Psych Final practice questions

Which statement made by a severely depressed client requires the nurse's immediate attention? 1. "Feeling better really isn't important to me anymore." 2. "No one can really understand what I've had to deal with." 3. "I really don't like the way that new depression pill makes me feel." 4. "I've not been the least bit interested in socializing since my divorce."

Answer: 1 Rationale:The suicidal client may subtly express the intention to harm oneself in the form of a covert suicidal threat. The statement in option 1 should receive the nurse's priority attention because it is directly related to the client's safety. The remaining options are not related to safety as directly.

The healthcare provider is assessing a child who has a diagnosis of autistic spectrum disorder (ASD). Which of these clinical findings supports this diagnosis? 1. Annoys other deliberately 2. Uninterested in playing with others 3. Cries for attention at inappropriate times 4. Utilizes manipulative behavior

Answer: 2

The nurse is creating a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care? 1. Promote complete independence in the client. 2. Strengthen the client's ability to manage stress. 3. Reward the client when a desired behavior is performed. 4. Provide consistent negative reinforcement to promote appropriate behaviors.

Answer: 3 Rationale:Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. None of the remaining options are characteristics or appropriate components of the plan of care for this form of therapy.

When interacting with a child diagnosed with Tourette syndrome (TS), the child states, "I am from Zychostan. I can speak Zycho." The child is demonstrating which type of communication? 1. Echolalia 2. Palilalia 3. Clanging 4. Neologism

Answer: 4; Neologism is use of new, made-up words.

A child is diagnosed with autistic spectrum disorder (ASD). Which of the following, if present in the patient's health history, will the healthcare provider identify as a factor associated with this disorder? Choose all answers that apply 1. Southeast Asian or Middle Eastern descent 2. Sibling diagnosed with Asperger syndrome 3. Concurrent diagnosis of fetal alcohol syndrome 4. Advanced age of the mother or father 5. Exposure to vaccines containing thimerosal

Answer: 2, 3, 4 Rationale: These are established risk factors for ASD.

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1. The client's noncompliance with medication therapy 2. The community's opposition to outpatient mental health clinics 3. The associated increased risk that the client may become homeless 4. The family's negative reaction to transferring the client to community-based care

Answer: 1 Rationale:Clients often forget to take their medications as scheduled, and this is the most prominent problem since medication therapy is vital to the function of clients with such a diagnosis. While the situations described in the remaining options may occur, these problems are not as impacting on the client's prognosis and can be addressed and often controlled.

During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior? 1. An unreasonable fear of something 2. Repetitive actions to manage anxiety 3. Misinterpretation of common events 4. Recurring thoughts that are intrusive

Answer: 2 Rationale:A compulsion is a repetitive act. The client with a phobia is likely to experience unreasonable fears. Illusions are characterized by misinterpretation of events. An obsession is a repetitive thought.

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury? 1. Developing lung cancer and/or other respiratory disorders 2. Withdrawal symptoms triggering a stress-induced relapse 3. Diminishing the effectiveness of psychotropic medication 4. Developing gastrointestinal disorders, including bleeding ulcers

2 Rationale:Both caffeine and nicotine can inhibit the action of psychotropic medications, which are commonly prescribed for schizophrenia. Although each of the remaining options presents a risk for injury, ineffective medication therapy presents the greatest risk for injury that currently affects this client.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

Answer: 1 Rationale:A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of an adolescent.

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? 1. Dementia 2. Schizophrenia 3. Seizure disorder 4. Obsessive-compulsive disorder

Answer: 1 Rationale:Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication.

The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support? 1. Anxiety 2. Agoraphobia 3. Schizophrenia 4. Posttraumatic stress disorder

Answer: 4 Rationale:The major clinical manifestation associated with posttraumatic stress disorder (PTSD) is client experience of flashbacks. Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for? 1. Coarse hand tremor, agitation, hallucinations, and hypotension 2. Hypotension, ataxia, muscular rigidity, and tactile hallucinations 3. Hypotension, stupor, agitation, headache, and auditory hallucinations 4. Fever, hypertension, changes in level of consciousness, and hallucinations

Answer: 4 Rationale:The symptoms associated with delirium tremens (DTs) typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, changes in level of consciousness, agitation, fever, and delusions. Therefore, the remaining options are incorrect.

An assessment of a child reveals deficits in communication and social interaction. The child tends to engage in repetitive behaviors such as arranging and rearranging toys. Based on this assessment, the healthcare provider suspects which of these disorders? 1. Tourette disorder (TD) 2. Attention deficit hyperactivity disorder (ADHD) 3. Intellectual development disorder (IDD) 4. Autism spectrum disorder (ASD)

Answer: 4, ASD

The nurse is creating a plan of care for a newly admitted client at high risk for suicide. With the focus of the plan being to promote a safe and therapeutic environment, which intervention should the nurse include? 1. Place the client in a private room. 2. Establish a therapeutic relationship. 3. Assign a leadership task to the client. 4. Maintain a distance of 10 inches at all times.

Rationale:A therapeutic relationship will increase feelings of acceptance in the suicidal client. Placing the client in a private room would intensify the client's feeling of worthlessness and prevent appropriate observation of the client. Placing the client in a leadership role can overwhelm the client, lead to failure, and reinforce the feelings of worthlessness. Distances of 18 inches or less constitute intimate space, and invasion of this space may increase the client's tension and feelings of helplessness. In addition, the client at risk for suicide is placed on one-to-one suicide precautions.

The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed? 1. Clonidine 2. Disulfiram 3. Pyridoxine hydrochloride 4. Chlordiazepoxide hydrochloride

Rationale:Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety. Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.

The children of a patient diagnosed with Alzheimer disease (AD) tell the healthcare provider, "Our mother seems better during the day, but she gets very confused and agitated in the late afternoon and evenings." How should the healthcare provider document the patient's behavior? 1. Depression 2. Delirium 3. Sundowning 4. Psychosis

Answer: 3 This patient is experiencing sundowning or sundowner syndrome, a phenomenon prevalent in patients diagnosed with dementia. Sundowning may be associated with impaired circadian rhythms, environmental or social factors, and impaired cognition.

Which client is at greatest risk for committing suicide? 1. A client with metastatic cancer 2. A client with a newly diagnosed cardiac disorder 3. A client who just had an argument with her fiancé 4. A newly divorced client who states she has custody of the children

Rationale:The person at greatest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.

Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply. 1. The client will keep scheduled appointments. 2. The client's physical wounds will begin to heal properly. 3. The client will verbalize feelings about the abusive event. 4. The client will resolve feelings of anxiety related to the event. 5. The client will participate in the various aspects of the treatment plan.

Rationale:Resolving feelings triggered by the event will take time and therapy and so is considered a long-term goal. Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal any physical wounds that were inflicted at the time of the rape.

A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time? 1. Remain with the client. 2. Put the client in a quiet room. 3. Teach the client deep breathing. 4. Encourage the client to talk about her feelings and concerns.

Answer: 1 Rationale:If left alone, the severely anxious client may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. Teaching the client deep breathing or relaxation is not possible until the anxiety decreases. Encouraging the client to discuss concerns and feelings would not take place until the anxiety has decreased.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1. Use of confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care

Answer: 1 Rationale:The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble

Answer: 1 Rationale:The first step in the 12-step program is to admit that a problem exists. Substituting other activities for gambling may be a strategy but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy? 1. Daily medication therapy 2. Involvement with a support group 3. Intense stress management training 4. Short exposure to the phobic object

Answer: 4 Rationale:Systematic desensitization is a form of therapy in which the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually, over a period of time, exposure is increased until the anxiety about or fear of the object or situation has ceased. Medication is associated with pharmacological therapy. While stress management techniques and self-help groups may be helpful, neither is the basis of this therapy.

A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact? 1. The client has experienced more than one sexual assault. 2. The client routinely incorporates foreign objects into the sex act. 3. The client actively initiating situations in which sex is forced is common. 4. The client regularly re-experiences the events associated with the assault.

Answer: 4 Rationale:The major trauma of rape or sexual assault involves the victim's emotional reaction to being physically forced to do something against his or her will. The life-threatening nature of the crime and feelings of helplessness, loss of control, and experiencing the self as an object of the perpetrator's rage combine to produce the victim's overpowering fear and stress. In this syndrome, which has been called rape trauma syndrome, the client re-experiences the trauma, as evidenced by recurrent recollections of the event. The remaining options are not associated with rape trauma syndrome.

Before giving the client the initial dose of disulfiram, what should the psychiatric home health nurse determine? 1. If there is a history of hyperthyroidism 2. When the last full meal was consumed 3. If there is a history of diabetes insipidus 4. When the last alcoholic drink was consumed

Rationale:Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic intake was consumed. The medication should be used cautiously in clients with hypothyroidism, diabetes mellitus, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in persons with severe heart disease, psychosis, or hypersensitivity to the medication. Food is not a consideration with this medication.

Which interventions should the nurse include in the plan of care for an acutely depressed client involved in cognitive-behavioral therapy? Select all that apply. 1. Assisting the client to identify and test negative cognition 2. Assisting the client to participate in the treatment process 3. Assisting the client to develop alternative thinking patterns 4. Assisting the client to rehearse new cognitive and behavioral responses 5. Assisting the client with the administration of antidepressant medications 6. Assisting the client's family to participate in group therapy on a regular basis

Answer: 1, 2, 3, 4 Rationale:The goal of cognitive-behavioral therapy is to change the way clients think and thus relieve the depressive syndrome. This is accomplished by assisting the client to identify and test negative cognition, participate in the treatment process, develop alternative thinking patterns, and rehearse new cognitive and behavioral responses. Although some clients are treated with antidepressant medications, this is not a component of cognitive-behavioral therapy. The focus of this therapy is on the client, not the family.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1. Restating 2. Listening 3. Asking the client "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval

Answer: 1, 2, 4, 5 Rationale:Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury? 1. Turn off the television and radio, and use a night-light. 2. Keep soft lighting and the television on during the night. 3. Change the client's room to one nearer the nurses' station. 4. Play soft instrumental music all night, and do not turn down the lights.

Answer: 1 Rationale:A night-light is needed for client safety to reduce the risk of falls if the client should get out of bed unattended. It is important to reduce environmental stimulation and provide a consistent daily routine for a disoriented client. Noise levels, including radio and television, may add to the confusion and disorientation. Moving the client to a room near the nurses' station is not the first action.

The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs? 1. Flashbacks 2. Amotivational syndrome 3. Enhanced physical strength 4. Absence of pain perception

Answer: 1 Rationale:Flashbacks, the recurrence of perceptual distortions, are unique to the use of hallucinogenic drugs. Enhanced physical strength and the inability to feel pain are indicative of phencyclidine use, whereas marijuana abuse can result in amotivational syndrome.

The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action should be the priority? 1. Interrupt the client, and offer to take her for a walk. 2. Allow the client to complete her exercise program. 3. Ignore the behavior, and return when the client is finished. 4. Tell the client that she is not allowed to exercise rigorously.

Answer: 1 Rationale:When working with a client diagnosed with anorexia nervosa, the nurse must limit the amount of rigorous exercise that the client performs while providing for appropriate types and amounts of exercise. Clients with anorexia nervosa are frequently preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake, which causes further deterioration of their physical state. The correct option stops the harmful strenuous exercise and provides an unharmful form of exercise. The remaining options are inappropriate priority actions.

Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply 1. The average series involves 8 to 12 treatments. 2. Some confusion may be noted after the procedure. 3. Memory loss will occur but will resolve with time. 4. This treatment is a permanent cure to the condition. 5. This treatment is tried before the use of medications.

Answer: 1, 2, 3 Rationale:Electroconvulsive therapy (ECT) as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client's condition.

The nurse is preparing a client for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1. Have the client void. 2. Obtain an informed consent. 3. Administer tap water enemas. 4. Avoid discussing the procedure. 5. Remove dentures and contact lenses. 6. Withhold food and fluids for 6 hours.

Answer: 1, 2, 5, 6 Rationale:Enemas are not a component of the pretreatment care for a client scheduled for electroconvulsive therapy (ECT). The nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure. The remaining options are a part of the pretreatment plan.

The nursing care plan indicates a problem of self-directed violence and the risk for suicide, related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome? 1. Displays less anxiety and agitation 2. Denies presence of suicidal ideations 3. Develops adequate problem solving skills 4. Establishes a relationship with staff and peers

Answer: 2 Rationale:A suicidal client may have numerous problems that encompass inadequate coping skills, anxiety, and strained interpersonal relationships. However, this question specifies that the problems that need to be dealt with are self-directed violence and risk for suicide, related to suicidal ideations with a specific plan. The expected outcome is that the client no longer has suicidal ideations. The remaining options are not related directly to the data stated in the question.

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1. "Do you think that having asthma will kill you?" 2. "You seem very distressed over learning you have asthma." 3. "Asthma is a treatable condition when medications are taken properly, so let's practice with your inhalant." 4. "It will be difficult to work with you if you can't view this as a challenge rather than 'a nail in your coffin.' "

Answer: 2 Rationale:Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Eliminate options that are sarcastic or punitive. The only correct option is the one that respectfully addresses the concern presented by the client.

The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action? 1. Engaging in self-mutilating acts 2. Observing rigid rules and regulations 3. Always reverting to the independent role 4. Constantly striving to avoid making decisions

Answer: 2 Rationale:Clients with anorexia nervosa have the desire to please others. Rules and rituals help them manage their anxiety. Their need to be correct or perfect interferes with rational decision making processes. These clients generally don't engage in self-mutilation.

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize which assessment finding as requiring immediate intervention? 1. Grandiose delusions of being a czar of Russia 2. Constant physical activity and poor oral intake 3. Constant, incessant talking, with sexual innuendoes 4. Outlandish behaviors and wearing odd, eccentric clothing

Answer: 2 Rationale:Mania is a period when the mood is predominantly elevated, expansive, or irritable. The client's mood may be characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Each of the options is reflective of possible symptoms. The need for adequate food and rest is the priority.

The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse? 1. "I am your friend." 2. "Our relationship is a therapeutic and helping one." 3. "I can't be your friend. I'm the nurse, and you're the client." 4. "You have plenty of friends. You don't need me to be your friend, too."

Answer: 2 Rationale:Nurses may struggle with requests by clients to "be my friend." When this occurs, the nurse should make it clear that the relationship is a therapeutic and helping one. This does not mean that the nurse is not friendly toward the client at times. It does mean, however, that the nurse follows the stated guidelines regarding a therapeutic relationship. The remaining options are inappropriate, particularly in their failure to define the relationship.

When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question? 1. "Are you drinking more than you did 5 years ago?" 2. "How do you feel when you haven't had a drink all day?" 3. "Does your drinking ever cause you problems with your family?" 4. "Do you ever feel that you really need a drink to calm your nerves?"

Answer: 2 Rationale:Physical dependency results in withdrawal symptoms; therefore, the option addressing that topic is the priority question. An increase in alcohol consumption may be an indicator of alcohol tolerance. Alcohol abuse is described as being willing to continue the use of alcohol regardless of the problems doing so causes. Needing a drink to calm the nerves is an indicator of a psychological dependency.

When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration? 1. Encouraging social interactions 2. Assessing all activities for safety risks 3. Focus upon providing verbal stimulation 4. Providing detailed instructions to ensure success

Answer: 2 Rationale:Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensoriperceptual deficits. Although providing social interactions, verbal communications, and familiarity and orientation are also appropriate interventions, the priority is safety.

The nurse is creating a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to provide which priority information to the family? 1. Brain anomalies that are responsible for this disorder 2. Signs that indicate the client may be considering suicide 3. The importance benzodiazepines play in the management of this disorder 4. The possibility that the client will experience medication-induced tinnitus

Answer: 2 Rationale:Suicide is the most serious concern for clients with a mood disorders. Early identification of behaviors that reflect the client's suicidal mind-set is vital to minimizing the risk of self-injury and/or death. Mood disorders are not typically a result of brain anomalies. Benzodiazepines are not the medication classification of choice for treating mood disorders. Tinnitus is not a typical side effect of antidepressant medication therapy.

An adolescent has been prescribed an amphetamine to help manage a diagnosis of attention deficient hyperactivity disorder. To best minimize the risk of abuse and/or overdose, the nurse expects that the medication will be administered via which method? 1. Sublingual tablets 2. Transdermal patch 3. Rectal suppository 4. Weekly intramuscular injections

Answer: 2 Rationale:The application of an transdermal patch is the method best suited to minimizing the risk of abuse and/or overdose from an amphetamine because it manages the release of the medication without requiring the client's handling of the medication. The remaining options lack that component.

Which assessment finding would be a manifestation associated with dementia? 1. Catatonia 2. Confabulation 3. Presence of ritualistic behaviors 4. Increased display of inhibited behaviors

Answer: 2 Rationale:The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or fabrication of events or experiences to fill in memory gaps is common. Ritualistic behaviors are associated with obsessive-compulsive disorder, while catatonia is a psychotic reaction. Often, lack of inhibition on the part of the client constitutes the first indication to the client's significant others that something is "wrong."

What is an appropriate short-term outcome for a client grieving the recent loss of a spouse? 1. The client reports three additional coping strategies. 2. The client verbalizes stages of grief and plans to attend a community grief group. 3. The client verbalizes connections between significant losses and low self-esteem. 4. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide.

Answer: 2 Rationale:The question is focused on grieving. The only option that deals with grief is option 2. The information in the remaining options is not related to grief.

A client whose wife recently died of cancer says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." What is the therapeutic nursing response? 1. "It will take time to adjust to your terrible loss." 2. "It must be hard to accept that she has passed away." 3. "Try to focus on the fact that you and your wife loved one another for years." 4. "Focus on the fact that her suffering is over and that she had a good life with you."

Answer: 2 Rationale:The therapeutic nursing response is the one that recognizes the difficulties of grieving the loss of a loved one and that facilitates expression of feelings. The remaining options are not therapeutic because they do not encourage expression of feelings.

A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic? 1. "I know just how you feel; I lost my husband last summer." 2. "You need to grieve, and expressing anger can be part of grieving." 3. "Although she means to help, you need to do what feels right for you." 4. "Focusing on the many good years you both enjoyed together will help."

Answer: 2 Rationale:The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest. The remaining options are all nontherapeutic. They do not encourage the client to express feelings.

Which behavior demonstrated by a client diagnosed with depression indicates a need for suicide precautions? 1. Refuses to attend group therapy 2. Asks about how to get a will notarized 3. Argues with family members during visiting hours 4. Becomes easily agitated when roommate changes the television channel

Answer: 2 Rationale:Warning signs of suicide include talking about suicide, preoccupation with death and dying, behavioral changes, giving away special possessions and making arrangements to take care of unfinished business, decreased appetite and difficulty with sleep, and a loss of interest in usual activities. The remaining options all deal with anger and "acting out" behaviors that can be associated with depression.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

Answer: 2, 3, 4, 5 Rationale:Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

The parents of a child diagnosed with attention deficit hyperactivity disorder (ADHD) inquire about the types of therapeutic interventions that may benefit their child. Which of the following interventions will the healthcare provider suggest? Select all that apply. 1. Develop several long-term goals for improvement 2. Assist the child to develop routines 3. Provide detailed instructions for expected tasks 4. Recognize and build on personal strengths 5. Plan activities that provide opportunities for success 6. Provide immediate feedback about behaviors

Answer: 2, 4, 5, 6 Rationale: Self-esteem can be increased by recognizing and building on personal strengths, and giving the child opportunities to be successful. Development of routines, helping with task organization, and providing frequent feedback will assist with building coping skills and will help the child learn to understand the consequences of behaviors. The child is highly distractible and may not be able to focus on multiple goals or instructions (option 3). Interventions are aimed at increasing self-esteem and developing coping skills (option 1).

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind? 1. "That doesn't sound like the real you talking!" 2. "I'm sure you have someone if you think hard enough." 3. "It sounds as though you are feeling all alone right now." 4. "I don't believe that, and I really don't think you do either."

Answer: 3 Rationale:The client is experiencing loss because of the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is the one that attempts to translate words into feelings. Communication would be discouraged by statements that deny the client's feelings or that do not address the client's concerns.

The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal? 1. Constipation, insomnia, and hallucinations 2. Staggering gait, slurred speech, and violent outbursts 3. Nausea, vomiting, diarrhea, muscle aches, and diaphoresis 4. Decreased heart rate and blood pressure and dry nose, mouth, and skin

Answer: 3 Rationale:The client who is experiencing opioid withdrawal (such as from heroin) may experience dysphoric mood, nausea, vomiting, diarrhea, abdominal cramping, muscle aches, diaphoresis and piloerection, runny eyes (lacrimation) and nose (rhinorrhea), yawning, low-grade fever, restlessness, insomnia, anxiety, mydriasis, and increased pulse and blood pressure. Therefore, the other options are incorrect.

A hospitalized client experiencing delusions reports to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? 1. "I don't believe this is true." 2. "The doctor is not talking to the mob." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the doctor wants to get rid of you?"

Answer: 3 Rationale:When delusional, a client truly believes what he or she thinks to be real is real. The client's thinking often reflects feelings of great fear and aloneness. It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusions is inappropriate.

The healthcare provider is obtaining a health history from the parents of a child diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following information about the child's behavior should the healthcare provider expect? Choose all answers that apply: 1. Speaks using delayed echolalia 2. Avoids eye contact 3. Interrupts conversations of others 4. Often talks excessively 5. Has difficulty finishing homework 6. Intimidates or bullies other

Answer: 3, 4, 5 Rationale: The healthcare provider may expect the parents to report behaviors such as excessive talking (hyperactivity), having difficulty completing tasks such as homework (inattentiveness), or intruding into the conversations of others (impulsivity). The use of delayed echolalia or "scripts" is a prominent feature of autism; it refers to the ritualized repetition of phrases that have been memorized - phrases the child may have heard from radio, television, videos, or from previous conversations.

A child diagnosed with attention deficit hyperactivity disorder (ADHD) is prescribed methylphenidate (Ritalin), immediate release (IR) tablets. When teaching the parents about the medication, which of the following will the healthcare provider include? 1. "Administer the medication daily, along with the evening meal." 2. "The best time to administer the medication is just before bedtime." 3. "We will need to periodically monitor your child's height and weight." 4. "Call our office if your child becomes dizzy because it can cause low blood pressure."

Answer: 3, we will need to periodically measure your child's height and weight Rationale: Methylphenidate can lead to growth restriction. It is recommended children and adolescents take medication vacations when possible to minimize this potential effect. The medication should be administered in the morning to avoid insomnia. Methylphenidate can increase blood pressure, not decrease.

A patient diagnosed with delirium sees the intravenous (IV) tubing and believes it to be a snake. How should the healthcare provider document this behavior? 1. Hallucination 2. Delusion 3. Confusion 4. Illusion

Answer: 4 Illusion is the misperception of an object in reality. A hallucination is something added to reality.

When planning care for a patient diagnosed with Alzheimer disease (AD), which of these interventions is most therapeutic? 1. Speaking in a loud, clear voice when talking to the patient 2. Providing immediate feedback by correcting errors in the patient's speech 3. Giving the patient several directions at a time to improve memory 4. Encouraging both verbal and nonverbal communication

Answer: 4 Rationale: As the ability to communicate verbally declines, nonverbal communication may become more prominent. Encouraging both can facilitate communication and decrease frustration. Speaking clearly and calmly is effective, but increasing the volume of the voice is not effective and can increase the patient's anxiety.

A patient diagnosed with dementia is prescribed a medication that inhibits acetylcholinesterase. Which of the following accurately explains how this medication benefits the patient? Choose 1 answer. 1. Acetylcholine increases norepinephrine activity and decreases depression 2. Inhibition of acetylcholinesterase improves the patient's motor function 3. Decreased levels of acetylcholine will help decrease the patient's anxiety 4. Acetylcholine is needed for memory and problem solving

Answer: 4 Rationale: Dementia and Alzheimer's Disease is associated with decreased acetylcholine. Acetylcholinesterase breaks down acetylcholine. By blocking this enzyme, acetylcholine increases, slowing progression of dementia and AD.

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client? 1. Isolating self 2. Inability to cope 3. Low self-esteem 4. Risk for self-harm

Answer: 4 Rationale:Clients with borderline personality disorder are most often hospitalized because of impulsive attempts at self-mutilation or suicide. The nursing intervention of constant close observation is usually initiated to protect the client from impulsive behavior. If any of the other options exist, they are of lesser priority.

Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship? 1. Facilitating behavioral change 2. Promoting self-esteem in the client 3. Promoting problem solving skills in the client 4. Establishing the parameters of the relationship

Answer: 4 Rationale:During the orientation phase of the therapeutic nurse-client relationship, four subjects need to be addressed. These subjects include the parameters of the relationship, the formal or informal contract, confidentiality, and termination of the relationship. Promoting problem solving skills and self-esteem and facilitating behavioral change are subjects of the working phase of the nurse-client relationship.

The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Based on this fact, what assumption can the nurse make about the client? 1. The admission will last at least 21 days. 2. The client is not a danger to himself or to anyone else. 3. The admission is being financed by a third-party payer. 4. The client has the right to demand and obtain release from the hospital.

Answer: 4 Rationale:Generally, voluntary admission is sought by the client or the client's family by written application to the facility. Voluntary clients have the right to demand and obtain release from the hospital. The remaining options are not necessarily true when considering a voluntary admission.

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? 1. "Inner voices tell me to perform my rituals." 2. "My behavior is a conscious attempt to punish myself." 3. "I'm demonstrating control when I engage in my rituals." 4. "My rituals are ways for me to control unpleasant thoughts or feelings."

Answer: 4 Rationale:In obsessive-compulsive disorder (OCD), the rituals performed by the client are an unconscious response that helps to divert and control the unpleasant thought or feeling and prevent acting on it. This decreases the client's anxiety. OCD is not associated with a need for control or punishment, or with hallucinations

As discharge approaches, the client has been quiet and withdrawn when interacting with the nurse. Which interpretation should the nurse make about the client's behavior? 1. An indication of the need for antidepressants 2. An inability of the client to terminate from the nurse 3. An indication of the need for additional therapy sessions 4. A normal behavior that can occur during the termination period

Answer: 4 Rationale:In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include the return of symptoms, anger, withdrawal, and minimizing the relationship. The behavior that the client is experiencing is normal during the termination phase and does not necessarily indicate the need for hospitalization, additional sessions, or antidepressants.

The spouse of a client prescribed an antidepressant tells the home health nurse, "Now that the antidepressant is working, the suicidal risk is over and you can stop making these home visits." How does the nurse appropriately respond? 1. "I need to continue with my visits since this disease tends to run in families." 2. "I agree with you that the medication will greatly reduce the risk for suicidal behavior." 3. "I agree with you that continuing to visit would reintroduce the possibility of suicidal ideations." 4. "I need to continue visiting since the client may now have the energy to act on suicidal intentions."

Answer: 4 Rationale:Most suicides occur within 3 months after the beginning signs of improvement, when the client has the energy to carry out suicidal intentions. The remaining options are incorrect because they fail to address safety and provide false information.

Which is the appropriate nursing intervention to address the poor nutritional intake demonstrated by a client diagnosed with depression? 1. Weigh the client three times per week before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist, and obtain a nutritional consultation as soon as possible. 4. Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.

Answer: 4 Rationale:Offering small meals at several different times during the day may be less overwhelming for the client. Being available during the meals can add to the social atmosphere of eating. Weighing the client does not address how to increase nutritional intake. The client is experiencing poor concentration and is not likely able to benefit from a nutrition lecture. The option of reporting to the psychiatrist and consulting with the nutritionist is to some degree correct but does not present a method to increase food intake.

The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse? 1. "I don't believe that what you are telling me is true." 2. "There are no religious cults in this area that are going to kill you." 3. "What makes you think that cult members are being sent to hurt you?" 4. "I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

Answer: 4 Rationale:The nurse who disagrees with a client's delusions may make the client more defensive and cling to the delusions even more firmly. It is most therapeutic for the nurse to empathize with the client's experience. The nurse can also use the opportunity to try to explore further the meaning of the experience for the client. The correct option presents reality to the client and then focuses on the client's feelings. None of the other options provide this support.

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1. Platelet count 2. Cholesterol level 3. Blood urea nitrogen 4. White blood cell count

Answer: 4 Rationale:Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.

The nurse is working with a client who shows signs of benzodiazepine withdrawal. The nurse should suspect that the client has suddenly discontinued taking which prescribed medication? 1. Sertraline 2. Diazepam 3. Fluoxetine 4. Haloperidol

Answer: Diazepam Rationale:The only benzodiazepine presented in the options is diazepam. Benzodiazepines are effective only when used for short-term therapy. Short-acting benzodiazepines can produce withdrawal symptoms within 1 to 2 days, whereas long-acting benzodiazepines take 5 to 10 days for withdrawal symptoms to occur following discontinuation. Manifestations include insomnia, agitation, anxiety, irritability, nausea, and diaphoresis. The other options list an antidepressant (setraline) and antipsychotics (fluoxetine and haloperidol).