PSYCH PRACTICE

other's safety

a client with schizophrenia is exhibiting impaired judgement, agitation and paranoia, what is the priority before speaking to the client in a calm manner.

CNS overstimulation such as muscle tremors, irritability

the earliest sign of opioid withdrawal is

eat planned nutritious meals rationale; this short term goal is realistic. whereas adding 10 lbs within a month might overwhelm the adolescent and trigger anxiety

the nurse, the family and the adolescent with anorexia nervosa are planning appropriate outcomes for the client. which is an appropriate short term goal for the client.

patient's safety

the priority goal in alcohol withdrawal is

provide the client with information and referral to other community resources

which intervention is best for a client who has not resolved her issues by the final session of crisis intervention

calm and soothing structure clear directions predictable routines stable staff who are familiar with the clients

clients with cognitive disorders will benefit from a milieu that includes;

report the child's conversation to CPS. Rationale; asking the child to describe the touch may worsen psychological trauma.

which action would the school nurse take for a child who tells the nurse "my father has been getting into bed with me at night and touching me?

lack of control over binge-eating episodes

which assessment data would the nurse find in a client who is recently admitted with a diagnosis of bulimia nervosa

it's disappointing to have plans change at the last minute. Rationale; expressing understanding of the client's disappointment recognizes and supports the justification of their feelings, it gives them opportunity to ventilate further

which response would the nurse make to a client with obsessive behavior whose scheduled visit with family was cancelled because of an unforeseen business crisis?

verbalizes the desire to increase control over stressful situations Rationale; the first step toward achieving control is expressing a desire to do so.

which short term outcome would the nurse use for a client with Bulimia nervosa who at times feels helpless in regard to the eating disorder

withdrawal, regressed behavior and lack of social skills

behaviors commonly exhibited by patients with schizophrenia

feeling comfortable with the nurse Rationale; first and foremost develop trust, so client can agree to open up to the nurse

which initial objective would the nurse plan for a client with bipolar disorder, depressive episode.

bulimia nervosa

Jefferson is an 18 year old male presents to his pediatrician for a routine physical. the pt is 5 feet 10 inches tall, and weighs 105lbs. he is requesting assistance to loose weight. he is noted to have worn tooth enamel and dental cavities.

somatization disorder

Martha is a retired school teacher, who was recently widowed, presents with HA, nausea, general weakness, and chronic constipation. all her diagnostic tests are negative. what is she suffering from?

begin to teach self-care of the colostomy by introducing the equipment. Rationale; beginning with the equipment is less threatening and may stimulate feelings of mastery. requesting for support group to speak with the client might take a while to achieve which won't meet the client's immediate needs

a client has surgically created colostomy, which is the most effective nursing intervention initially to help the client accept the colostomy

Whatever action you took, it was the right action because it saved your life. Rationale; this observation is supportive and reaffirms the woman's action (it was the right action). words such as submit or gave in are emotionally charged and increase feelings of guilt.

a client who has been sexually assaulted says "i should have fought back" which response is the most therapeutic.

invite the client to attend an activity he or she enjoys Rationale; the nurse will use distraction to direct the client away from the door. this intervention provides safety without confrontation

a client with dementia is trying to open the door and says "i want to leave now", which intervention will the nurse use

engaging in conversation while walking slowly in the hall rationale; by slowing the pace, the nurse can slow the client's hyperactivity from accelerating into maniac episodes

activity the nurse will suggest for a client with bipolar disorder who has accelerating maniac episodes

have the client identify specific behaviors as example of wellness Rationale; asking clients to identify positive changes can reinforce those changes and help the client prepare for discharge. asking about future plans is important, but the questions would need to be more specific (e.g. what will you do when you begin to feel anxious?)

after 3 weeks of mental health therapy a client says "i feel ready to go home" which intervention would provide the best evaluation of the client's readiness for discharge?

structures consistent activities one on one trusting relationship

confused patients need the following initially before joining a therapy group.

suppression Rationale; the affected person intentionally avoids thinking about disturbed problems

conscious defense mechanism used to cope with anxiety

exercise, suppression and talking to friends

conscious healthy coping behaviors a client can use to reduce anxiety

anticonvulsant medication

medication designed to treat rapid-cycling bipolar disorder

beta blocker

medication used to reduce tremors caused by lithium therapy

learning acceptable behaviors

part of recovery is;

risk for self-injury

priority concern the nurse will observe in a client withdrawing from cocaine

fresh flowers in glass vase

the nurse is assessing the hospital room for items that the client can use to inflict self-harm and commit suicide, which finding indicates a need to modify the client's environment for safety

sharing this information is a positive step in getting the help. Rationale; offer emotional support first to create a safe environment where the client can express their feelings

which response will the nurse initially use when a 15 year old client tearfully states that her father has been sexually abusing her for the past 8 years

i'll be sitting with you for a while today. Rationale; this answer removes the burden for the depressed client from making a decision and the client is worth spending time with. "do you mind?" might make them say no quickly because they have no energy to make the decision which blocks all communication

which response will the nurse make when approaching a depressed client sitting alone in the day room

minimizing scarring is the goal of the entire professional staff. Rationale; this statement is truthful and it offers hope without any assurance.

A client with full thickness burns of the entire right arm states " I'll never be able to use my arm again, I'll be scarred forever" which is the best initial response by the nurse?

Repression

A raped victim uses _____ to cope with trauma in order to forget the event. hence cannot deliberately remember

paranoid schizophrenia

scott is a 21 year old with no prior psychiatric hx. is brought to the ER because he is refusing to bathe, thinks his food is poisoned and will only eat wrapped foods. suddenly he is talking to imaginary people and his speech is nonsensical. what is he suffering from?

decreased coordination vomiting diarrhea

side effects of lithium toxicity that can be observed in a client with a mood disorder, maniac episode.

establishing an eye contact

what is the best indication to the nurse that a trusting relationship is beginning to develop with a client with major depressive disorder.

weight gain

what is the best indicator of the client's improvement with anorexia nervosa

one on one supervision

what is the best intervention for a patient with suicidal ideation.

client in crisis need to first trust the nurse "i'm here to help"

what is the initial crisis intervention for a client in crisis

mild

what type of anxiety enhances learning ability

Displacement Rationale; these individuals use this as a defense mechanism in which one's pent-up feelings against a threatening person are discharged on those who are less threatening.

which defense mechanism is most often used by individuals who physically abuse others

confusion immediately after the treatment

which side effect will the nurse monitor for after ECT (electro-convulsive therapy) treatment

give assurance of respect for the client's wishes

while in the PACU after surgery to create a colostomy, a client requests that no visitor be allowed to visit. to support the client, which action should the nurse take

Malingering

exaggerate or fake illness in order to escape duty, jail or work

phobias

high levels of anxiety over the fear of e.g elevators, heights etc.

I know its hard for you to see him like this, hooked up to so many machines, and you don't know what to expect. Rationale; focusing on the client's feelings permits her to work through her fears, which she must do before she can focus on her son and his care.

The nurse watches as a new mother timidly approaches her critically ill preterm son for the first time in the NICU. which statement by the nurse would best foster the bonding process btw the mother and baby

ETOH dependence

Gina smith recently lost her job, and is depressed and anxious. her liver enzymes are elevated. she is complaining of episodic gastric pain. what is suffering from

accompany the depressed client to her room and encourage her to express her feelings. rationale; after a recent loss, the client needs therapeutic one on one interaction. talking with clients is the responsibility of the nurse, in group therapy, clients do not have the expertise to help each other with intense grief. (look for answers that focus on the client or that are directed toward the clients feelings)

a depressed client whose spouse recently died begins to cry when another group member talks about her divorce and feelings of abandonment. which intervention would the nurse use

Rationalization

defense mechanism that offers self-justifying explanations in place of the real, more threatening, unconscious reasons for one's actions e.g an alcoholic

Undoing

patient with OCD washes hands 20x/day to relieve anxiety. what defense mechanism is this?

denies seriousness of the disorder engages in excessive exercises to loose weight fears gaining weight and becoming fat has disturbance in the way the body is viewed

restricting behaviors that occurs in a client with anorexia nervosa

performs a relaxation exercise

which behavior by a client indicates that they have successfully achieved the long term outcome of using effective coping responses when the feeling of anxiety begins

talks about the anger. Rationale; talking about angry feelings is better than acting it out. this is a positive coping method. taking a long jog is ok but it doesn't permit sharing of feelings.

which behavior indicates that the client has learned the most effective method to cope with anger.

where would you like to walk with me? Rationale; the client is too distraught to sit. requesting to walk with the client demonstrates concern.

which initial question by the nurse would be most therapeutic to alleviate the anxiety of the client who is pacing the floor and appears extremely anxious

establishing clear boundaries Rationale; they are very impulsive and unable to respect and identify other people's boundaries.

which intervention is best for a client with borderline personality disorder (BPD).

you feel that they may be harmful. Rationale; this statement will illicit the parents to express more feelings about the topic. telling them "have they discussed it with the HCP" will make the parent become defensive.

A toddler has no inoculations, the parents say "they don't believe in them" which is the best response from the nurse.

divide the staff into opposing factions to gain self esteem Rationale; dividing the staff allows them to gain a sense of power and control. they also act out to discharge anxiety and rather than intimidate others. they usually comply to prevent a feeling of abandonment.

which behavior would the nurse expect from a client with BPD.

client's potential to perform ADL

which concern is most important after the initial crisis issues have been addressed.

Disulfiram

What drug is used to prevent alcohol consumption by blocking aldehyde dehydrogenase? pts will experience a metallic or garlic taste in their mouth.

instruct him to seek an emergency intervention for his wife Rationale; woman is exhibiting sign of depression. wife's emotional state takes priority over husband's.

a woman gave birth to a baby 2 weeks ago, and her husband says "she just lies in bed while the baby is wet, dirty and crying in the crib" which intervention should the nurse use

teaching problem solving Rationale; parents must be involved in developing alternative methods to cope with current crisis and this involves problem solving

which crisis intervention would be best to assist the parents of an 11 year old who has failure to thrive.

you must leave people alone, this behavior is unacceptable Rationale; limits must be set when client's behavior physically or emotionally impose on other clients. initial statement is to set limits and keep other clients safe

which initial statement will the nurse say to a client with BPD who is badgering clients in the day room

accepting the client's statement as real to the client Rationale; the nurse must accept the client's statement as real to the delusional client to develop trust and move toward a therapeutic relationship. clients cannot be argued out of delusions, redirecting the client's conversation whenever negative topics are brought up may cut off conversation and the development of trust during the initial approach

which initial nursing approach would the nurse take for a self-accusatory, guilt-ridden, delusional client.

introduce the client to the primary nurse who will be assigned to work on a one-on-one basis with the client. Rationale; it is extremely important the client is assigned for one-on-one basis because the client can be assisted back to reality by a nurse who is interested in the client's feelings. reassuring the client that it is safe will have no effect because the client is under a strong delusion.

which initial action would the admitting nurse take for a client with a history of increasingly bizzare behavior who says "i'm wired to the TV, and it told me that my family is out to kill me.

explore anxiety provoking situations assist the client in examining coping mechanisms Rationale; they are not manipulative, introducing client to social situations redirects the client from accessing ways to cope with anxiety and ADL.

actions that the nurse would take to help a client with OCD discuss how anxiety influences feelings and the ability to function.

recognize feelings point out reality teach strategies to push aside hallucinations

after assessing the content of the hallucination and it isn't to harm others or self, what are other interventions the nurse need to implement.

you may heal more slowly because of your age, and you may need the special care and equipment available in the hospital

an older adult client was brought to the hospital by a family friend because of deep partial thickness burns on arms and hands. the client protests being hospitalized and asks "why can't I just go home and have my spouse take care of me? which is the best response by the nurse

Re-channeling the client's energies into more appropriate behaviors

nursing mgt of a client with dementia who is disoriented, forgetful and with inappropriate behaviors would be directed toward which?

disorientation, forgetfulness and anxiety

behaviors commonly exhibited by patients with dementia

document the observation Rationale; if its true seizure the patient will not be chewing gum.

which action would the nurse take when shortly after admission to a mental health unit, an adolescent falls to the floor and exhibits tonic-clonic movement but still continues to chew gum

grandiosity, talkativeness, pressured speech and distractibility

clinical findings a nurse will observe in a client with bipolar disorder, maniac episode

saying "i see that you are crying. tell me whats going on in your life and we can work on helping you. Rationale; sitting next to the client quietly and waiting for the client to talk might take weeks or month. but the statement above acknowledges the client's feeling and promotes a trusting environment.

which approach would the nurse take for a fearful silent client who is admitted to the mental health unit after attempting suicide.

giving the client one simple direction at a time in a firm, low pitched voice Rationale; clients with delirium typically respond to simple directions stated one at a time in a firm, low pitched voice.

which initial nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the day room.

Imipramine

drug of choice for patients with bulimia nervosa, major depressive disorder. takes 3 weeks to reach therapeutic levels and also not to be taken with MAOI

Benzodiazepines (lorazepam)

drug of choice to administer during alcohol detoxification to control and manage alcohol withdrawal symptoms.

listen to the client's breath sounds Rationale; anxiety is frequently an early manifestation of hypoxemia

during the evening after thoracentesis, the client reports anxiety, which action will the nurse take first?

teaching relaxation Rationale; teaching requires being attentive and participating. failure to learn will increase the client's anxiety, teaching can be done when client is calm.

for a client who is increasingly agitated, which immediate nursing intervention will most likely increase anxiety

Confabulation Rationale; alcoholics have loss of memory and adapt to this by unconsciously filling in with false informations

for clients with chronic alcoholism, which communication pattern suggests marked memory loss

it fulfills emotional needs Rationale; they feel unloved, unworthy and inadequate. also they are greater risk of dehydration due to purging

for individuals with bulimia nervosa, which function does food serve

to decrease an alcoholic's desire to drink

in what situation will the nurse administer naltrexone

suggesting that the client turn on the radio or television when alone. Rationale; competing stimuli such as television or radio will encourage the client to remain reality oriented and it's useful in controlling hallucinations. having family or friends stay the client will cause the client to be very dependent and will be unable to cope with the problem and will also increase the fear of being alone

which approach would the nurse use for a client with an inoperable temporal lobe tumor who is experiencing frightening auditory hallucinations, especially when alone.

the client stares at the stoma during dressing changes Rationale: willingness to view the stoma indicates the beginning of acceptance and integration of the colostomy into the body image. discussing the necessity of the colostomy is evidence of intellectualization rather than acceptance

the nurse is caring for a client 5 days after the surgical creation of a colostomy. the client has displayed signs of depression since the surgery. the nurse would determine that there is some movement toward adaptation to the change in the body image when the client exhibits which behavior.

0.6-1.2mEq/L

therapeutic level of lithium

seizures

untreated alcohol withdrawal can lead to

anergy (low energy) flat effect inadequate social skills withdrawal isolation

what are negative S&S of schizophrenia

delusions hallucinations disorganized/pressured speech bizarre behavior disorganized thoughts

what are positive S&S of schizophrenia

it is an unconscious means of reducing stress Rationale; their anxiety is relieved by their illness or symptoms. their symptoms are real to them.

what factor will the nurse consider when planning care for a patient with conversion disorder

command hallucinations

what type of hallucination requires immediate intervention during an assessment. it pushes a person to perform an action

you behaved well today Rationale; this statement states a fact and delivers praise without making demands. "your behavior today was much better than it was yesterday" is wrong because the client may not recall what happened yesterday and may not know why today's behavior is better

when a hyperactive female client acts appropriately which statement would the nurse make in an effort to let the client know of her improvement?

Listen attentively to what the client is saying Rationale; listening to the client shows to them that what they are saying is important. a paranoid individual cannot be talked out of his or her feelings hence no need to explain anything to them.

when a newly admitted client with paranoid ideation talks about people coming through the doors to commit murder, which action would the nurse use.

cooling blankets ice packs stop all anti psychotic medications immediately administer benztropine for the extra-pyramidal S&S

when a pt is exhibiting a rigid extended neck and thickening tongue with hyperthermia. what is the initial intervention to treat pt's hyperthermia?

stay with the client during meals Rationale; taking the client to the dinning room will not make him or her eat if he or she lacks the physical or emotional energy to eat

which action for nutritional needs would the nurse take for a depressed client who has been sitting alone in a chair most of the day and displays no interest in eating

provide emotional support while demonstrating acceptance of the client Rationale; establish contact with reality for client who have lost contact with reality.

which action will the nurse take for a client who is pacing back and forth across the floor, speaks incoherently and continually talks to and verbally fights with people who are not present

assure the client that the symptoms are part of the withdrawal syndrome Rationale; assuring the client provides reality based feedback, dimming the lights can cause visual distortions and illusions making the withdrawal syndrome worse

which action will the nurse take for a client with alcohol withdrawal delirium

visit frequently for short periods with the client each day Rationale; spending a day with the client may overwhelm the client and cause the client to withdraw more.

which action will the nurse take to establish trust with a depressed client

reward weight gain by increasing privileges. Rationale; discussing the importance of eating healthy diets is ineffective because they are more concerned with loosing weight than eating a balanced diet. behavior modification works better for them than group therapy.

which action would the nurse take for an adolescent client with anorexia nervosa.

letting the client pace around the hallway from others Rationale; allowing them to pace will let them work off their energy without upsetting other clients. their current state of mind limits their concentration to do anything else.

which intervention will the nurse perform for an extremely agitated client who begins to pace around the mental health dayroom

discuss life situations that the client is able to manage Rationale; focusing on situations that are manageable will enable the client to experience a sense of personal power.

which intervention would the nurse include in the plan of care for a client with PTSD, who verbalizes a desire to have control over personal feelings related to being the only survivor

documenting client's behavior and the events leading up to the seclusion.

which nursing responsibility is specific to caring for a client who is placed in seclusion.

shall we walk together for a while? Rationale; the client is too distraught to sit, so be where the client is.

which question to help reduce anxiety would the nurse ask a client who is pacing the floor and appears extremely anxious

tell me how spending time in the bathroom helps avoid being nervous Rationale; focus on feelings and not on task, this response encourages the client to explore defenses employed to cope with anxiety

which response with the nurse make to a client with OCD who spends 30mins in the bathroom and states that "it keeps me from getting nervous"

I have no problems with any of my other children Rationale; identification of one child in the family as being different by the parents or siblings, coupled with other signs of abuse, should prompt an investigation of possible physical abuse.

which statement by the mother supports a suspicion of child abuse for a 3 year old girl admitted to the hospital with many poorly explained injuries.

simple daily routines Rationale; simple daily routines is less stressful and least anxiety producing. extremely depressed client are unable to make simple decisions

which type of setting will the nurse maintain for extremely depressed client.