract reasoning and comprehension, a nurse might give a client a proverb to interpret. To test attention and concentration, the nurse asks the patient, without a pencil or paper, to start with 100 and subtract 7 until reaching 65 or start with 20 and subtract 3. There are four spheres of memory to check: recall, or immediate, memory; short-term memory; recent memory; and long-term, or remote, memory. Insight and judgment are related concepts that involve the ability to examine thoughts, conceptualize facts, solve problems, think abstractly, and possess self-awareness. Insight is a person's awareness of his or her own thoughts and feelings and ability to compare them with the thoughts and feelings of others.

A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement? affect blocking mood feelings

affect Affect refers to a person's emotional expression (in this case, the manner in which the client talks about the client's experiences). Feelings are emotional states or perceptions. Blocking is the interruption of thoughts. Moods are prolonged emotional states expressed by the affect.

The nurse should introduce information about the end of the nurse-patient relationship: * at least one or two sessions before the last meeting when the patient was able to tolerate it as the goals of the relationship is reached during the orientation phase

as the goals of the relationship is reached

Assessment data about the client's speech patterns are categorized in which of the following areas? a.History b.General appearance and motor behavior c.Sensorium and intellectual processes d.Self-concept

b

The client tells the nurse "I never do anything right. I make a mess of everything. Ask anyone, they'll tell you the same thing." The nurse recognizes these statements as examples of a.emotional issues. b.negative thinking. c.poor problem-solving. d.relationship difficulties.

b

When the nurse is assessing whether or not the client's ideas are logical and make sense, the nurse is examining which of the following? a.Thought content b.Thought process c.Memory d.Sensorium

b

Which of the following is an example of an open-ended question? a.Who is the current president of the United States? b.What concerns you most about your health? c.What is your address? d.Have you lost any weight recently?

b

Thought withdrawal example:

believes that her thoughts have been removed from her mind by an outside agency

Which intervention uses the reading of written materials to express feelings or gain insight?

bibliotherapy Bibliotherapy is the reading of selected written materials to express feelings or gain insight under the guidance of a health care provider. Reminiscence, which is thinking about or relating to past experiences, is used as a nursing intervention to enhance life review in older patients. Behavior modification is a specific, systematized behavior therapy technique that can be applied to individuals, groups, or systems. Behavior modification aims to reinforce desired behaviors and extinguish undesired ones. Used in inpatient settings and group homes, a token economy applies behavior modification techniques to multiple behaviors. In a token economy, patients are rewarded for selected desired behaviors with tokens, which they can use to purchase meals, leave the unit, watch television, or wear street clothes.

Which intervention uses the reading of written materials to express feelings or gain insight? token economy behavior modification bibliotherapy reminiscence

bibliotherapy Bibliotherapy is the reading of selected written materials to express feelings or gain insight under the guidance of a health care provider. Reminiscence, which is thinking about or relating to past experiences, is used as a nursing intervention to enhance life review in older patients. Behavior modification is a specific, systematized behavior therapy technique that can be applied to individuals, groups, or systems. Behavior modification aims to reinforce desired behaviors and extinguish undesired ones. Used in inpatient settings and group homes, a token economy applies behavior modification techniques to multiple behaviors. In a token economy, patients are rewarded for selected desired behaviors with tokens, which they can use to purchase meals, leave the unit, watch television, or wear street clothes.

The client's belief that a news broadcast has special meaning for him or her is an example of a.abstract thinking. b.flight of ideas. c.ideas of reference. d.thought broadcasting.

c

To assess the client's ability to concentrate, the nurse would instruct the client to do which of the following? a.Explain what "a rolling stone gathers no moss" means. b.Name the last three presidents. c.Repeat the days of the week backward. d.Tell what a typical day is like.

c

"i feel, i kneel, do you steal?

clang association

In regards to the mental status exam, the fewer tasks the client completes accurately, the greater the ____ ____.

cognitive deficit

the nurse asks a patient to list the days of the week in reverse order. the nurse is assessing which of the following

concentration

The nurse encourages an older adult client to write a letter to an old friend. What therapy is the nurse utilizing as an intervention? behavior therapy reminiscence cultural brokering bibiliotherapy

cultural brokering With a client who needs to navigate the healthcare system, the nurse can assist the client through cultural brokering. Cultural brokering can bridge, link, or mediate messages, instructions, and belief systems between groups of people to help reduce conflict or produce change. Cognitive intervention relates to changing or reframing a client's thought processes that develop over time and cause the individual to not function as well as possible. Behavior modification would be a technique used to reinforce positive behaviors and extinguish negative ones. With token economy, the client has behavior modification with multiple behaviors through earning tokens for positive behavior.

Which of the following is an example of a closed-ended question? a.How have you been feeling lately? b.How is your relationship with your wife? c.Have you had any health problems recently? d.Where are you employed?

d

The client who believes everyone is out to get him or her is experiencing a(n)

delusion.

The patient states that he is 14 trillion years old and created the world. The nurse documents this statement as an example of which type of thinking displayed by the patient?

delusional thinking

Which of the following would best assess a client's judgment?

discussing hypothetical situations

loose association

disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts

A client states to the nurse "I am so excited about my family coming to visit" and is smiling and laughing. How will the nurse document the client's mood? euthymic dysphoric labile euphoric

euphoric The nurse would document that the client is exhibiting a euphoric mood, which means being elated, when expressing excitement and appearing happy by smiling and laughing. If a client's mood is described as euthymic, this is considered normal. A client exhibiting a dysphoric mood appears depressed, disquieted or restless. The client with a labile mood is exhibiting a changeable mood that varies widely over a short period of time.

Circumstantiality

eventually gets to the point

Delusions

false beliefs, often of persecution or grandeur, that may accompany psychotic disorders

A patient shows no facial expression when engaging in a game with peers during an outing at a park. The nurse uses which of the following terms when documenting the patient's affect?

flat affect

A nurse is completing an assessment interview, and is attempting to bring the conversation back to the questions at hand when the client goes off on a tangent. Which assessment interview behavior is the nurse using? presenting reality restating focusing reflecting

focusing When using focusing, the nurse attempts to bring the conversation back to the questions at hand when the client goes off on a tangent. Reflecting occurs when the nurse presents the client's last statement as a question. The nurse presents reality when the patient makes unrealistic or exaggerated statements. The nurse tries to clarify what the patient is trying to say by restating it.

Communication is a basic element of psychiatric nursing interventions. Which of the following techniques of communication is appropriate when initiating a conversation? * focusing giving broad opening reflecting use of silence

giving broad opening

A client is admitted to the psychiatric unit and states, "I am president of the largest corporation in the world. Everyone comes to me for advice." The client is exhibiting which of the following?

grandiosity

False sensory perceptions that do not really exist; can involve any of the five senses and bodily sensations

hallucinations

the client tells the nurse that new tv anchor is telling the world about me. example of

ideas of reference

The client's belief that a news broadcast has special meaning for him or her is an example of

ideas of reference.

When the nurse asks the client, Are you thinking about killing yourself?" The nurse is questioning which component of a suicide assessment?

ideation

A client at a mental health facility states to the nurse "I am not sure why I am here; there is nothing wrong with me." This indicates to the nurse a lack of which concept for the client? judgment insight comprehension cognition

insight The client who doesn't understand the reason for admission to a mental health facility is demonstrating a lack of insight, which means that the client is not aware of how others view his or her own behavior. The client's cognition would be the ability to think and know and is tested by the nurse performing calculation, reasoning, or memory tests. The client's comprehension is understanding and would be determined by showing an object such as a coin and asking what the object is. The client's judgment is the ability to reach a logical decision about a situation and choose a course of action and the nurse would give the client a simple scenario and ask the client to identify the best response.

The nurse asks the client, "What is similar about a cow and a horse?" and "What do a bus and an airplane have in common?" These questions would best assess which of the following areas?

intellectual function

A patient reports to the nurse that on his way to the clinic a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the patient sates, "I pulled over of course.' The nurse documents that the patient displayed appropriate:

judgment

A patient reports to the nurse that on his way to the clinic a policeman in a patrol car turned on his lights and pulled him over. When asked what he did next, the patient sates, "I pulled over of course.' The nurse documents that the patient displayed appropriate:

judgment.

In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as

labile mood

In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as: lack of insight. tangential thinking. flight of ideas. labile mood.

labile mood. Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight of ideas is manifested by excessive amount and rate of speech composed of fragmented or unrelated ideas. Lack of insight would be manifested by the lack of the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Tangential thinking would be manifested by wandering off the topic and never providing the information requested.

Throughout the assessment, the client displays disorganized thinking, jumping from one idea to another with no clear relationship between the thoughts. The nurse would assess the client as having which of the following?

loose associations

waxy flexibility

maintenance of posture or position over time even when it is awkward or uncomfortable

The nurse is interviewing a client admitted for obsessive-compulsive disorder and states to the client "I notice your foot is tapping, do you feel nervous?" Which interview behavior is the nurse using? making observations giving recognition focusing restating

making observations The nurse is making an observation when drawing attention to a behavior by the client that will allow the client to speak to the behavior. If giving recognition, the nurse would be listening actively to the client and demonstrate this through asking the client to continue and appearing open and interested. The nurse who restates would be trying to clarify what the client is saying. The nurse would focus the client who may go off in a tangent and needed to be brought back to the questions being asked.

when assessing a patient's mental health status, the nurses include which of the following as a major focus of the assessment

mental capacity

The nurse must determine whether the depressed or hopeless client has suicidal ideation or a lethal plan. When the nurse asks the client, "How do you plan to kill yourself?" the nurse is questioning which component of a suicide assessment?

method

What is a nursing intervention used in the social domain?

milieu therapy Examples of nursing interventions used in the social domain include behavior therapy, milieu therapy, and various home and community interventions. Counseling is a nursing intervention related to the psychological domain. Self-care and nutrition are related to the biologic domain.

The client tells the nurse "I never do anything right. I make a mess of everything. Ask anyone, they'll tell you the same thing." The nurse recognizes these statements as examples of

negative thinking.

tangentially

never gets to the point

neologism

new word "daddle"

mutism

no attempt to communicate

thought broadcasting

others know ones thoughts

psychomotor retardation

overall slowed movements

During the assessment, the nurse asks the client to describe his problems. The purpose of this question is to obtain information about the client's

perception of the problem

What is part of the social component in a psychiatric-mental health nursing assessment?

quality of life Components of the social assessment include functional status, social systems, and quality of life. Mental status is part of the psychological assessment. The biologic assessment includes current and past health status, physical examination with review of body systems, review of physical function, and pharmacologic assessment. A risk factor assessment is part of the psychological assessment.

Sexuality and self-harm behaviors are often difficult areas for nurses to assess. An effective way for nurses to deal with this discomfort includes:

recognizing that these areas may also be uncomfortable for the patient to discuss.

automatism

repeated, seemingly purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot; unconscious mannerism

The basis for a therapeutic nurse-patient relationship begins with the nurses? * self-awareness and understanding sincere desire to help others acceptance of others sound knowledge of psychiatric nursing

self-awareness and understanding

Mood

sustained emotion

The patient on antipsychotic drug has been found to exhibit bizarre facial and tongue movements. Based on these findings the patient is most likely exhibiting signs and symptoms of which disorder? * tardive dyskinesia akinesia pseudoparkinsonism oculogyric crisis

tardive dyskinesia

A nurse assesses that a depressed client is lethargic during the day and does not actively participate in unit activities. The notes from the night shift document that the client did not sleep well. The most probable interpretation of these data is:

the client's depressed mood is impairing restful sleep patterns. Emotional problems often affect some areas of physiologic function. Emotional problems can greatly affect eating and sleeping patterns. However, this does not necessarily mean that the client's medications are ineffective. Noise keeps many clients awake, but the most likely explanation involves the client's admitting diagnosis and priority problem. There is no indication of noncompliance.

A nurse assess that a depressed patient is lethargic during the day and does not actively participate in unit activities. When reviewing the chart form the night shift it is noted that the patient did not sleep well. The most probable interpretation of this data is:

the patient's depressed mood is impairing restful sleep patterns.

ideas of reference

the tv is talking to me

A client arrives to the mental health clinic in the summer and is wearing a sweater. In which area would the nurse determine that the client has a disturbance? insight memory thermoregulation hydration

thermoregulation The client wearing a sweater in the summer likely has a disturbance in thermoregulation which may be due to a psychiatric disorder or medication. It is important to educate clients regarding this potential problem and strategies for protection. Having a memory disturbance regarding the month would not affect the client's ability to sense temperature changes. The client's insight would involve the client not being aware of what others think. The client's hydration would potentially be affected with thermoregulation but there is not information related to hydration status to make this judgment.

A delusion represents a problem in which of the following areas?

thinking

A nurse is initiating a home visit for a client diagnosed with schizophrenia. In which phase of the home visit is the implementation of service initiated?

third The implementation of service is the third phase of the home visit. The first phase is the greeting phase, in which the nurse establishes rapport with family members. The second phase establishes the focus of the visit. The fourth phase is closure or the end of the home visit.

thought insertion

thoughts are put into their head

A patient reports drinking 1-2 drinks when drinking behavior first began. Now the patient reports drinking at least 6 drinks with every episode in order to "Have a good time". The patient is describing the phenomenon known as:

tolerance.

thought process

using the mind; psychosis

A patient is known to express tangential thinking. The nurse would assess for which of the following when interacting with the patient?

wandering off the topic and never answering the question

tangential thinking

wandering off the topic and never providing the info requested

The nurse is developing a teaching plan for the patient receiving Clozapine. The nurse should include the importance of which aspect of follow-up care? * weekly routine complete blood count a monthly EEG a monthly serum sodium level an echocardiogram

weekly routine complete blood count

The nurse best assesses a patient's memory by asking which of the following questions?

who is the current president