Psych final

A client who is hospitalized with depression tells a nurse, "I don't want to take the medication because I'm afraid I'll become suicidal." Which response by the nurse would be most appropriate?

"Have you ever thought about hurting yourself?"

The family of a 22-year-old client with bipolar disorder is having difficulty coping with the client's rapid mood swings, irritability, grandiose delusions, and overly intrusive behaviors. Following a visit to the unit, the parents discuss their frustration and anger with the nurse and ask what they should do to help the client. Which reply by the nurse is most appropriate?

"Help the client monitor medication adherence and watch for changes in mood and sleep."

A client calls the emergency department of the local hospital reporting that after 16 years of heavy drinking, the client is tired and wants to quit "cold turkey." What would be the best response by the nurse?

"It is not safe to stop drinking suddenly without medicine."

A client is diagnosed with terminal kidney failure. The client's spouse demonstrates loss and grief behaviors. Which term accurately describes the spouse's experience?

Anticipatory grief

A client is diagnosed with intermittent explosive disorder (IED). What drugs are likely to be prescribed for the client? Select all that apply.

Antidepressant drugs Mood-stabilizing drugs

To care for an acutely suicidal client, which is the most effective initial mode of treatment?

Inpatient care

Which is the priority for admission to inpatient care?

Safety of self or others

The ultimate goal of the treatment plan in inpatient care settings is what?

Stabilize the client

A hospice nurse is providing emotional care and support for a family who lost a child. The nurse will provide care on the basis of what knowledge?

Stages of grief reactions may overlap and are individualized

A client with obsessive-compulsive disorder (OCD) spends several hours each day cleansing the home and washing the hands. The client tells the nurse, "I don't think you quite realize how many bacteria, viruses, and fungi live around us." What is the nurse's most accurate interpretation of this client's statement?

The client may lack insight into the OCD.

In which ways can anticipatory grief be helpful for the client and family?

acceptance of impending death

Which personality disorder is most often treated within the inpatient psychiatric setting?

borderline

When assessing a client's potential for aggression and violence, which would the nurse identify as the most important predictor?

client history

A nurse is assessing a child diagnosed with autism spectrum disorder. When assessing the child's communication, which of the following would the nurse expect to find? Select all that apply.

echolalia (repeating others) delayed language skills

Ecstasy is an example of which type of substance?

hallucinogen

A client has lost a job of 20 years. This is an example of which type of crisis?

situational

A client with schizophrenia is reluctant to take prescribed oral medication. Which is the most therapeutic response by the nurse to this refusal?

"What is it about the medicine that you don't like?"

A client with a persecutory delusion has been explaining to the nurse the specifics of the conspiracy against the client. The client pauses and says, "I get the feeling that you don't actually believe that what I'm telling you is true." How should the nurse respond?

"What you're telling me is difficult for me to believe. This may be real for you, but not me."

Which client is most at risk for experiencing anticipatory grief?

61-year-old spouse of a client experiencing symptomology of moderate-stage Alzheimer disease

A nurse is caring for clients who are psychologically abused. Which clients should the nurse screen for psychological abuse? Select all that apply.

A partner of a client who has destroyed the front door of their home. A client whose partner is monitoring the amount of money spent on food and clothing. A parent of a client who is threatening to injure the family's pet. A partner of client who does not want the client to spend any time with family or friends.

A nurse is preparing an educational session for family members affected by substance abuse. Which point should the nurse include in the session? Select all that apply.

An individual with substance abuse issues typically cannot use drugs socially. (potential for relapse) Substance abuse is an illness like any other.

A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?

Approximately 2 weeks after starting antidepressant medication

A person with temperament traits of high harm avoidance would most likely suffer from which personality disorder?

Avoidant

A 15-year-old is admitted for treatment of anorexia nervosa. Which is characteristic of anorexia nervosa?

Body weight less than normal for age, height, and overall physical health

When teaching a client with generalized anxiety disorder, which is the priority for the nurse to teach the client to avoid?

Caffeine

A client is brought to the emergency department by a friend who tells the staff that the friend thinks the client has overdosed on cocaine. Which findings would help support this situation? Select all that apply.

Cardiac dysrhythmia Chest pain Respiratory depression

The client stated, "I was so upset about my sister ignoring me when I was talking about being ashamed." Which nontherapeutic communication technique would the nurse be using if the nurse stated, "How are your stress reduction classes going?"

Changing the subject

A nurse is preparing a presentation for a local middle school health class about eating disorders as a means for prevention and early detection. Which would the nurse incorporate into the presentation as being common to both anorexia nervosa and bulimia nervosa? Select all that apply.

Cognitive distortions Obsessiveness Body dissatisfaction

Which are effects of alcohol withdrawal syndrome? Select all that apply.

Delirium tremens Hand tremors Seizures Increased pulse

A client in a psychiatric clinic has a history of two distinct personality states. The client is also unable to remember important personal information. What is the client likely to be suffering from?

Dissociative identity disorder

Which is the most important skill the nurse must bring to the therapeutic nurse-client relationship?

Empathy

The nurse is preparing to perform the initial interview of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What action should the nurse prioritize during this interaction?

Establishing therapeutic rapport with the client

During a session with a client, the client asks the nurse what the client should do about the client's "cheating" spouse. The nurse replies, "You should divorce. You deserve better than that." The nurse used which nontherapeutic communication technique?

Giving advice

When documenting observations of the behaviors exhibited by a client diagnosed with borderline personality disorder, the nurse can correctly use which terms?

Impulsive, self destructive, unstable

A nurse is reviewing the history of a client diagnosed with antisocial personality disorder. Which would the nurse expect to find? Select all that apply.

Inflated view of self Rationalization for harming an individual

Which steps are involved in limit setting? Select all that apply.

Inform clients of the rule or limit. Explain the consequences if clients exceed the limit. State the expected behavior.

The traumatized client has suddenly changed demeanor and voice pitch. Which is true about the use of touch with a client with dissociative identity disorder?

It is best not to touch the client without his or her permission.

A client suffers from drug-induced parkinsonism. The nurse notices this client walking with a shuffling gait. What other symptoms might this client show? Select all that apply.

Masklike facies Cogwheel rigidity Drooling Akinesia (slow movement)

Which nursing intervention would be most likely to help the client with anorexia to establish healthy eating patterns?

Offer liquid protein supplements if the client is unable to complete a meal.

Which type of service is provided to medically stable clients who do not require inpatient, residential, or home care environments?

Outpatient care

A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would likely assess which physiologic symptoms of depression?

Psychomotor retardation and poor appetite

A client is being discharged on disulfiram. Which instruction for disulfiram should the client receive?

Read product labels carefully to avoid all products containing alcohol. (cough drops, mouthwash, vanilla extract, lotions, perfume, aftershave, vinegar)

The nurse documents that the client is exhibiting negative symptoms of schizophrenia when observing the client doing what? Select all that apply.

Repeatedly turning down invitations to join in unit activities Inability to maintain to complete a goal-directed activity

Which is the primary objective of nursing interventions in the care of a client with anorexia nervosa?

Restoring nutritional status to normal

When assessing a client with borderline personality disorder (BPD), which behaviors would the nurse expect to find? Select all that apply.

Self-directed anger Learned helplessness Repeated, frequent crisis episodes Deceptive competence

A client with mental illness expresses interest in having a date with the nurse. Which would be the nurse's best response in this situation?

Set boundaries of a professional relationship.

A nurse is assessing a client who has experienced trauma. The nurse determines that the client is experiencing physiologic hyperarousal based on which finding? Select all that apply.

Startles easily Overreacts to others

A nurse is assessing a client with posttraumatic stress disorder (PTSD). Which symptoms in the client would indicate a need for hospitalization? Select all that apply.

The client has suicidal tendencies. The client is overwhelmed with flashbacks of the traumatic event.

The nurse is assessing a client who has been diagnosed with leukemia. Which behavior of the client would indicate that the client is experiencing the anger stage of Kubler-Ross's stages of grieving?

The client is verbally abusive.

The nurse is working with a 17-year-old client with a complex and dysfunctional family background. What aspect of this client's history should the nurse identify as the most significant risk factor for posttraumatic stress disorder (PTSD)?

The client was sexually abused by the mother's boyfriend at a young age

A client with opioid addiction is prescribed methadone maintenance therapy. When explaining this treatment to the client, which of the following would the nurse need to keep in mind?

The drug helps to satisfy the craving for the opioid.

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

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

A client with major depressive disorder is prescribed new drug therapy. To best test the client's adherence to this therapy, which information would the nurse include in the teaching plan for the client? Select all that apply.

The possibility that two or more drugs will be prescribed The length of time treatment is anticipated A detailed description of possible side effects The importance of staying in touch with mental health care provider

Which is one of the most common reasons clients are often concerned about confidentiality of treatment for mental health problems?

They are worried about the opinions of people who know them outside the hospital, due to shame produced by societal views of mental illness.

A nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a client believed to be exhibiting characteristics of a personality disorder?

This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened.

A nurse tells a client that the nurse will come back in 10 minutes to reassess the client's pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing?

Trust (fidelity)

A client taking lithium for bipolar disorder comes to the clinic and reports symptoms which the nurse interprets as consistent with moderate lithium toxicity. Which action should the nurse perform? Select all that apply.

Withhold additional doses of lithium. Push fluids. Contact the physician. Obtain a blood sample for lithium level. Lithium: 0.4-1.4

A nurse is conducting a visit to a client who is receiving palliative care at home for dying. The client's husband tells the nurse, "I know she needs to be with God. This is not a good place for her now." The client is experiencing which stage of Kubler-Ross' stages of grieving?

acceptance

Which stages of grieving, according to Kubler-Ross (1969), occurs when the person asks God or fate for more time to delay the inevitable loss?

bargaining

An intoxicated client was admitted for trauma treatment last night at 2:00 AM (0200). When should the nurse expect to be alert for withdrawal symptoms?

between 8:00 and 10:00 AM (0800 and 1000) today (6 to 8 hours after drinking stopped)

A pre-teen client has been considered a neighborhood bully for several years. Peers avoid him, and the mother says she cannot believe a thing he tells her. Recently, the client was observed shooting at several dogs with a pellet gun and setting fire to a vacant lot for the first time. A nurse would assess these behaviors as being most consistent with which disorder?

conduct disorder

When working with the family of a client with anorexia nervosa, which issue must be addressed?

control

The client is a 29-year-old who is having a great deal of difficulty with a new job. The client has been unable to make decisions individually and feels overwhelmed when the client needs to begin a new project. The client often relies on one of her coworkers to help with decisions and projects. Which would describe the client correctly?

dependent personality

Clonidine is most effective for which symptom of opioid withdrawal?

diarrhea, nausea, vomiting

A nurse is assessing a client with bipolar disorder who is experiencing mania. The client states, "I'm just so beautiful. Everyone just stops and stares at how gorgeous I am. People constantly want to have sex with me." The nurse interprets these statements as indicative of which type of mood?

expansive

A client with a specific phobia of spiders is seeing a therapist for the first session of treatment. The therapist hands the client a clear container with a large house spider inside. This activity is repeated continuously until the client's fear subsides. Which strategy is being used to treat the client's specific phobia?

flooding

What activity should be included in the first step of self-awareness?

identifying one's own values, attitudes, strengths and weakness

The psychiatric nurse expects similar experiences among all clients diagnosed with a Cluster A personality disorder related to ...

interpersonal relationships.

A nurse is seeing a female client who has been mandated to counseling sessions after shoplifting numerous times. Which disruptive behavior disorder is the client most likely experiencing?

kleptomania

A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?

monitor respiratory function

A 20-year-old client arrives at the emergency department by ambulance. The client is unconscious, with slow respirations and pinpoint pupils. There are "tracks" visible on the client's arms. The friend who came with the client reports that the client had just "shot up" heroin when the client became unconscious. Which medication would the nurse most likely expect to administer?

naloxone

Several medications are prescribed for a client who has anorexia. Which medication may be prescribed to help treat the client's distorted body image?

olanzapine

Which disorder is characterized by pervasive mistrust and suspiciousness of others?

paranoid personality disorder

The client says to the nurse that the client is having trouble keeping up with things. The nurse is assessing a client with early signs of dementia. What is the nurse trying to determine when asking what the client ate for breakfast that morning?

recent memory

A nurse is seeing a client in the emergency department who repeatedly presents with gastrointestinal discomfort. Despite exhaustive medical investigations, there are no significant medical findings to explain the discomfort. The nurse should suspect:

somatic symptoms

Which would be most important to assess and document in a client with depression?

suicide risk

The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning their head as if listening to another person. The nurse assesses this behavior as indicating that the client is experiencing auditory hallucinations. What statement by the nurse is most appropriate?

"Are you hearing something?"

When conducting a focused assessment on a newly admitted client who attempted suicide, which question should the nurse include to ensure the client's safety? Select all that apply.

"Are you willing to tell us if you plan to harm yourself again?" "Have you ever tried to hurt yourself before?" "Do you still have a plan to harm yourself?"

The client tells the nurse, "I'm frightened about my surgery tomorrow." What response by the nurse is best?

"Can you tell me what frightens you?"

The client with mania attempts to hit the nurse. Which is the best response by the nurse?

"Do not swing at me again. If you cannot control yourself, we will help you."

When talking with the spouse of a client who attempted suicide, the psychiatric nurse demonstrates understanding of the priority areas of assessment by asking which questions? Select all that apply.

"Does your spouse harm himself or herself physically when stressed?" "Has your spouse attempted to kill himself or herself by injuring him- or herself."

A nurse is counseling a client who lost family members in a cyclone but has never had therapy related to the trauma. Which statement by the client suggests that the client is likely to develop posttraumatic stress disorder (PTSD)?

"I am fine, I am going to move on."

The nurse is working with a client who is experiencing a crisis due to a divorce. Which statement would alert the nurse to the client's need for referral for further mental health counseling?

"I am trying to work through this but have had to cut myself a few times."

If a client states, "I carry this lucky rabbit's foot for luck, my dad did too, and it really works," which statement by the nurse reflects respect for the client's belief?

"I can accept that you feel it is lucky, so let's get to our activities for the day."

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 stomach ache and felt like vomiting. I couldn't help it. I was just so mad at my dad." Which would be the most appropriate response by the nurse?

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

A client diagnosed with schizophrenia tells the nurse, "I hear the voice of Elvis." Which is the most therapeutic response by the nurse?

"I don't hear the voice, but I know you hear what sounds like a voice."

A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

"I'm here to help you just as all the staff members are."

A client with schizophrenia is attending a follow-up appointment at the community mental health clinic. The client reports to the nurse, "I stopped taking the antipsychotic medication because I can't get an erection with my girlfriend anymore." Which should the nurse recommend to enhance the client's well-being?

"It is important for you to take an antipsychotic medication, but perhaps a different type will be less likely to affect your sexual functioning. I would like to call your health care provider about this."

A client who is manic states, "What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?" Which response by the nurse would be most appropriate ?

"Please slow down. I'm not sure what you need first."

A client states, "I am dead. I have come back from the dead." What is the most appropriate response by the nurse?

"Show me what you did in art therapy this morning."

A family member is the primary caregiver to a client with dementia. Which statement by the nurse would be most appropriate?

"Spending some time relaxing and doing what you like to do will help you manage the demands of caregiving."

A client is readmitted to the substance abuse program for the second time in 6 months for alcohol abuse. On admission, the client tells the nurse, "I am so ashamed." What should the nurse reply?

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

The nurse is using limit setting with a child diagnosed with conduct disorder. Which statement 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."

An 80-year-old client with Alzheimer's disease is prescribed donepezil. Which teaching points should the nurse provide to the client's spouse about the new medication?

"The drug won't cure the client's Alzheimer's, but it has the potential to slow down the progression of the disease."

A client comes to the health care provider's office for an annual checkup. During the interview, the nurse learns that the client's spouse died unexpectedly of a heart attack 2 months ago. Which would be the most appropriate response by the nurse?

"The loss of your spouse must be very painful for you."

After an angry outburst, the client is tearful and remorseful. Which statement by the nurse would be most supportive?

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

A client with antisocial personality disorder is begging to use the phone to call the client's spouse, even though it is against the unit rules. The client begs, "It is just this once, and my spouse will be so hurt if I don't call." Which would be the most appropriate response by the nurse?

"You may not use the phone to call your spouse.

Which are cognitive-behavioral therapy techniques that may be used effectively with anxious clients? Select all that apply.

Assertiveness training Decatastrophizing Positive reframing

A client who has been prescribed fluoxetine for depression and has just had the dosage increased comes to the emergency department. The nurse suspects serotonin syndrome based on which assessment? Select all that apply.

Ataxia Change in mental status Diaphoresis Fever Inadequate washout period of taking MAO'I's and SSRI's or when MAOI's are taken with meperidine.

During the nursing assessment, a client describes constantly hearing voices mumbling in the background. The client denies that the voices are telling the client to do anything harmful. The nurse documents that the client is experiencing what?

Auditory hallucinations

A client is being transferred from a group home to an evolving consumer household. The goal of this transition is for the client to eventually do what?

Fulfill daily responsibilities without supervision.

The dentist of a client noticed that the client's teeth were losing enamel and that the client looked extremely thin. The dentist refers the client for follow up based on the understanding that eating disorder is most often associated with dental caries and enamel loss?

Anorexia nervosa, purging type (because thin and weight loss- bulimia is usually normal weight or slightly overweight)

Which drug classification is the primary medication treatment for schizophrenia?

Antipsychotics

The nurse is planning the type of approach that will be most effective in developing a therapeutic relationship with the client. The nurse should use a matter-of-fact approach with clients with which types of personality disorders? Select all that apply.

Antisocial Narcissistic Paranoid

A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time?

Accompany the client to his or her room to get dressed.

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

Alcohol withdrawal syndrome

A nurse is interviewing a client who is suffering from posttraumatic stress disorder (PTSD). Which intervention would help the nurse ensure the client's comfort during the interview?

Keep environmental noises to a minimum.

A 30-year-old client who has not paid rent in 4 months is being evicted from an apartment. The client is brought to the hospital after the client uses a kitchen knife to cut the client's wrist in response to the stress of the eviction. The client's behavior is consistent with what?

Borderline personality disorder always appear to be in a state of crisis, exaggerated response to stressors

A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?

Decrease the client's environmental stimuli.

A nurse is preparing to administer pharmacotherapy as part of the treatment plan for a client with bipolar disorder. The nurse understands that this therapy is designed to achieve which goal? Select all that apply.

Decreased frequency of manic episodes Prevention of future episodes Rapid control of symptoms Decreased severity of manic episodes

What is the primary difference between anorexia nervosa and bulimia nervosa?

Clients who are anorexic are proud of their control over eating, and clients with bulimia are ashamed of their behavior.

With a client who is aggressive with a potential for violence, which item would the nurse want to limit or remove from the breakfast tray?

Coffee

nurse is describing the effects of inhalants to a group of high school students attending a substance abuse prevention class. Which effects would the nurse include in the description? Select all that apply.

Dizziness Hallucinations Slurred speech Euphoria

A client enters the emergency room exhibiting tremors, agitation, and restlessness. Upon assessment, the client's blood pressure is 160/90, pulse is 110, and respirations are 22. It has been 36 hours since the client's last drink of alcohol. The nurse would suspect which conditions to be occurring?

Delirium tremens

A client states, "I'm worthless, and I don't deserve to live." This theme in the client's expressed thought may signal a maladaptive response to which disorder?

Depression

A nurse is assessing a 13-year-old client with intermittent explosive disorder (IED). The nurse suspects that the client has other psychiatric disorders. What findings would lead the nurse to conclude this? Select all that apply.

Depression Drug abuse Hyperactivity (ADHD)

A nurse is developing a plan of care for a client diagnosed with an antisocial personality disorder who has been admitted to the inpatient psychiatric unit. Which would the nurse likely include? Select all that apply.

Developing a therapeutic relationship Holding the client responsible for behavior no arguing or bargaining about rules

Which of the following disorders involves the emergence of varying personalities in a person that is associated with stress and conflict?

Dissociative identity disorder (at least two or more personalities)

Before a client became depressed, the client was an active, involved parent with three children, often attending school functions and serving as a volunteer. The client is hospitalized for a major depressive episode and now reveals feeling like an unnecessary burden on the family. Which nursing diagnosis is most appropriate?

Disturbance of self-concept related to feelings of worthlessness

A client is being discharged on lithium. The nurse encourages the client to follow which health maintenance recommendations? Select all that apply.

Drink a 2 L bottle of decaffeinated fluid daily. Do not alter dietary salt intake. See the doctor if the client gets the flu. (dehydration)

The nurse has used wrist and ankle restraints for a client who was extremely aggressive. What assessments should the nurse perform on a regular basis after restraining the client? Select all that apply.

Emotional well-being Peripheral circulation Skin condition Side effects of medication

Initially, the nurse should focus on successfully achieving which goal in order to effectively provide care for a client diagnosed with a mental illness?

Establishing trust and rapport with the client

A married couple arrives at the outpatient clinic. Upon assessment, the nurse finds that the couple believes that the police have been following them and tapping their phones for 2 months. This couple most likely suffers from which disorder?

Folie à deux (shared psychotic disorder) when two people in a close relationship share the same delusion

The parents of a child with attention deficit hyperactivity disorder (ADHD) express to the nurse, "We get so frustrated when our child never minds us." Which parenting strategies should the nurse discuss with the parents? Select all that apply.

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

A 21-year-old client has been recently diagnosed with agoraphobia. Which situation is most likely to cause the client anxiety?

Going to a crowded, outdoor market independently

Before eating a meal, a client with obsessive-compulsive disorder must wash the hands for 14 minutes, comb the hair for 114 strokes, and switch the light off and on 44 times. When evaluating the progress of the client, what is the most important objective for this client?

Gradually decrease the amount of time spent for performing rituals.

A client diagnosed with delusional disorder is telling everyone that the client is the president of the United States. This client is exhibiting which type of delusion?

Grandiose

Which would the nurse expect to assess in a client with narcissistic personality disorder?

Grandiose and superior self-concept

A nurse suspects that a client has overdosed on the prescribed tricyclic antidepressant. Which assessment findings would support this suspicion? Select all that apply.

Hallucinations Confusion Agitation

A nurse is assessing a child with a diagnosis of autism spectrum disorder. The child has severe uncontrollable temper outbursts and repeatedly bangs the head on the wall or door. When considering medication for treatment, the nurse knows which will be the most effective?

Haloperidol (Haldol) - antipsychotic

Which meal would the nurse provide to best meet the nutritional needs of a client who is manic?

Ham sandwich, cheese slices, milk (finger foods)

Which would most likely be a type of behavior that would be manifested by a client who has histrionic personality disorder?

Having a tantrum if not getting enough attention

Which intervention would be appropriate for a client with anorexia nervosa?

Having the client in view of staff for 90 minutes after each meal

Assessment of a child with autism spectrum disorder reveals stereotypic behavior. Which behavior would the nurse most likely document being demonstrated by the child?

Head banging Hand flapping Rocking

While conducting a class on anxiety and stress reduction, a nurse describes the symptoms of anxiety (including panic), informing the class that the physical symptoms of a panic attack can mimic what?

Heart attack

The client is talking to staff members individually and attempting to manipulate them. Which are important in the limit-setting technique to deal with manipulative behavior? Select all that apply.

Identifying the consequences if the limit is exceeded Stating the behavioral limit Identifying the expected or desired behavior

While conducting a mental status examination, the client accuses the nurse of recording the interview so that it can be sent to the Federal Bureau of Investigation. What type of delusion is this client experiencing?

Paranoid

A nurse is providing education about trauma and its effects to a community group in a community that has just been hit by a devastating tornado. One of the participants asks about what kind of support a survivor of the tornado will need. Which would be the best response of the nurse?

If a person is reluctant to share his or her feelings, he or she may be denying his or her importance and may be at increased risk for future problems such as posttraumatic stress disorder (PTSD).

All of the following nursing diagnoses are appropriate for the care of a client with anorexia nervosa. Which nursing diagnosis has the priority?

Imbalanced nutrition: less than body requirements

The nurse teaches an antisocial client to take a time-out in the client's room when challenged by another person instigating an argument. What is the main reason for the time-out?

It allows an opportunity for the client to regain control of emotions.

Which statements identify positive aspects of methadone as a substitute for heroin? Select all that apply.

It is a legal medication. It is controlled by a health care provider. It is available in tablet form. no IV form

The nurse is leading a family therapy group for clients and families of individuals who are addicted to substances. The family of a cocaine addict is angry and cannot understand why the client cannot just stop using. The nurse guides the group to discuss their understanding of the nature of addiction. Which statements would the nurse identify as an accurate understanding of the nature of addiction? Select all that apply.

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

The nurse is teaching a client with paranoid personality disorder to validate ideas with another person before taking action. Which is the best rationale for this intervention?

It will assist the client to start basing decisions and actions on reality.

A client with a long history of alcohol abuse has presented to the emergency department with hallucinations and an incoherent story about being followed by the police. The client is likely experiencing which physiologic effect of alcohol use?

Korsakoff's psychosis (physiologic effect of long-term alcohol use and manifests with hallucinations and making up or confabulating stories to mask the fact that there is significant memory loss.)

The nurse is caring for a 16-year-old client with a history of sexual abuse. What might the nurse expect to assess in this client?

Long-term emotional trauma

A client is exhibiting signs of mild delirium such as occasional confusion about why the client is in the hospital and what day of the week it is. When developing a care plan, the nurse identifies several strategies to improve the client's cognitive function. Which intervention will be helpful to the client?

Make up a daily calendar with the date and the times of scheduled activities.

A client on a medical unit has a comorbid diagnosis of depression and has been taking mirtazapine for several months prior to the current admission. When providing care to the client, which action would be most appropriate for the nurse to do? Select all that apply.

Monitor the client's mood and affect over the course of the admission. Ensure that the client is not cheeking or stockpiling the medication.

The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, "I saw you sitting alone and thought I might keep you company." The client turns away from the nurse. Which would be the most therapeutic nursing intervention?

Move to a chair a little further away and say, "We can just sit together quietly."

The nurse is assessing a client with bulimia nervosa. Which symptoms would the nurse expect to find? Select all that apply.

Normal weight for height (some over or under) Metabolic alkalosis (vomiting) Dental erosion (vomiting)

A nursing student is preparing to care for a client diagnosed with schizophrenia. When interacting with the client, the student notices that the client is highly suspicious and guarded, stating, "They're out to get me." The student identifies this as what?

Paranoia

`The client is a 32-year-old diagnosed with bipolar disorder. The client attends group therapy for 6 hours a day and then returns home to the client's residence. In which setting would the client receive this type of care?

Partial hospitalization program

A child has been displaying behaviors associated with conduct disorder. As the nurse evaluates these behaviors, the nurse will further assess for which common risk factors seen in children with conduct disorder? Select all that apply.

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

In clients who do not completely recover from the trauma of rape, which mental illness is most likely to develop?

Post traumatic stress syndrome

A nurse is conducting an inservice program on personality disorders. When describing obsessive-compulsive personality disorder, which characteristics would the nurse likely include? Select all that apply.

Preoccupation with control Difficulty with decision making Relationships primarily formal and polite Strict attention to rules

A client is brought to the emergency department stating, "I'm scared because the Federal Bureau of Investigation is now tapping my home phone, and I can hear them talking between my two telephones during the night." The client's eyes dart around the room while the nurse is trying to interview the client, and the client is tapping the client's fingers on the table. The nursing priority with this client is what?

Reassure the client that the client is in a safe place where the client will be helped.

A nurse is teaching a client with borderline personality disorder to reshape thinking patterns. Which is an example of a cognitive restructuring technique that would be helpful for this client?

Recognize negative thoughts and replace them with positive ones.

A client is experiencing a panic attack while in the recreation room. Which intervention would be a priority to promote the client's safety? Select all that apply.

Remaining with the client to assess needs Turning off any televisions or radios in the immediate area

A client with Alzheimer's disease has a nursing diagnosis of risk for injury related to memory loss, wandering, and disorientation. Which nursing intervention should appear in this client's care plan to prevent injury?

Remove hazards from the environment.

A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?

Setting limits on aggressive and intimidating behavior

When developing the plan of care for a client with borderline personality disorder (BPD), which areas would the nurse identify as likely problematic? Select all that apply.

Sleep Self-harm Nutrition

The nurse is caring for a client who is being treated in the emergency department for a panic attack. Which nursing intervention would be most appropriate?

Stay with the client, emphasizing that the client is safe and that the nurse will remain with the client

A client presents to the emergency department with a flat affect. The nurse suspects the client may be experiencing a major depressive episode. Which variable would the nurse need to keep in mind as representing the highest risk for this condition? Select all that apply.

Substance abuse Divorced Mood disorder in first-degree relatives

When preparing to educate a client regarding a newly prescribed antipsychotic medication, which action would be most appropriate for the nurse to do? Select all that apply.

Suggest methods to minimize the potential for weight gain Advise the client to discuss any concerns regarding sexual dysfunction Identify lifestyle adjustments that the resulting lethargy may require Encourage the use of sugar-free gum to help manage dry mouth

An aggressive client has obtained a piece of sharp glass and holds it threateningly to prevent anyone from entering the room. What interventions should the nurse perform to ensure safety of the client, staff, and other clients? Select all that apply.

Summon help from others. Shift other clients to a safe place. Leave the area immediately.`

A concerned family member tells the nurse, "I am concerned about my sibling. My sibling has been acting very different lately." Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the sibling has bipolar disorder?

Taking unnecessary risks

The nurse is assessing a client who has been receiving treatment for obsessive-compulsive disorder (OCD). What finding helps the nurse to evaluate the effectiveness of the treatment?

The client is able effectively carry out functional and occupational tasks.

A 74-year-old is being seen in the mental health clinic. The client has never fully regained the level of activity the client had prior to the death of the client's spouse. The client continues to have symptoms of depression and has not been able to work or volunteer. In addition, the client complains of "anxiety attacks" that occur nearly every night. What type of grief reaction is this client exhibiting?

The client is experiencing complicated grieving reaction. The client needs to have a comprehensive mental health assessment.

A client who has suspicion has been placed in a room with a roommate. The night nurse assesses the situation and reports that this client has been awake for the past 3 nights. The likely explanation for the client's wakefulness is what?

The client is fearful of what the roommate might do to the client while sleeping.

A nurse is assessing a young client who has recently witnessed a murder. Despite directly witnessing the crime, the client has been unable to provide proper information about the event to the police. The client tells the nurse that the client does not remember anything related to the crime scene. What is the most likely cause for the inability to remember the events related to the scene?

The client may have dissociative amnesia.

Which nursing action would be a protective factor in the prevention of suicide for a client who has been identified at risk?

The nurse facilitates a referral to a drug and alcohol recovery program.

The nurse is dealing with a difficult client. Which reasons make it necessary for the nurse to examine his or her beliefs and attitudes about substance abuse? Select all that apply.

The nurse may have different attitudes about various substances of abuse. The nurse or close friends and family of the nurse may abuse substances. The nurse may be overly harsh and critical of the client. The nurse may unknowingly act out old family roles and engage in enabling behavior.

A nurse observes a middle school student having an angry outburst in the hallway. The nurse is aware that the student has these outbursts frequently. The nurse suspects that the student has intermittent explosive disorder (IED). What other assessment findings would support this conclusion? Select all that apply.

The student has had outbursts of anger without any warning. The student has caused extensive damage to school property. The student has experienced anger episodes over very minor events.

What would be the most appropriate action by the student nurse when the client asked the student nurse to keep it a secret that the client plans to kill a family member?

The student nurse must tell the client that the student nurse cannot keep that secret and then report it to the instructor and/or staff members.

A nurse works in a psychiatric clinic. A client who lost a spouse during a robbery at their home 1 month ago approaches the nurse for consultation. How would the nurse differentiate posttraumatic stress disorder (PTSD) from acute stress disorder?

The symptoms began 3 months after the trauma. acute stress is immediate, PTSD is a more delayed reaction

The nurse who is developing a suicide prevention strategy would need to ensure which step is included?

Using assertive interventions if there is a threat of suicide Determining imminent risk of suicide Following up with interventions to prevent suicide in the future Figuring out who is at risk for suicide

A nurse is caring for a client who has been taking clozapine for 2 weeks. The client tells the nurse, "My throat is sore, and I feel weak." The nurse assesses the client's vital signs and finds that the client has a fever. The nurse notifies the physician, expecting an order to obtain which laboratory test?

WBC count clozapine has a risk of agranulocytosis

Which diagnosis is associated with a pervasive disregard for and violation of the rights of others?

antisocial

The nurse suspects that a client is a victim of intimate partner violence. What should the nurse consider when caring for this client? Select all that apply.

availability of support support can be accessed safely

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 and are formulating a collaborative plan. The child is experiencing signs of which disorder?

conduct disorder

Which can correctly be identified as a behavioral response to grief?

crying uncnotrollably

Which is a term used to describe grief over a loss that is not or cannot be acknowledged openly, mourned publicly, or supported socially?

disenfranchised grief (abortion, suicide)

The nurse is assessing a client with an eating disorder. Which personality characteristic would the nurse expect to detect when interacting with the client?

eager to please (perfectionists, above-average intelligence, achievement-oriented, eager to please, seeking approval)

Inflated view of self Rationalization for harming an individual

eccentric and a loner

The nurse learns that a client has been receiving unwanted gifts and visits from someone in the neighborhood. For which unwelcomed behavior should the nurse plan interventions for this client?

stalking

A client comes to the clinic for an evaluation. During the interview, the client states that the client feels insects crawling all over the skin on the client's arms and legs. The nurse interprets this as which type of sensorium or processing deficit?

tactile hallucination

A client was admitted to the intensive care unit after a motor vehicle accident. The client sustained a right parietal injury, resulting in an acute confusional state or delirium. The client reports that there are "bugs crawling around" on the arms. The nurse understands this as:

tactile hallucinations from delirium

A client with obsessive-compulsive disorder describes all doorknobs as being contaminated with a variety of viruses. The client cleans each knob three times with paper towels before use. Such behavior allows the client to do what?

temporarily reduce anxiety

Antidote for inhalants

there is no antidote

Which phase of the aggression cycle is defined as occurring when an event or circumstance in the environment initiates the client's response?

triggering

client is being assessed after experiencing house damage from a tornado. Which client need would be a priority for the nurse to determine?

where the client will stay temporarily