psych

A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client?

"What is causing you to become agitated?"

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Parkinson's disease

A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse plans to do which of the following initially with this client?

Accept the client as a person and make the client feel safe.

A nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. The finding that requires the nurse's immediate intervention is the:

Client's inadequate attention to activities of daily living (ADL) and poor nutritional intake

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which of the following observations, if made by the nurse, are indicative of the clinical manifestations associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea

A nurse is preparing to admit a client diagnosed with obsessive-compulsive disorder (OCD) to the mental health unit. The nurse observes this client for behavioral characteristic(s) of one who is:

Inflexible and rigid

A client cannot leave the house without checking the stove and the iron many times. The client is often late for appointments and occasionally even misses engagements as a result of this behavior. The nurse interprets that this client's symptoms are compatible with which of the following anxiety disorders?

Obsessive-compulsive disorder

A nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

Places the client on one-to-one suicide precautions

A nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The nurse interprets that this client is exhibiting a sign of:

Posttraumatic stress disorder (PTSD)

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. A nurse assigned to care for the client would first:

Take the client to a quiet room

A nurse is preparing a client for the termination phase of the nurse-client relationship. Which nursing task would the nurse appropriately plan for this phase?

Assist in making appropriate referrals.

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present at the time should respond by stating which of the following?

"Are you fearful and think that others may want to hurt you?"

During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which of the following responses by the nurse would be therapeutic?

"I can see that you are upset about this. Let's talk about this some more."

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." The nurse's best response is:

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

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills?

"I feel better able to care for my father now that I know where to obtain assistance."

A nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for additional information about this self-help group?

"The leader of this self-help group is a nurse or psychiatrist."

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse appropriately responds by stating:

"What do you and your husband believe is the right thing for your children?"

A nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is:

"What leads you to seek help now?"

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." The therapeutic response by the nurse is:

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

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse makes which therapeutic response to the client?

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

A nurse employed in a psychiatric unit receives a client assignment for the day. Which of the following clients assigned to the nurse is at the highest risk for committing suicide?

A client with severe depression and cancer

Which behavior should the nurse expect a client diagnosed with agoraphobia to describe when discussing the disorder?

A fear of leaving the house

A nurse is assisting in a group therapy session. During this session, the members are identifying tasks and boundaries. The nurse understands that these activities are characteristic of which stage of group development?

Beginning stage

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:

Feed, bathe, and dress the client as needed until the client can perform these activities independently.

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, the priority nursing action is to:

Notify the social worker to investigate the situation.

A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which of the following to assist the client in meeting nutritional needs?

Provide small, frequent meals

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves:

Re-experiencing recollections of the trauma

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy workup. In planning care for this client, it is important that the nurse understand that the client is suffering from:

Somatization disorder

A nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which of the following data would indicate that the client is a very high risk for suicide?

The client has an immediate plan for a suicide attempt.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on:

The physical condition of the client

A client in the mental health unit engages in repeated handwashing throughout the day. The nurse understands that these repetitive behaviors develop because the client is:

Unconsciously attempting to control unpleasant thoughts or feelings

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. In the planning, the nurse understands that it is important that:

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to:

Use a night light and turn off the television.

A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within how much time after cessation or reduction of alcohol intake?

Within a few hours

A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse observes the client for compulsive behavior that denotes repetition in:

Actions

A client is attending a Gamblers Anonymous meeting for the first time. The model used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse understands that the first step in the 12-step program is which of the following?

Admitting to having a problem

A nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research the disorder?

Body weight well below ideal range

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to:

Call the nursing supervisor

Which data indicates to the nurse that a client may be experiencing ineffective coping?

Constantly neglects personal grooming

A nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?

Develops a relationship to help reduce the frequency of the delusions

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse identifies that this client is using which type of coping mechanism?

Distancing

A nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place first priority on which of the following when planning care for this client?

Establish a trusting nurse-client relationship.

A psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following?

I cannot discuss any client situation with you."

A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with:

Improvement

A client with Alzheimer's disease became very agitated when a group of children came to sing and dance at a long-term care facility and the resident tried to take one of the children to her room. The nurse should use which of the following pieces of information when approaching the client about this behavior?

Individuals with Alzheimer's disease have difficulty tolerating excess stimulation and changes in routine.

A nurse is caring for a client who verbalizes a need to increase her self-esteem. The nurse plans to assist the client to achieve the goal of gaining self-esteem by encouraging the client to:

Maintain a well-groomed appearance.

A nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is:

Ping-pong

A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which of the following actions should the nurse take first?

Remove both clients to a separate, safe location.

A nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which of the following?

Sit beside the client in silence and verbalize occasional open-ended questions.

A nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse makes which therapeutic response to the client?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

A nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which of the following nursing responses would be therapeutic?

"Your health care provider wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?"

A nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse determines that:

An informed consent needs to be obtained from the client.

A client was admitted to a medical unit with acute blindness. Many tests are performed and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. The nurse suspects that the client may be experiencing a:

Conversion disorder

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to:

Escort the manic client to his or her room.

A nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which of the following as the primary means to accomplish work with this client?

Goals and objectives

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing that which of the following is the priority action?

Look for organic causes of the paralysis.

A nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, the appropriate nursing action would be to:

Notify the registered nurse.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?

One-to-one suicide precautions

A nurse is assigned to care for a client who is experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

A nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to:

Provide safety for the client and other clients on the unit.

An agoraphobic client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. To meet the client's nutritional needs, the nurse plans to:

Provide small frequent meals.

A nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by:

Psychomotor retardation and side effects of medication

Which nursing approach to administering an antianxiety agent to a client with acute severe anxiety is most appropriate?

Stay with the client until the medication becomes effective

A nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings related to loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a prized CD and a cherished autographed picture of the performer.

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on:

Weight loss

A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which of the following occurs?

When no acts of aggression are observed within 1 hour after release of two extremity restraints

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which clinical manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea

A nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which of the following would be the best response of the nurse at this time?

"I can see that you're upset. I'm willing to listen."

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?

"You seem very distressed over learning you have asthma."

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

"You sound very upset. Are you thinking of hurting yourself?"

A client with a diagnosis of a recurrent major depression who is exhibiting psychotic features is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse importantly designs a plan of care that deals specifically with the client's:

Altered thought processes

A nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. After reasoning that the client's symptoms are compatible with a somatization disorder, the nurse recalls that obesity for this client most likely represents:

Protection from the risk of intimacy

A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with:

Somatization disorder

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to:

Help the client identify and examine dysfunctional thoughts and beliefs.

A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse monitors for which of the following?

Hypertension, disorientation, hallucinations

A nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?

"Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."

The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to:

Examine and treat the wound sites.

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. The appropriate nursing action is to:

Quietly approach the client, escort her to her room, and assist her in getting dressed.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? Select all that apply.

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother:

Restrict the amount of chocolate and caffeine products in the home.

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which of the following community groups?

Alcoholics Anonymous

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and plans to:

Assign a staff member to the client who will remain with him or her at all times.

A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

Therapy that involves pairing a stimulus attractive to the client with an unpleasant event is known as which of the following?

Aversion therapy

A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The nurse reviews the data obtained and identifies which of the following as a priority concern?

The client's report of suicidal thoughts

A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by:

The death of a loved one

A nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which of the following?

The false belief that one is being singled out for harm by others

A nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you?"

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:

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

A nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response is which of the following?

"I cannot promise to keep a secret."

A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client?

Drawing

A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family. Select all that apply.

Encourage expression of feelings, concerns, and fears. Extend touch and hold the client's or family member's hand if appropriate. Be honest and truthful and let the client and family know that you will not abandon them.

In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following is best?

Encourage the client to participate in a structured daily program of activities.

Following a group therapy session, a client approaches the licensed practical nurse (LPN) and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Get a written prescription from the health care provider (HCP) and obtain an informed consent.

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by:

Observing rigid rules and regulations

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. The appropriate initial nursing intervention related to this concern is:

Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client would plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse likely expects that the client:

Presents a harm to self

A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing:

Social phobia

A nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following?

Suggest that the client stop talking and try listening to others.

Which data collection finding would indicate the possibility of the sexual abuse of a child?

Swelling of the genitals

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse interprets the client's behavior as:

The client is at increased risk for suicide.

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which of the following?

Client involvement in goal setting

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

Communicate expected behaviors to the client. Assist the client in developing means of setting limits on personal behavior. Follow through about the consequences of behavior in a nonpunitive manner. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

A licensed practical nurse (LPN) enters a client's room, and the client is demanding release from the hospital. The LPN reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder, and that the admission was a voluntary admission. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Contact the health care provider (HCP).

A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse would expect which of the following?

The client will participate in the treatment plan.

A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as:

Denial

A nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

A nursing assistant is assigned to work with a nurse to care for a client who is at risk for suicide. Which of these statements made by the nursing assistant indicates to the nurse that the nursing assistant understands suicide?

"Discussing suicide with a client is not harmful."

A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client would best indicate to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

A client 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, ready to plan our activities for the day." Which of the following is the therapeutic nursing response?

"It must be hard to accept that she has passed away."

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

"My husband always brings me flowers and apologizes after he hits me." "My boyfriend yells and accuses me of having an affair if I am late after work." "I have bruises all over my body. I am frequently clumsy and fall a lot."

A male phobic client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which of the following responses by the nurse would be therapeutic?

"Perhaps you could just enjoy the music without singing."

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse makes which therapeutic response to the client?

"Tell me about your difficulty sleeping."

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it." Which of the following is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous testing to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client's record, the nurse notes that the client became deaf after witnessing a murder. Based on this information and the results of the diagnostic tests, the nurse suspects that the client may be experiencing:

A conversion disorder

A nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. In the event that tardive dyskinesia occurs, the nurse would likely observe:

Abnormal movements and involuntary movements of the mouth, tongue, and face

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has:

Agoraphobia

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as:

Evidence of the client's altered and distorted body image

A nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which of the following nursing interventions is least likely to be helpful to this client at this time?

Initiate confinement measures

A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

A nurse is assigned to care for a client who is suicidal. The appropriate nursing intervention in dealing with this client during this crisis is to:

Provide authority, action, and participation.

A nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which of the following actions by the nurse would be most beneficial?

Share the observation with the client and help the client to recognize feelings.

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be:

"What do you find difficult about this situation?"

A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point."

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action?

Approach the client quietly, take her to her room, and assist her in getting dressed.

A nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which of the following is accurate regarding depression and the older client? Select all that apply.

Depression in an older person is likely to have physical manifestations. Some indications of dementia may actually originate as depression. Suicide is a frequent cause of death among the older population.

A nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action would the nurse take first to best deal with these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." The nurse understands that this medication is:

Disulfiram (Antabuse)

The best rationale for using group therapy as an accepted way of treatment of clients in the milieu is because:

Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right!" The best nursing action would be to:

Identify recent behaviors or accomplishments that demonstrate skill or ability.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The appropriate interpretation of the behavior is that the client:

Is displaying typical behaviors that can occur during termination

A nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. The best nursing action is to:

Keep the client talking and signal to another staff member to send help to the client.

A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise.

A nurse is monitoring a female client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

A nurse is employed in a mental health clinic that specifically manages somatization disorders. The nurse understands that which of the following is a characteristic of a somatization disorder?

The client experiences disruption in integrative functions of memory, consciousness, or identity.

A nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate initially for this client?

Writing

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." The appropriate response by the nurse is:

"I hear what you are saying, but I don't share your belief."

A nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say:

"I no longer feel that I deserve the beatings my husband inflicts on me."

The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this—it's private and personal." Which statement by the nurse indicates a therapeutic response?

"I know that some of these questions are difficult for you, but, as a nurse, I must legally respect your confidentiality."

A nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk.

Which of the following are appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate.

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

"It's okay to grieve and be angry with your daughter and anyone else for a time."

A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse makes which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"