Saunders Mental health Q's

Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving? 1) Increased number of hours slept at 1 time and is increasingly alert 2.Appears to be delirious but has stopped trying to pull out the nasogastric tube 3.Tells his wife, "I do feel better, but why are snakes in the corner of my room?" 4.Appears anxious whenever approached by staff but relaxes when family is present

1) Increased number of hours slept at 1 time and is increasingly alert The foreign environment of a hospital's critical care unit, the loss of a normal sleep-wake cycle, effects of injuries, and succumbing to placement of invasive lines, tubes, and possibly restraints can lead to delirium and feelings of powerlessness. The symptoms of psychosis are more likely to resolve when the client resumes a more normal sleep cycle and is physiologically stable. Improvement from intensive care unit (ICU) psychosis is evidenced by decreased hallucinations, anxiety, and aggressive behavior, along with increased sleep and absence of injuries.

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1)Chess 2.Writing 3.Ping pong 4.Basketball

1)Chess Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.

A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action? 1.Sit and talk with the client about the feelings. 2.Ask the assistive personnel to check on the client. 3.Administer the prescribed as-needed antianxiety medication. 4.Call the client's primary health care provider to report the client's anxiety.

1.Sit and talk with the client about the feelings. The appropriate initial nursing action is to sit and talk with the client expressing anxiety. An assistive personnel is not prepared to deal with the client's anxiety. Antianxiety medication may be necessary, but this would not be the initial appropriate nursing action. While it may become necessary, calling the health care provider is premature initially.

The nurse notes that a client attending a group therapy session is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How should the nurse interpret this behavior? 1)Manipulation 2.Improvement 3.Attention seeking 4.Desire to be accepted

2.Improvement The behaviors identified in the question indicate improvement in the client's condition. The question presents no information indicating that the client is being manipulative. Acting out is attention-seeking behavior. All clients have a desire to be accepted

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression? 1)Restrict the client smoking for 12 hours. 2.Enforce nothing by mouth (NPO) status for 16 hours. 3.Limit the client's participation in unit activities for 24 hours. 4.Assure that an electrocardiogram is performed within 24 hours

4.Assure that an electrocardiogram is performed within 24 hours Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.

Which statement by the nurse indicates a need for further teaching concerning family violence? 1."Abusers use fear and intimidation." 2."Abusers usually have poor self-esteem." 3."Abusers often are jealous or self-centered." 4."Abusers are more often from low-income families.

4."Abusers are more often from low-income families. Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic groups is incorrect.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1.Provide authority, action, and participation. 2.Display an attitude of detachment, confrontation, and efficiency . 3.Demonstrate confidence in the client's ability to deal with stressors. 4.Provide hope and reassurance that the problems will resolve themselves.

1.Provide authority, action, and participation. A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) "takes over" for the client (authority) who is not in control and devises a plan (action) to secure and maintain the client's safety. When this has occurred, the nurse works collaboratively with the client (participates) in developing new coping and problem-solving strategies. Note the strategic word, priority. A client who experiences a suicidal crisis is in a state of acute disequilibrium. Remember that in a crisis an authority figure must emerge to take action

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. 1)Dental decay 2.Moist, oily skin 3.Loss of tooth enamel 4.Electrolyte imbalances 5.Body weight well below ideal range

1)Dental decay 3.Loss of tooth enamel 4.Electrolyte imbalances Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

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

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

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initiallyimplement 1)Setting limits on the client's behavior 2.Asking the client to leave the group session 3.Asking another nurse to escort the client out of the group session 4.Telling the client that he or she will not be able to attend any future group sessions

1)Setting limits on the client's behavior Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action. Test-Taking Strategy(ies):Note the strategic word, initially. Eliminate options that are comparable or alike and relate to the client leaving the session. Next, eliminate the option that violates the client's right to receive treatment and is a threatening action. Remember that setting firm limits with the client initially is best.

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

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

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1.Provide safety for the client and other clients on the unit. 2.Provide the clients on the unit with a sense of comfort and safety . 3.Assist the staff in caring for the client in a controlled environment . 4.Offer the client a less stimulating area in which to calm down and gain control.

1.Provide safety for the client and other clients on the unit. Safety of the client and other clients is the immediate priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.

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

1.The client will keep scheduled appointments. 2.The client's physical wounds will begin to heal properly . 3.The client will verbalize feelings about the abusive event.5.The client will participate in the various aspects of the treatment plan Resolving feelings triggered by the event will take time and therapy, so it is considered a long-term goal. Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal any physical wounds that were inflicted at the time of the rape

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1) Ask the client why he started taking illegal drugs. 2.Ask the client about the amount of drug use and its effect. 3.Ask the client how long he thought that he could take drugs without someone finding out. 4.Do not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2.Ask the client about the amount of drug use and its effect. Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a prioritybasis? 1) "I check my weight every day without fail." 2."I've been told that I am 10% below ideal body weight." 3."I exercise 3 to 4 hours every day to keep my slim figure." 4."My best friend was in the hospital with this disease a year ago."

3."I exercise 3 to 4 hours every day to keep my slim figure." Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to immediately assess this statement further to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check weight every day. Many clients with anorexia nervosa check their weight 20 times or more each day. A body weight 15% below the ideal weight or less is most significant with anorexia nervosa. Although it is unfortunate that the client's best friend had the disease, this is not considered a major threat to the client's physical well-being

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

3."It sounds as though you are feeling all alone right now." The client is experiencing loss because of the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is the one that attempts to translate words into feelings. Communication would be discouraged by statements that deny the client's feelings or that do not address the client's concerns.

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement? 1)Place the client in seclusion for 30 minutes. 2.Tell the client that the behavior is inappropriate. 3.Escort the client to their room, with the assistance of other staff. 4.Tell the client that their telephone privileges are revoked for 24 hours.

3.Escort the client to their room, with the assistance of other staff. The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client. Eliminate option 2 because this intervention has already been attempted. Next, use Maslow's Hierarchy of Needs theory to answer the question. Remember that if a physiological need is not present, focus on safety. Look for the option that promotes safety of the client, other clients, and staff.

Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety? 1)"What makes you think that I am a vampire?" 2."I'll leave and come back later for the specimen." 3."Do you remember discussing the lab work earlier?" 4."It must be frightening to think that others want to hurt you."

4- "It must be frightening to think that others want to hurt you." The correct option helps the client focus on the emotion underlying the delusion but does not argue with it. Avoid statements that place the client in a position that requires a response. Attempting to avoid the situation will not address the client's anxiety. The incorrect responses may cause the client to hold the delusion more strongly.

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms 1) "Well, a picture paints a thousand words." 2."You just felt like destroying your textbooks?" 3."Your parents and teachers are very concerned about your drawings." 4."I am concerned about you. Are you now or have you ever been abused?

4."I am concerned about you. Are you now or have you ever been abused? The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. The remaining options are insensitive, not focused on the possible sexual abuse, or too indirect to be useful Also note that the correct option is client-focused.

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

4."I need to continue visiting since the client may now have the energy to act on suicidal intentions." Most suicides occur within 3 months after the beginning signs of improvement, when the client has the energy to carry out suicidal intentions. The remaining options are incorrect because they fail to address safety and provide false information

During a group therapy session a client begins yelling, "I can't listen to this. You people are no different from the ones I have to deal with at home." What is the nurse's immediate action? 1.Inform the yelling client to leave the group immediately. 2.Call security personnel to the session to ensure everyone's safety . 3.Ask the other clients to describe how the aggressive yelling made them feel. 4.Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated.

4.Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated. The client is displacing anger. The nurse sets limits on behavior, reinforces group rules, and ensures physical safety and a sense of control. Requiring the client to leave the group would be an immediate action if the client presents with escalating behavior. The question presents no data indicating such behavior. Calling security and exploring the responses of other clients are premature actions at this point. Exploration may occur later in the group process.

When should the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior? 1.Administered medication has taken effect. 2.The client verbalizes the reasons for the violent behavior. 3.The client apologizes and tells the nurse that it will never happen again. 4.No aggressive behavior has been observed for 1 hour after the release of 2 of the extremity restraints.

4.No aggressive behavior has been observed for 1 hour after the release of 2 of the extremity restraints. The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. The remaining options do not ensure that the client has controlled the behavior.

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit should expect to note which behaviors in the client? 1.Sad and tearful 2.Suspicious and hostile 3.Frightened and delusional 4.Rigidness in thought and inflexibility

4.Rigidness in thought and inflexibility Rigid and inflexible behaviors are characteristic of the client with obsessive-compulsive disorder (OCD). Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion because this behavior is what decreases the anxiety. None of the other options are associated with OCD

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

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

What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia? 1)Their child will very likely experience difficulty in school. 2.The prognosis for their child is good because he is so young. 3.With medication, their child is not likely to experience relapses. 4.Their child will be treated for an imbalance of the chemical dopamine

4.Their child will be treated for an imbalance of the chemical dopamine The dysregulation theory regarding the cause of schizophrenia shows a relationship between the brain levels of dopamine and the symptoms of schizophrenia. The prognosis is negatively affected when the onset of symptoms occurs during the adolescent years. Although medication compliance is a strong factor in minimizing the recurrence of relapses, it is not the only factor that has an effect. Moreover, although schizophrenia has an effect on reasoning and perception, the likelihood of experiencing difficulty in school is not certain.