saunders mental health part 2

Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply. 1. Speak slowly. 2. Use simple statements. 3. Encourage the client to punch the wall. 4. Provide the client with high-calorie beverages. 5. Place the client in a room, alone at the end of the hall.

1,2,4

The nurse is working with a client who is delusional. 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?"

4

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first? 1. Examine the neck area and assess the airway. 2. Encourage the client to talk about the experience. 3. Obtain a detailed history of events leading to the attempt. 4. Administer an anxiolytic medication as prescribed at once.

1

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which signs/symptoms or behaviors as requiring immediate intervention? 1. Constant physical activity and poor oral intake 2. Grandiose delusions of being the King of England 3. Constant, incessant talking with sexual innuendos 4. Outlandish behaviors and wearing odd, eccentric clothing

1

A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which would be a therapeutic response by the nurse? 1. "It's sad for you, but when children are hurt as you hurt them, people want you identified and isolated." 2. "Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?" 3. "You seem angry, but you must understand that your neighbors are frightened because of your serious crimes against children." 4. "Try to realize how fortunate you are that our society doesn't let the group escalate to more punitive measures after your crimes against children."

2

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, should take which action? 1. Stay with the client at all times. 2. Request that a friend of the client remain with the client at all times. 3. Have the client put on a hospital gown and remove the client's clothing from the room. 4. Suggest placing the client in a seclusion room where all potentially dangerous articles are removed.

1

A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior? 1. Continue to monitor the client's behavior from a distance. 2. Document that the client is adapting to the unit and is feeling safe. 3. Notify the staff of these observations at the team meeting due to begin in 3 hours' time. 4. Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide.

4

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time? 1. "What is causing you to become agitated?" 2. "Please stop so I don't have to put you in seclusion." 3. "Why are you intent on upsetting the other clients?" 4. "You are going to be restrained if you do not change your behavior."

1

The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse should avoid choosing which client as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client who had back surgery 3. A client with a fractured pelvis 4. A client who had a myocardial infarction

1

The nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which nursing response is appropriate to assist the client in achieving the goal that has been set for this client? 1. "When your psychiatrist comes in, I will ask for a pass for the weekend." 2. "When the psychiatrist arrives on the unit, I will let her know that you have a question." 3. "I will call the psychiatrist and find out if you can have a pass so that you can make your arrangements." 4. "You can't have a pass for the weekend. You are not ready, and I'm sure that your psychiatrist will say no."

2

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which? 1. "I am your friend." 2. "Our relationship is a therapeutic and a 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."

2

he nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease should expect to observe which behaviors in this client? Select all that apply. 1. Incontinence of stool 2. Confusion as to day and time 3. Misplacing a valuable object 4. Forgetfulness of recent events 5. Difficulty coming up with the right word

3,5,

he nurse caring for a client with schizophrenia prepares to document which signs/symptoms exhibited by the client as negative? Select all that apply. 1. Pressured speech 2. Magical thinking 3. Avolition 4. Delusions 5. Anergia

3,5,

The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply. 1. Emphasis on group and social interaction and that rules and expectations are mediated by peer pressure. 2. Increased exposure to an object or situation that causes anxiety increases until the anxiety about the object ceases. 3. Punishment (e.g., punishment applied after the client has had an alcoholic drink) 4. Cognitions (verbal or pictorial events) based on attitudes or assumptions developed from previous experiences. These cognitions may be fairly accurate, or they may be distorted. 5. Avoidance training (e.g., client avoids punishment by pushing a glass of alcohol away within a certain time limit) 6. Pairing of a maladaptive behavior with a noxious stimulus (e.g., pairing the sight and smell of alcohol with electric shock), so that anxiety or fear becomes associated with the once-pleasurable stimulus

3,5,6

A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which response by the nurse would be therapeutic? 1. "You are certainly entitled to your own opinion." 2. "I know just how you feel. I have those days myself once in a while." 3. "I disagree with you; we all have some value and accomplishments in life." 4. "You seem very discouraged. Can you think of anything recently that went as you planned?"

4

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction? 1. The client will take medication daily to control the condition. 2. The client will talk to self to control actions more effectively. 3. The client will meet with others with the same problem in a support group. 4. The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.

4

The nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which is the appropriate nursing action? 1. Allow the client to leave. 2. Attempt to persuade the client to stay. 3. Call security to assist in restraining the client. 4. Tell the client that the primary health care provider will be contacted regarding discharge.

4

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply. 1. Stay with the client. 2. Give detailed directions to the client. 3. Administer anxiolytics medications if prescribed. 4. Ensure the client is in an environment with little stimuli. 5. Refrain from speaking until the client's anxiety is decreased.

1,3,4

The nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of the client's loss of a spouse, which occurred several years ago. The client progresses well and is approaching discharge. Which is an appropriate goal for this client's care? 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.

2

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply. 1. Client had not bathed in 2 days. 2. Client threatened to commit suicide. 3. Client threatened to kidnap his spouse. 4. Client quit taking antipsychotic medications 4 days ago. 5. Client wrote the Declaration of Independence in chalk on the sidewalk.

2,3

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply. 1. Polyuria 2. Incoordination 3. Fine hand tremor 4. Mental confusion 5. Muscle hyperirritability

2,4,5

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply. 1. "I really hate my wife." 2. "I hid my silverware from dinner last night." 3. "I really have trouble controlling my anger." 4. "I wish that I would be able to live my life over again." 5. "I know that by this time tomorrow all my troubles will be over."

2,5

A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply. 1. Monitor airway. 2. Notify the registered nurse (RN). 3. Place the client in seclusion for safety. 4. Remain with the client to provide support. 5. Administer a prescribed antipsychotic medication. 6. Administer a prescribed intramuscular (IM) antiparkinsonian medication.

1,2,4,6

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply. 1. Hallucinations 2. Anhedonia 3. Delusions 4. Neologisms 5. Flat affect

1,3,4

A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action? 1. Ask direct questions to encourage talking. 2. Leave the client alone but check on her every 30 minutes. 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients for added supervision.

3

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care? 1. Encourage the client to lead a support group. 2. Encourage the client to socialize with other clients. 3. Avoid joking or laughing in the presence of the client. 4. Inform the client about support groups that are available in the community.

3

The nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client? 1. "It is very, very hard to get over these types of feelings after being raped." 2. "What do you think you need to do to reduce the likelihood that you will be raped again?" 3. "Tell me more about what happened that causes you to feel like the rape just occurred." 4. "It's hard, but try to keep a sense of perspective. After all, it's been a while since the rape occurred."

3

1. Do not allow the client to express negative thoughts. 2. Immerse the client with all the details of past events. 3. Request that the client perform undemanding, self-care tasks. 4. Reinforce teaching the client techniques to maintain present reality. 5. Assist the client to reestablish relationships with significant others

3,4,5

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply. 1. Lanugo 2. Amenorrhea 3. Russell's sign 4. Normal weight 5. Tooth erosion

1,2

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply. 1. Provide high-calorie finger foods. 2. Decrease the light and noise level on the unit. 3. Restrict the client's access to money and other valuables. 4. Encourage the client to play volleyball with other clients on the unit. 5. Avoid rest periods during the day to ensure for adequate rest at night.

1,2,3

A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply. 1. Sit by client's bed holding his or her hand. 2. Reminisce with the client and share a humorous story that the client enjoys. 3. The nurse asks: "What can I do, that might make you feel more comfortable today?" 4. The nurse states: "Just think; you will soon be in a better place where you will not be in pain." 5. The nurse asks: "I noticed you grimacing earlier when I walked in your room. Are you in pain?" 6. The nurse states: "It must be very frustrating to be in pain and not be able to get complete relief from your pain."

1,2,3,5,6

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply. 1. "I notice you are wearing a blue shirt." 2. "Do you have any plans of harming yourself?" 3. "I know that everything will look better tomorrow." 4. "I will sit here with you even if you choose not to talk with me." 5. "I think you need to realize that everyone has bad days from time to time."

1,2,4

The nurse is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which action would be appropriate for the nurse to suggest including in the plan of care? 1. Avoid providing rewards to the client. 2. Promote complete independence in the client. 3. Reward the client when a desired behavior is performed. 4. Provide consistent negative reinforcement to promote appropriate behaviors.

3

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which community group? 1. Al-Anon 2. Fresh Start 3. Families Anonymous 4. Alcoholics Anonymous

1

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care? 1. Provide safety for both the client and other clients on the unit. 2. Assist in caring for the client in a controlled environment, such as a quiet room. 3. Offer the client a less stimulating area in which to calm down and gain control. 4. Provide the other clients on the unit with a sense of comfort and safety by isolating the client.

1

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time? 1. "You sound very unhappy. Are you thinking of harming yourself?" 2. "Have you talked to anyone specifically about what is bothering you?" 3. "Those feelings will go away once your medication really takes effect." 4. "I know what you mean; everyone gets that way when they are depressed.

1

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse? 1. "This is not a good time to make that decision." 2. "What would your spouse think about your decision?" 3. "What aspects of this situation are the most difficult for you?" 4. "You seem to have a good grip of this situation; you probably need to get out."

3

The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions in response to this client's medication refusal? Select all that apply. 1. Document the refusal of medication. 2. Notify the registered nurse. 3. Ask the client why he is refusing the medication. 4. Crush the pill and sprinkle it on the client's meal. 5. Administer the medication as an intramuscular injection.

1,2,3

The nurse is collecting data on a client in crisis. Which question should the nurse ask to determine the client's perception of the precipitating event that led to the crisis? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3

The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal? 1. Increased appetite, irritability, anxiety, restlessness, and altered concentration 2. Tachycardia, mild hypertension, fever, sweating, nausea, vomiting, and marked tremor 3. Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia 4. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis

3

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination? 1. The admission was mandated by a court order. 2. The admission was made without the client's consent. 3. The client has the right to demand and obtain release from the hospital. 4. The client was committed by a group of designated mental health professionals.

3

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply. 1. Offering self 2. Giving recognition 3. Minimizing feelings 4. Changing the subject 5. Asking "why" questions

3,4,5

The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs/symptoms of anxiety and attempts to assist the client back to the client's hospital room. Which is the next appropriate nursing action at this time? 1. Notify the registered nurse (RN). 2. Call security and persuade the client to stay. 3. Help the client pack his or her personal belongings in preparation for discharge. 4. Inform the client that discharge is not possible because of the type of admission process involved.

1

The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply. 1. Diaphoretic 2. Lack of muscle tone 3. Temperature of 104.8° F 4. Pulse of 56 beats per minute 5. Blood pressure of 210/130 mm Hg

1,3,5

The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings? 1. Use open-ended questions and silence. 2. Focus on the components of adequate nutrition. 3. Focus on the fact that the client's beliefs are untrue. 4. Instruct the client about the need for adequate nutrition.

1

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply. 1. Reinforce the client's problem-solving abilities. 2. Focus attention on the client's physical complaints. 3. Voice doubt in the reality of the client's physical symptoms. 4. Assess "secondary gains" that the somatic illness provides the client. 5. Only spend time with the client when physical illness is not discussed.

1,4

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." The nurse should make which appropriate response? 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."

3

The nurse in the mental health clinic hears a client yelling and threatening to hurt his sister. The nurse reports this episode to the mental health therapist. Which should the nurse anticipate the therapist to do? Select all that apply. 1. Identify the specific person being threatened. 2. Tell the client that this behavior is not appropriate. 3. Take appropriate action to protect the identified victim. 4. Threaten the client that the police are going to be called. 5. Have the client sign a document promising not to harm his sister. 6. Assess and predict the client's danger of violence toward another.

1,3,6

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply. 1. Male gender 2. Caucasian race 3. Age less than 32 years 4. Practicing a religion 5. Married over 10 years

3,4,5

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply. 1. Severe suicidal tendencies 2. Immediate family's request 3. Extremely unstable medical and psychiatric conditions 4. Desire for punishment of client or convenience of staff 5. Delirium or dementia leading to inability to tolerate decreased stimulation 6. Severe drug reactions or overdoses or need for close monitoring of drug dosages

1,3,4,5,6

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action? 1. Call for the registered nurse. 2. Call security to block the exits from the nursing unit. 3. Restrain the client and call the primary health care provider. 4. Tell the client that readmission is not possible after leaving against medical advice (AMA).

1

The nurse is assisting in conducting a group therapy session. During the session a client threatens to act out physically and states that he will punch another member of the group. Which is the appropriate nursing action? 1. Tell the client that he must leave immediately. 2. Call security to come to the session immediately. 3. Tell the client that he may talk about his anger but cannot act on it during the group session. 4. Tell the client that if he hits another client, he will be restrained and placed in seclusion.

3

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the primary health care provider immediately. Which nursing intervention is appropriate? 1. Inform the client that the behavior is unacceptable. 2. Tell the client to wait in her room until report is over. 3. Offer to assist the client to an examination room until the primary health care provider is notified. 4. Tell the client that the primary health care provider will be called as soon as report is completed.

3

The nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse would be therapeutic? 1. "The last few weeks?" 2. "You haven't had an appetite at all?" 3. "Once the medication begins to work, you will begin to feel better." 4. "Think about everything that you have been through. It will take time for your appetite to improve."

2

The nurse is assisting in conducting a group therapy session. A client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which nursing action is appropriate? 1. Tell the client that it is not safe to leave. 2. Encourage the client to stay and ask the client what she is feeling. 3. Tell the client that if she leaves, she cannot return to this therapy group. 4. Lock the door so that the client cannot leave at this potentially vulnerable time.

2