EAQ Psych HESI

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs? 1 Allow the client to undress when ready to help maintain identity. 2 Provide two outfits and help the client decide which one to wear. 3 Explain that clean clothes will look more attractive and increase self-esteem. 4 Get assistance and remove the clothing to meet the client's basic hygiene needs.

1 Any approach other than allowing the client to undress when ready will probably be seen as threatening, increase anxiety, and result in a physical confrontation. Providing two outfits and helping the client make a simple decision will increase anxiety, not foster decision-making. Explaining that clean clothes will look more attractive and increase self-esteem will increase anxiety, not increase self-esteem. Getting assistance and removing the clothing to meet the client's basic hygiene needs will increase the client's anxiety and will probably result in a physical confrontation.

A client with a borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client? 1 Provide an unstructured environment to promote self-expression. 2 Be firm, consistent, and understanding and focus on specific target behaviors. 3 Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. 4 Record but ignore marked shifts in mood, suicidal threats, and temper displays, because these last only a few hours.

2 Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with borderline personality disorder. To be therapeutic, the environment needs structure, and the staff must help the client set short-term goals for behavioral changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings of rejection and withdrawal. Ignoring the client's behavior is nontherapeutic and may reinforce underlying fears of abandonment.

A nurse is caring for a client with an obsessive-compulsive personality disorder that involves rituals. What should the nurse conclude about the ritual? 1 It has a purpose but is useless. 2 It is performed after long urging. 3 It appears to be performed willingly. 4 It seems illogical but is needed by the person.

4 The client's exact adherence to the compulsive ritual relieves anxiety, at least temporarily. Furthermore, it meets a need and is necessary to the client. The compulsive act is purposeless repetition and useful only in that it temporarily eases the client's anxiety. Urging has no effect getting the the client to start or stop the ritualistic behavior. The person cannot stop the activity; it is not under his voluntary control.

A client sits huddled in a chair and leaves it only to assume the fetal position in a corner. The nurse observing this identifies the behavior as what? 1 Reactive 2 Regressive 3 Dissociative 4 Hallucinatory

2 Curling up in a corner reflects the early fetal position; the individual curls up for both protection and security. The client's behavior is not in response to an observable stimulus, does not indicate dissociation or depersonalization, and gives no indication of a hallucinatory pattern.

A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse? 1 "Tell me why you did this." 2 "You must have been upset to try to take your life." 3 "Of course you're good; we'll take excellent care of you." 4 "You've been through a rough time; let me take care of you."

2 Identifying and showing understanding of the client's feelings by giving feedback help establish a therapeutic relationship and promote exploration of feelings. Asking why the client attempted suicide is too direct; it does not allow the client time to reflect and explore feelings. Saying the client is good and promising to take care of the client negates the client's feelings and cuts off any further communication of feelings. Saying "Let me take care of you" encourages dependence; it does not permit exploration of feelings.

A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify? 1 Sublimation 2 Suppression 3 Compensation 4 Rationalization

4 The attempt to justify a behavior by giving it acceptable motives is an example of rationalization. Sublimation is the substitution of a maladaptive behavior for a more socially acceptable behavior. Suppression is the intentional exclusion of things, people, feelings, or events from consciousness. Compensation is the attempt to emphasize a characteristic viewed as an asset to make up for a real or imagined deficiency.

What characteristic uniquely associated with psychophysiologic disorders differentiates them from somatoform disorders? 1 Emotional cause 2 Feeling of illness 3 Restriction of activities 4 Underlying pathophysiology

4 The psychophysiologic response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatoform disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.

A female client with obsessive-compulsive disorder has become immobilized by her elaborate handwashing and walking rituals. Which feelings does the nurse recall are often the basis of obsessive-compulsive disorder? 1 Anxiety and guilt 2 Anger and hostility 3 Embarrassment and shame 4 Hopelessness and powerlessness

1 Ritualistic behavior seen in this disorder is aimed at controlling feelings of anxiety and guilt by maintaining an absolute set pattern of action. Although the person with an obsessive-compulsive disorder may be angry and hostile, the feelings of anger and hostility do not precipitate the rituals. Although the person with an obsessive-compulsive disorder may be embarrassed and ashamed by the ritual or feel hopeless and powerless to the ritual, the basic feelings precipitating the rituals are usually anxiety and guilt.

A nurse is caring for a male client who was admitted to the mental health unit with the diagnosis of schizophrenia. The client is hostile and experiencing auditory hallucinations and states that the voices are saying that they are going to poison him because he is bad. What type of schizophrenic behavior does the nurse identify? 1 Residual 2 Paranoid 3 Catatonic 4 Disorganized

2 Clients with paranoid schizophrenia tend to experience persecutory or grandiose delusions and auditory hallucinations and exhibit behavioral changes such as anger, hostility, or violence. Residual schizophrenia is characterized by the negative symptoms of schizophrenia, but the client does not experience delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior. Catatonia is a state in which the client displays extreme psychomotor retardation to the point of not talking or moving. There may be brief intermittent hyperactive episodes with catatonia. Disorganized schizophrenia is characterized by a disintegration of the personality and withdrawn behavior.

A nurse revises the care plan when the client's responses indicate that goals have not been met. What phase of the nursing process is being applied? 1 Planning 2 Evaluation 3 Assessment 4 Implementation

2 Evaluation includes assessing the client's response to care, judging the effectiveness of the plan of care, and changing the plan as necessary. Planning includes the development of a plan focused on specific goals and actions unique to the client's needs. Assessment entails collecting and reviewing objective and subjective data about the client's health status. Implementation includes performing specific actions designed to achieve the stated goals.

A 5-year-old with attention deficit-hyperactivity disorder (ADHD) exhibits a short attention span and demonstrates intermittent head-banging and hair-pulling, as well as excessive motor activity. What is the priority nursing objective for this child? 1 Facilitating sleep 2 Maintaining safety 3 Promoting body image 4 Increasing nutritional intake

2 Excessive motor activity with intermittent head-banging and hair-pulling is self-destructive behavior that may result in injury; prevention of self-injury has the highest priority. Facilitating sleep, promoting body image, and increasing nutritional intake are not the most important nursing objectives in light of the data presented; prevention of self-injury is primary.

What should the nurse do when implementing a tertiary preventive program for cognitively impaired individuals? 1 Teach children how to feed themselves. 2 Encourage the use of birth control by women. 3 Refer children for evaluation if they fail to meet developmental milestones. 4 Use the Denver Developmental Screening Test to evaluate children attending well-child clinics.

1 Tertiary prevention is focused on interventions that prevent complete disability or reduce the severity of a disorder or its associated disabilities. Referring children for evaluation if they fail to meet developmental milestones is secondary prevention aimed at case-finding and early intervention. Encouraging the use of birth control by women who are cognitively impaired is primary prevention. Using the Denver Developmental Screening Test to evaluate children attending well-child clinics is secondary prevention aimed at case-finding and early intervention.

A client comes to the mental health clinic with the complaint of a progressing inability to be in enclosed spaces. The primary healthcare provider makes the diagnosis of claustrophobia and prescribes desensitization therapy. The nurse recalls that desensitization therapy is used successfully with clients experiencing phobias because it is focused on what technique? 1 Imagery 2 Modeling 3 Role-playing 4 Assertiveness training

1 Imagery is a therapeutic approach used to facilitate positive self-talk; mental pictures under the control of and initiated by the client may correct faulty cognitions. Modeling, role play, and assertiveness training are useful general behavioral approaches but are not specific desensitization techniques.

A client in the terminal stage of cancer is admitted to the hospital in severe pain. The client refuses the prescribed intramuscular analgesic for pain because it puts her to sleep and she wants to be awake. One day, despite the client's objection, a nurse administers the pain medication, saying, "You know that this will make you more comfortable." What could the nurse in this situation be charged with? 1 Assault 2 Battery 3 Invasion of privacy 4 Lack of informed consent

2 Battery is the intentional touching of one person by another without permission of the person being touched. Assault is an intentional act without touching that makes a person fearful or produces reasonable apprehension of bodily harm. Invasion of privacy refers to the right of clients to have their private affairs protected. Informed consent applies to permission for procedures and treatments to be performed.

A client has entered a drug rehabilitation facility as a result of a family intervention. Although this was done voluntarily, the client is agitated and angry. Two weeks after admission the client's parents come to the facility for a luncheon visit. At the last minute the client refuses to have lunch with them and angrily shouts at them to go away. What is the most therapeutic nursing intervention after the parents leave? 1 Encouraging the client to have lunch 2 Confronting the client about the behavior 3 Explaining why the visit was important to the parents 4 Suggesting that the client go to the gym to work off some of the hostility

2 Confronting the client about the behavior prevents the client from avoiding responsibility for the behavior; such avoidance is characteristic of the addicted individual. This approach may also help the client develop some self-awareness. Encouraging the client to have lunch ignores the client's behavior, which should be addressed. The focus should be on the client, not the parents. Although a visit to the gym to work off some of the hostility may provide an outlet for the anger, it supports acting out rather than control of feelings.

During a therapy session with a recently formed group, two members who like to talk want to take the floor simultaneously. Another member interrupts and says angrily, "I wish both of you would shut up. I'm tired of listening to you." What response by the nurse facilitator will be most beneficial for the group? 1 Planning to discuss this problem at the next group session 2 Discussing the behavior and feelings observed in the group 3 Making no comment and allowing the group to deal with the situation 4 Asking a fourth group member to divulge her thoughts about what is happening in the group

2 Discussing behaviors and feelings in the group helps members learn new, more constructive ways to behave. An emotionally charged situation should not be left until the next group session. Because the group has just formed, the members are probably not yet able to handle problems constructively without a leader. Selecting members to participate in the group discussion decreases spontaneity and hinders group responsibility for its members.

Which nursing intervention is indicated for a client with an anxiety disorder? 1 Encouraging suppression of anger by the client 2 Promoting verbalization of feelings by the client 3 Limiting involvement of the client's family during the acute phase 4 Explaining why the client should accept the psychological factors that are precipitating the anxiety

2 Freedom to express feelings serves as a safety valve to reduce anxiety. Suppression of anger or hostility may add to the client's anxiety. Limiting involvement of the client's family during the acute phase may or may not be helpful; the client's family members may provide support. Explaining why the client should accept the psychological factors that are precipitating the anxiety is not therapeutic; accepting current situational stresses may not be possible.

A nurse who is working on a psychiatric unit notes that a client with schizophrenia is beginning to pace around the lounge while glaring at other clients. How should the nurse respond to this behavior? 1 By pointing out the behavior to the client 2 By walking with the client to a quiet area on the unit 3 By suggesting that the client go to the gym to work out 4 By arranging for an additional staff member to be present in the vicinity of the client

2 The client is demonstrating signs of agitation, and stimuli from the environment must be reduced. Pointing out the behavior is confrontational and may increase the client's agitation. The client should not be left unattended at this time; aggressive physical activity at this time may increase the agitation. Arranging for the presence of another staff member will not interrupt the client's behavior, which is the priority at this time.

After a cocaine binge an individual is found unconscious and is admitted to the hospital with acute cocaine toxicity. What should the initial nursing action be directed toward? 1 Being understanding 2 Establishing a patent airway 3 Maintaining a drug-free environment 4 Establishing a therapeutic relationship

2 The client is unconscious and unable to meet physical needs; a patent airway, breathing, and circulation are essential needs. Understanding and support are important once the client's physical condition has stabilized. Maintaining a drug-free environment will be a priority later in the treatment program. Establishment of a therapeutic relationship will increase in importance once the client's physical condition has stabilized.

A client with a history of atrial fibrillation has a stroke, and vascular dementia (multiinfarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? 1 Memory impairment 2 Abrupt onset of symptoms 3 Difficulty making decisions 4 Inability to use words to communicate

2 The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Both vascular dementia and dementia of the Alzheimer type are associated with this deficit in function. Memory impairment may or may not be a symptom of vascular dementia, it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment, but the client does not have abrupt onset of symptoms. Difficulty making decisions is a major part of Alzheimer disease, but may not be manifested with vascular dementia, depending on which part of the brain is affected. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

A client with a history of aggressive, violent behavior is admitted to the psychiatric unit involuntarily. The nurse, who understands the need to use deescalation approaches during the preassaultive stage of the violence cycle, monitors the client's behavior closely for progression of signs of impending violence. List these client assessments in order of escalating aggression, from the lowest risk to the highest. 1. Having difficulty waiting to take turns during a group project 2. Increasing tension in facial expression 3. Pacing in the hall 4. Engaging in verbal abuse toward the nurse 5. Pushing another client while waiting in line to the dining room

2,1,3,4,5 Increasing tension in facial expression indicates increasing anxiety, but the client is still maintaining self-control. Impulsivity, as demonstrated by the inability to take turns with others, indicates that the client is having some difficulty setting limits on his or her own behavior. When anxiety escalates to the point of hyperactivity and pacing behaviors, the client is attempting to cope with the anxiety and to discharge physical and psychic energy. Engaging in verbal abuse may precipitate physical abuse and is a sign that the client is not able to maintain self-control. The laying on of the hands in an offensive manner is a physical act of aggression.

A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies? 1 "How have you managed your problems in the past?" 2 "What do you feel that you've learned from this suicide attempt?" 3 "How will you manage the next time your problems start piling up?" 4 "Were there other things going on in your life that made you want to die?"

3 "How will you manage the next time your problems start piling up?" focuses the interaction toward the future and invites the client to explore alternative coping strategies. "How have you managed your problems in the past?" explores past coping strategies and should have been asked as a part of the initial assessment. "What do you feel that you've learned from this suicide attempt?" is an attempt to explore the client's insight into current coping strategies that should have been made before any discussion of the alternatives. "Were there other things going on in your life that made you want to die?" asks the client once more to ensure that all the precipitating stressors have been identified; this should have been done in the initial assessment.

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. What impact does this disability have on their education? 1 Will probably not be self-directed learners 2 Have intellectual deficits that interfere with learning 3 Experience perceptual difficulties that interfere with learning 4 Are usually performing two grade levels below their age norm

3 ADHD interferes with the ability to perceive and respond to sensory stimuli, resulting in a deficit in interpreting new sensory data. This makes learning difficult. It is not true that children with ADHD have intellectual deficits that interfere with learning; there is no cognitive impairment present. It is not necessarily true that children with ADHD are not self-directed learners or that they perform two grade levels below their age norm.

To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors as the central factors that influence development? 1 Cognitive theory 2 Psychosocial theory 3 Interpersonal theory 4 Psychosexual theory

3 The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachments and a longing to meet biologic and psychological needs are two dimensions associated with this theory. Cognitive theory is associated with Jean Piaget; cognitive theory explains how thought processes develop, are structured, and influence behavior. Psychosocial theory is associated with Erik Erikson; psychosocial theory identifies social interaction as the source that influences human development. Erikson identified eight stages of human life, with each stage built on the previous stages and influenced by past experiences. Psychosexual theory is associated with Sigmund Freud; psychosexual theory views child development as a biologically driven series of conflicts and gratifying internal needs.

A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her top away. Is it something I've done?" What is the most therapeutic initial response by the nurse? 1 Asking the father about his relationship with his wife 2 Asking the father how he held the child when she was an infant 3 Telling the father that it is nothing he has done and sharing the nurse's observations of the child 4 Telling the father not to be concerned and stressing that the child will outgrow this developmental phase

3 The nurse provides support in a nonjudgmental way by sharing information and observations about the child. This child exhibits symptoms of autism, which is not attributable to the actions of the parents. Asking the father about his relationship with his wife or how he held the child when she was an infant indirectly indicates that the parent may be at fault; it negates the father's need for support and increases his sense of guilt. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase is false reassurance that does not provide support; the father recognizes that something is wrong.

How should a nurse at an assisted living facility encourage a client to effectively complete the tasks of older adulthood? 1 By redefining the resident's role in society 2 By investing the resident's energies into nurturing others 3 By trying to complete missed opportunities with significant others 4 By fostering a sense of contentment when the client looks back on past achievements

4 Accepting one's past as meaningful and fulfilling is a sign of achieving the task of ego integrity. Redefining one's life indicates that ego integrity has not occurred. Investing the energies into nurturing others is a task of middle adulthood. An attempt to recapture lost opportunities is evidence of despair; it indicates that ego integrity has not been achieved.

When assessing the characteristics of an adolescent with anorexia nervosa, how does the nurse expect to describe the adolescent? 1 Manic 2 Rebellious 3 Hypoactive 4 Perfectionistic

4 Perfectionistic standards and extremes of self-discipline are an attempt to maintain control and meet the client's own and others' expectations. People with anorexia nervosa are often anxious and depressed, not manic. People with anorexia nervosa are frequently compliant in an attempt to meet the expectations of others. People with anorexia nervosa usually use excessive exercise routines as a means of losing weight. Also, many are trying to become the thin, fit ideal woman depicted in the media.

A client who has severe rheumatoid arthritis becomes depressed and is admitted to the psychiatric unit. The nurse begins to work with the client in one-on-one sessions to help with coping with the depressive episode. What is the best long-term outcome for this client? 1 The client will eat at least two meals per day with other clients. 2 The client will maintain self-care and attend structured activities. 3 The client will make a positive verbal comment to another client daily. 4 The client will decrease negative thinking about self, others, and life.

4 The best long-term goal is that the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has been effective and the client may be discharged. Eating at least two meals per day with other clients is a short-term goal associated with a therapeutic milieu. Maintaining self-care and attending structured activities is a short-term goal and an expected behavior on an inpatient unit. Making a positive verbal comment to another client daily is an intermediate goal that helps the client focus on others; this goal is a step toward achieving long-term goals.

A nurse taking calls at a local crisis center hotline receives a telephone call from a suicidal adolescent. The nurse can safely terminate the call when the client does what? 1 Wishes to terminate the conversation 2 Has responded to the nurse's initial assessment of suicide risk 3 Begins repeating the same information that has already been discussed 4 Can state a preventive plan of action for dealing with self-destructive behaviors

4 The client should be able to state specific behaviors that can be used to decrease self-destructive thoughts and actions; the client must be empowered. Terminating the conversation is ineffective because the client may end the conversation and remain suicidal. The nurse may gather data through the suicide risk assessment tool, but the client may not have attained catharsis; therefore the dialogue should be continued until a contract has been set or self-destructive behaviors have diminished. Repeating the same information that has already been discussed is an indication that the nurse should help the client focus on life and not on suicide; the client has not yet attained catharsis.

Although upset by a young client's continual complaints about all aspects of care, the nurse ignores them and attempts to divert the conversation. Immediately after this exchange with the client, the nurse discusses with a friend the various stages of development of young adults. Which defense mechanism is the nurse using? 1 Sublimation 2 Substitution 3 Identification 4 Intellectualization

4 The nurse is using facts and knowledge to detach herself from the emotional impact of the client's problem and to ease the anxiety it is causing. Sublimation is the channeling of unacceptable thoughts or feelings into acceptable activity. Substitution is similar to displacement; anxiety is reduced with a transfer of the emotions associated with an object or person to another, safer, object or person. Identification is trying to unconsciously imitate the behavior of another who is considered important in an attempt to incorporate the relevant aspects of this individual into the self.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? 1 Are unaware that the ritual serves no purpose 2 Can alter the ritual depending on the situation 3 Should be prevented from performing the ritual 4 Do not want to repeat the ritual but feel compelled to do so

4 The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.

The nurse tells a client that talking with the staff members is part of the therapy program. The client responds, "I don't see how talking to you can possibly help." What is the most appropriate response by the nurse? 1 "I can see how you might feel that way now, but I hope you'll change your mind." 2 "You'll never know whether or not it's helpful unless you're willing to give it a try." 3 "The one-on-one relationship has proved helpful for others, and you should give it a try." 4 "I hope I'll be able to help you sort out your thoughts and feelings so you can understand them better."

4 The response "I hope I'll be able to help you sort out your thoughts and feelings so you can understand them better" is optimistic and supportive and clarifies the purpose of the relationship. The statement "I can see how you might feel that way now, but I hope you'll change your mind" diminishes the client's response and sets up a challenge; it does not foster a therapeutic relationship. The statement "You'll never know whether or not it's helpful unless you're willing to give it a try" diminishes the client's response and sets up a challenge; it does not foster a therapeutic relationship. The statement "The one-on-one relationship has proved helpful for others, and you should give it a try" diminishes the client's response and sets up a challenge; it does not foster a therapeutic relationship.

The nurse manager is evaluating a primary nurse who is working with a hospitalized adolescent client with the diagnosis of conduct disorder. Which intervention by the primary nurse should the nurse manager question? 1 Discussing unit rules 2 Giving the client choices 3 Explaining the consequences of not following unit regulations 4 Encouraging the verbalization of negative feelings toward others

4 Verbalization of negative feelings to others may escalate and result in antisocial or acting-out behavior. The environment must be consistent and predictable to limit manipulative behavior. Allowing opportunities for choices provides opportunities for the client to have some control. Consequences for unacceptable behavior can motivate individuals to act appropriately.

A nurse is creating a therapy group for low-functioning clients. Which client is the most appropriate member? 1 A 77-year-old man with anxiety and mild dementia 2 A 52-year-old woman with alcoholism and an antisocial personality 3 A 38-year-old woman whose depression is responding to medication 4 A 28-year-old man with bipolar disorder who is in a hypermanic state

1 An older person with mild dementia and anxiety can participate in a low-functioning group in which there is greater structure and staff direction. A depressed client who is responding to medication should be able to participate in a higher-functioning group. An alcoholic, antisocial client or one in a hypermanic state might be disruptive in a low-functioning therapy group.

A nursing assistant interrupts the performance of a ritual by a client with obsessive-compulsive disorder. What is the most likely client reaction? 1 Anxiety 2 Hostility 3 Aggression 4 Withdrawal

1 Because the compulsive ritual is used to control anxiety, any attempt to prevent the action will increase anxiety. Underlying hostility is considered part of the disorder itself, not a reaction to an interruption of the ritual. Aggression is possible only if the anxiety reaches a panic level and causes the person to express anger overtly. Withdrawal is not a pattern of behavior associated with obsessive-compulsive disorder.

Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat what? 1 Clinical depression 2 Substance abuse disorders 3 Antisocial personality disorder 4 Psychosis occurring in schizophrenia

1 ECT is used to treat clinical depression in clients who do not respond well to a trial of psychotropic medications or are so severely depressed that immediate intervention is needed. ECT is not used as a primary treatment for clients with substance abuse disorders, antisocial personality disorder, or schizophrenic psychosis.

A nurse is planning activities for a withdrawn client who is hallucinating. Which activity will be most therapeutic for the client? 1 Going for a walk with the nurse 2 Watching a movie with other clients 3 Joining a card game with other clients 4 Playing solitaire alone in the dayroom

1 Going for a walk with the nurse facilitates one-on-one interaction and the development of a trusting relationship. Watching a movie with other clients will allow the client to withdraw further. Joining a card game with other clients will foster competition and may increase anxiety. Playing solitaire alone in the dayroom will allow the client to withdraw further.

Which approaches should a nurse use during crisis intervention? Select all that apply. 1 Active 2 Passive 3 Reflective 4 Interpretive 5 Goal directed

1,5 The nurse should assume an active role in assessing the situation and conduct the interview with authority. During crisis intervention the nurse should be goal directed to help the client cope with the crisis. A passive approach is not appropriate; the client usually needs direction to move forward. A reflective approach might be more appropriate for long-term therapy. An interpretive (analytical) approach is not appropriate for crisis intervention.

A 22-year-old client with the diagnosis of schizophrenia has been in a mental health facility for approximately 2 weeks. After the parents visit the client is seen pacing in the hall, talking loudly alone. What should the nurse's initial intervention be? 1 Obtaining a prescription for a tranquilizer 2 Asking the client about the events of the day 3 Calling the parents to find out what happened 4 Assigning a nursing assistant to remain with the client

2 A broad opening encourages communication that may elicit the client's perception of the day's events. Obtaining a prescription for a tranquilizer is premature. What is most important is the client's, not the parents', perception of what has occurred. Assigning a nursing assistant to remain with the client is premature; there are no data to indicate that the client may self-harm or harm others.

While caring for an older adult client, what symptom requires an immediate reassessment of the client's needs and plan of care? 1 Memory loss or confusion 2 Neglect of self-care 3 Increased daily fatigue 4 Withdrawal from usual activities

1 All are common signs of depression due to the aging process, however, memory loss or confusion may require immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention.

A young college student tells the nurse at the school's health service that his girlfriend's period is late and they both think that she is pregnant. The client, with a broad smile on his face, says loudly and angrily, "If she's pregnant I'll drop out of school, marry her, and get a full-time job." The best initial assessment of the client's verbal and nonverbal behaviors is that they are what? 1 Uniform 2 Consistent 3 Appropriate 4 Incongruent

4 Although the client's facial expression suggests happiness, the client's tone of voice gives the message of anger; the behaviors do not go together. The data given do not support an assessment of uniformity, consistency, or appropriateness.

After an electroconvulsive therapy treatment, a client complains of loss of memory. What is the nurse's best response? 1 "This is temporary; your memory will return after the therapy is done." 2 "It's better if you don't remember what happened before you became ill." 3 "I'll help you try to remember things when the treatments are completed." 4 "Knowing that you're getting well is the most important thing for you right now."

1 "This is temporary; your memory will return after the therapy is done" is a true statement that addresses the client's concern regarding the temporary memory loss, although information about the therapy will not be recalled. The statement "It's better if you don't remember what happened before you became ill" denies the client's fears and feelings and may be frightening and upsetting. The statement "I'll help you try to remember things when the treatments are completed" denies the client's fears and feelings and does not address the current concern. The statement "Knowing that you're getting well is the most important thing for you right now" denies the client's fears and feelings and may not be important to the client at this time.

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation? 1 Electroconvulsive therapy 2 Short-term psychoanalysis 3 Nondirective psychotherapy 4 High doses of anxiolytic drugs

1 Electroconvulsive therapy, which interrupts established patterns of behavior, helps relieve symptoms and limits suicide attempts in clients with severe, intractable depression that does not respond to antidepressant medication. The client's depressed mood limits participation in psychotherapy; feelings precipitated by therapy may lead to suicidal acting out. Psychotherapy is directed toward helping the person learn new coping mechanisms and better ways of coping with problems; the depressed client needs direction to accomplish this. Antianxiety medications are usually not prescribed for clients with depression.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate? 1 Flight of ideas 2 Ritualistic behaviors 3 Associative looseness 4 Auditory hallucinations

1 Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders. Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

A nursing team holds a conference to develop goals for the care of a withdrawn, shy male client with low self-esteem who is afraid to talk to members of the opposite sex. Which objective should be given priority and documented in the client's plan of care? 1 "The client will increase his self-esteem." 2 "The client will understand his sexual disorder." 3 "The client will examine his feelings toward women." 4 "The client will increase his knowledge of sexual function."

1 If the goal to increase the client's self-esteem is met, the client's relationship with others should improve in all aspects, including sexual. Increasing insight may be helpful but should not receive priority. The client may or may not have a sexual disorder. Examining his feelings toward women is not appropriate at this time; examining these feelings is nonproductive until the client's self-esteem improves. Increasing the client's knowledge of sexual function may be done, but improvement of self-esteem should receive priority.

A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar disorder, manic phase. In which type of room should the nurse tell the admissions clerk to place this client? 1 Private 2 Isolation 3 Semi-private 4 Negative-airflow

1 The client who is manic needs a nonstimulating environment. A person who is bipolar is not contagious and does not require an isolation room. The presence of another person in the room is considered stimulating and may interfere with the rest and sleep of both clients. A client who is bipolar does not need a negative-airflow room. This type of room is appropriate for a client with a communicable disease, such as tuberculosis, that requires airborne precautions.

The nurse is assigned to work with a 20-year-old client on an inpatient unit. In assessing the woman, the nurse notes that she is mute, does not show any type of movement, is unresponsive, and appears unaware of her surroundings. What is the best term for the nurse to use to describe these symptoms? 1 Alogia 2 Catatonia 3 Echopraxia 4 Affective flattening

2 Catatonia is the term to describe stupor, rigidity, or extreme flexibility of the limbs; excitability; confusion; and lack of verbal expression. Alogia is a term used to describe an inability to speak or near-absence of speech. Echopraxia is the term for the mimicking or repetition of the actions of another person. Affective flattening is the term for blunted or constricted facial expression.

A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy? 1 "Unconscious feelings influence actions." 2 "Negative thoughts can precipitate anxiety." 3 "People can act their way into a new way of thinking." 4 "Maladaptive behaviors will continue as long as they are reinforced." 00:00:03 Question Answer Confidence ButtonsJust a guessPretty sureNailed it EAQ Home Class ToolsProgressAssignmentsGradesCustom Quiz Credits

2 Cognitive behavioral therapy (CBT) is a highly structured psychotherapeutic method used to alter distorted beliefs and problem behaviors by identifying and replacing negative inaccurate thoughts and changing the rewards for behaviors. Cognitive therapy seeks to discover underlying thoughts that lead to feelings of depression and anxiety; also, it teaches the client to replace these thoughts with more positive, realistic thinking. The response, "Unconscious feelings influence actions," reflects a psychoanalytical approach to treatment. The response, "People can act their way into a new way of thinking," reflects a behavioral approach to treatment. The response, "Maladaptive behaviors will continue as long as they are reinforced," reflects a behavioral approach to treatment.

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse? 1 "You shouldn't give up hope." 2 "Being incapacitated is difficult for you." 3 "Would you like to speak to a religious advisor?" 4 "Have you talked to your family about your feelings?"

2 The response "Being incapacitated is difficult for you" is an open-ended, accepting response that permits and encourages the client to continue to express feelings. The response "You shouldn't give up hope" rejects the client's feelings and implies that it is wrong to feel this way. The response "Would you like to speak to a religious advisor?" avoids the issue and attempts to refer discussion of the client's feelings to someone else. The response "Have you talked to your family about your feelings?" changes the focus from the client's feelings to the family's role.

A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit for 2 weeks is to be discharged home. The client is vacillating between being happy and sad about going home. What term best describes these conflicting emotions? 1 Double bind 2 Ambivalence 3 Loose association 4 Inappropriate affect

2 The simultaneous existence of two conflicting emotions, impulses, or desires is known as ambivalence. A single communication containing two conflicting messages is known as a double-bind message. A lack of connections between thoughts is known as loose associations. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.

What statement by a male client during a yearly physical examination indicates to a nurse that the client may have a sexual arousal disorder? 1 "I have no interest in sex." 2 "I don't get hard during sex anymore." 3 "I climax almost before we even get started." 4 "It takes forever before I finally have an orgasm."

2 The statement "I don't get hard during sex anymore" indicates a sexual arousal disorder, which is a partial or complete failure to achieve a physiologic or psychological response to sexual activity. The statement "I have no interest in sex" may indicate a sexual desire disorder in which the individual has deficient or absent interest in, or extreme aversion to and avoidance of, sexual activity. "I climax almost before we even get started" and "It takes forever before I finally have an orgasm" are both indicative of an orgasmic disorder, which is a delay in or absence of an orgasm or premature ejaculation.

A nurse working on a mental health unit is caring for several clients who are at risk for suicide. Which client is at the greatest risk for successful suicide? 1 Young adult who is acutely psychotic 2 Adolescent who was recently sexually abused 3 Older single man just found to have pancreatic cancer 4 Middle-age woman experiencing dysfunctional grieving

3 Older single men with chronic health problems are at the highest risk of suicide. This is because men have fewer social supports than women do. (Men are less social then women in general.) Less social support at times of stress can increase the risk of suicide. Also, chronic health problems can lead to learned helplessness, which can lead to depression. People who are acutely psychotic as a group are at higher risk for suicide, but they do not have the suicide rate of older single adult men with chronic health problems. An adolescent who was recently sexually abused, although severely traumatized, does not have the risk of suicide of an older single man with chronic health problems. Dysfunctional grieving is prolonged grieving that is characterized by greater disability and dysfunctional patterns of behavior. Although people with complicated dysfunctional grieving may be at risk for self-directed violence, they do not have the suicide risk of older single men with chronic health problems.

A client who was sexually assaulted 3 hours ago comes to the emergency department of the hospital. The priority is for the staff to help the client feel what? 1 Loved 2 Believed 3 Protected 4 Accepted

3 Safety and security are basic needs that assume significance immediately after a sexual assault. Although all people have a need to belong and be loved, these are not priorities at this time and are not responsibilities of the staff. Although belief is important, it is not the priority. Although acceptance is important, it is not the priority.

What does the nurse recall is the major defense mechanism used by an individual with a phobic disorder? 1 Splitting 2 Regression 3 Avoidance 4 Conversion

3 The person transfers anxieties to activities or objects, usually inanimate objects, which are then avoided to decrease anxiety. Splitting is the compartmentalization of opposite affective states and the inability to integrate the positive and negative aspects of others or self. Regression, the return to an earlier, more comfortable level of development, is not the defense mechanism used by someone with a phobia. Conversion, the transfer of a mental conflict to a physical symptom, is not the defense mechanism used by someone with a phobia.

A nurse manager on the psychiatric unit discusses the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with a group of staff members. Which statement by the nurse manager reflects the primary purpose of the manual? 1 It aids in teaching psychopathology to mental health practitioners and nurses. 2 It facilitates research and improves communication between researchers and clinicians. 3 It provides clinicians with a classification of mental disorders and guidelines to aid diagnosis. 4 It assists in collecting and communicating accurate public health statistics through the use of specific diagnostic codes

3 The prime purpose of the DSM-5 is to serve as a guide in determining a client's mental health/psychiatric diagnosis. Although the manual can be used in teaching, research and communication, and the collection and communication of public health statistics, none is the prime purpose of this publication.

Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care, because these clients have a need to do what? 1 Relate in a consistent manner to staff 2 Learn that the staff cannot be manipulated 3 Accept controls that are concrete and fairly applied 4 Have sameness and consistency in their environment

4 A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality oriented. It is the staff members who need to be consistent. Clients who have this disorder do not attempt to manipulate the staff. Acceptance of controls that are concrete and fairly applied is not needed when working with clients who have this disorder; consistency is most important.

What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position? 1 Sitting down in a chair by the client and saying, "I'm here to spend time with you." 2 Touching the client gently on the shoulder and saying, "I'm going to sit with you for a while." 3 Going to the client and saying, "I'll be waiting for you in the community room, so please get up and join me." 4 Leaving the client alone because the behavior demonstrates that the client has regressed too far to benefit from talking with the nurse

1 "I'm here to spend time with you" accepts the client at the client's current level and allows the client to set the pace of the relationship. Touching the client may be misinterpreted and may precipitate an aggressive response. Going to the client and saying, "I'll be waiting for you in the community room, so please get up and join me," asks the client to reach out to the nurse; in the therapeutic relationship, the nurse must reach out to the client. Even if the client is too withdrawn to respond, the nurse's physical presence can be reassuring, so leaving the client alone is not the most appropriate choice.

A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example? 1 Dissociation 2 Transference 3 Displacement 4 Identification

1 Speaking in the third person reflects poor ego boundaries and dissociation from the real self. Transference is the movement of emotional energy and feelings that one has for one person to another person. Displacement is an attempt to reduce anxiety by transferring the emotions associated with one object or person to another. Identification is an attempt to increase self-esteem by acquiring the attributes or characteristics of an admired individual.

A nurse decides to use the CAGE screening questionnaire with a client admitted for substance abuse. What is the client abusing? 1 Alcohol 2 Barbiturates 3 Hallucinogens 4 Multiple drugs

1 The CAGE questionnaire is one of the simplest and most reliable screening tools for alcohol abuse. CAGE is an acronym for the key words ( Cut down, Annoyed, Guilty, and Eye-opener) in the four questions asked of people suspected of abusing alcohol. The CAGE questionnaire is not designed to screen clients for barbiturate, hallucinogen, or multiple drug abuse.

A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing which imbalance? 1 Thiamine deficiency 2 A reduced iron intake 3 An increase in serotonin 4 Riboflavin malabsorption

1 The deficiency of thiamine (vitamin B1) is thought to be a primary cause of alcohol-induced amnestic disorder. Reduced iron intake, increased serotonin, and riboflavin malabsorption are all unrelated to alcohol-induced amnestic disorder.

A client is found to have a mood disorder, hypomanic episode. To support the diagnosis, the nurse should identify the signs and symptoms associated with this disorder. Select all that apply. 1 Distractibility 2 Flight of ideas 3 Low self-esteem 4 Increased need for sleep 5 Psychomotor retardation

1, 2 These individuals have a short attention span; their attention is easily drawn to unimportant or irrelevant external stimuli. These individuals shift from one idea or topic to another and express their thoughts in a rapid flow of speech. These individuals have an inflated self-esteem or grandiosity. These individuals have a decreased need for sleep. These individuals have psychomotor agitation or an increase in goal-directed activity.

Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing? 1 Illusion 2 Delusion 3 Confabulation 4 Hallucination

2 A delusion is a fixed false belief. An illusion is a false sense interpretation of an external stimulus. Confabulation is the client's attempt to fill gaps in memory with imaginary events. A hallucination is a false sensory perception with no external stimulus.

What does the nurse leader expect all members to be doing when a therapy group is achieving its objective? 1 Attending every session of the group 2 Commenting on each topic discussed by the group 3 Making an effort to include one another in discussions 4 Following through on obeying rules governing behavior

3 Making an effort to include one another in discussions demonstrates an increase in socialization and an awareness of the behavior of others. Attendance alone is an insufficient basis for evaluation of the effectiveness of group therapy. The quantity and extent of comments are not significant. Following through on obeying rules governing behavior may indicate a greater degree of impulse control on the part of the members, but this is not the primary goal of group therapy.

A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified. What should the nurse consider most unusual for the child to demonstrate? 1 Interest in music 2 Ritualistic behavior 3 Attachment to odd objects 4 Responsiveness to the parents

4 One of the symptoms that an autistic child displays is lack of responsiveness to others; there is little or no extension to the external environment. Music is nonthreatening, comforting, and soothing. Repetitive behavior provides comfort. Repetitive visual stimuli, such as a spinning top, are nonthreatening and soothing.

A 24-year-old woman states that she no longer enjoys any of the activities that she once found fun and pleasurable, such as socializing, sports, and hobbies. What term should the nurse use to describe this condition? 1 Anergia 2 Anhedonia 3 Grandiosity 4 Learned helplessness

2 Anhedonia is the inability to experience pleasure in events or activities that once were enjoyable. Anergia is lethargy and a decreased level of energy. Grandiosity is a symptom seen during manic episodes in which an individual displays an inflated self-esteem. Learned helplessness is a theory proposing that depression occurs when an individual believes that he or she has no control over life situations. This results in the individual's giving up and becoming passive and dependent.

A nurse determines that a client is pretending to be ill. What does this behavior usually indicate? 1 Psychosis 2 Malingering 3 Use of conversion 4 Lack of contact with reality

2 When an individual consciously pretends to have an illness with no physical basis, it is called malingering. People who are psychotic experience delusions, hallucinations, and disorganized thoughts, speech, or behavior. The use of conversion defenses is not a conscious act. A person out of contact with reality is unable to pretend to be ill.

What is a therapeutic nursing action in the care of a depressed client? 1 Playing a game of chess with the client 2 Allowing the client to make personal decisions 3 Sitting down next to the client at frequent intervals 4 Providing the client with frequent periods of time for reflection

3 Sitting down next to the client at frequent intervals gives the client the nonverbal message that someone cares and views the client as being worthy of attention and concern. The concentration required for chess is too much for the client at this time. The client is incapable of making decisions at this time. Depressed clients often have too much thinking time.

A 10-year-old child in whom autism was diagnosed at the age of 3 years attends a school for developmentally disabled children and lives with parents. The child has frequent episodes of self-biting and head-banging and needs help with feeding and toileting. What is the priority nursing goal for this child? 1 Controlling repetitive behaviors 2 Being able to feed independently 3 Remaining safe from self-inflicted injury 4 Developing control of urinary elimination

3 The priority is safety; the child must be protected from self-harm. Repetitive behaviors are comforting, and unless they are harmful their limitation is not a priority. Although feeding independently is a basic need that may be achieved, it is not the priority. Children who need help with toileting are not necessarily incontinent, and it is not the priority.

When counseling the 20-year-old parents of a 13-month-old child, the nurse considers that the defense mechanism most often used by physically abusive parents is what? 1 Idealization 2 Manipulation 3 Transference 4 Displacement

4 Displacement is a defense mechanism in which one's pent-up feelings toward others who are a threat are discharged on others who are less threatening. Idealization is attributing overstated positive characteristics to others. Transference is a mechanism by which affects or emotional tones are shifted from one individual to another. Manipulation is a mechanism by which individuals attempt to manage, control, or use others to suit their own purpose or to gain an advantage.

The nurse determines that the plan for bolstering an overweight adolescent's self-esteem has been effective when, 3 months later, the adolescent's mother reports that the adolescent is doing what? 1 Seems to be doing average work in school 2 Has asked her how to bake bread and cookies 3 Imitates a sibling's manner of speech and dress 4 Joined a dirt bike group that meets at the school

4 Joining a dirt bike group demonstrates a movement toward peer group activity and interests; exercise demonstrates an interest in an improved physical condition. There are no data to indicate that school is a problem. Average work in school and an interest in baking do not demonstrate an increase in self-esteem.

What is a constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome? 1 Role experimentation 2 Adherence to peer standards 3 Sublimation through schoolwork 4 Development of dependence on parents

1 Adolescents learn about who they are by assuming and experiencing a variety of roles; experimentation results in the retention or rejection of behavior and roles. Adherence to peer standards is not constructive; it does not allow experimentation with a variety of roles. Sublimation is not constructive and delays and interferes with the successful completion of the struggle to formulate one's identity. Development of dependence on parents is not constructive; it does not allow the development of independence.

While a client is attending an Alcoholics Anonymous (AA) meeting, a nurse talks with the client's spouse about the purpose of AA. What is the priority goal of this self-help group? 1 Changing destructive behavior 2 Developing functional relationships 3 Identifying how people present themselves to others 4 Understanding patterns of interacting within the group

1 The purpose of a self-help group is for individuals to develop their strengths and new, constructive patterns of coping. Developing functional relationships, identifying how people present themselves to others, and understanding patterns of interaction within the group are purposes of group therapy.

A nurse admits a client with the long-standing obsessive-compulsive behavior of washing the hands and body to the psychiatric unit. What should the initial treatment plan include? 1 Determining the purpose of the ritual 2 Allowing enough time for the ritualistic behavior 3 Distracting the client from the ritualistic behavior with unit activities 4 Suggesting a variety of symptom substitutions to refocus the ritualistic behavior

2 Until trust has been developed and the client is less anxious, the ritual should be allowed. However, limits should be set if the handwashing leads to skin problems. Although identification of the purpose of the ritual is one of the objectives to be fulfilled, this should be done during the working phase of the nurse-client relationship, not in the initial phase. Distraction from the ritualistic behavior is ineffective initially but may be used later. Symptom substitution to delay the performance of a compulsive behavior is an appropriate intervention for the working phase of the nurse-client relationship, not for the initial stage.

A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation? 1 Ideas of grandeur 2 Need to get attention 3 Marked loss of memory 4 Difficulty accepting the truth

3 Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered. Ideas of grandeur do not occur in this disease. A need to get attention is unrelated to confabulation. These individuals are not purposely lying but instead are trying to cover memory losses.

A young adult is being treated in the emergency department for injuries sustained as a result of physical battering by her partner. On learning that there is a history of such abuse, the nurse plans which tertiary nursing interventions? Select all that apply. 1 Contacting family members to provide support 2 Discussing the legal ramifications of not pressing charges 3 Offering to discuss the abusive behavior with the woman's partner 4 Identifying the benefits of attending a support group for battered women 5 Providing her with information regarding local domestic violence shelters

4,5 Providing information regarding support groups or local domestic violence shelters does qualify as a tertiary intervention because it is focused on preventing further abuse. Contacting family members should not be done without the consent of the client; it violates the client's confidentiality. Discussing the legal ramifications of not pressing charges against the partner implies pressuring the client to act in a manner that she may not be comfortable engaging in at this point. Offering to discuss the behavior with the partner is not advised because it could worsen tensions and result in additional battering; furthermore, such an intervention is not within the scope of nursing practice.

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. What should the nurse keep in mind regarding confusion when planning care for this client? 1 Confusion occurs with a transfer to new surroundings. 2 Confusion will be unchanged despite reality orientation. 3 Confusion is a common finding and is expected with aging. 4 Confusion results from brain changes that make interventions futile.

1 A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with dementia-type disorders; with appropriate intervention, including frequent reorientation, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. The assertions that reality orientation is ineffective, that confusion is an expected finding in aging, and that brain changes in dementia make interventions futile are all untrue.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? 1 Increase in serotonin 2 Deficiency of thiamine 3 Reduction in iron intake 4 Malabsorption of riboflavin

2 Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism.

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom? 1 Edema 2 Diarrhea 3 Amenorrhea 4 Hypertension

3 Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration.

At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we both mean the same thing." What technique is this an example of? 1 Reflecting feelings 2 Making observations 3 Seeking consensual validation 4 Attempting to place events in sequence

3 Seeking consensual validation is a technique that prevents misunderstanding so the client and the nurse can work toward a common goal in the therapeutic relationship. Reflecting feelings, making observations, and trying to place events in sequence do not provide for clarification or understanding.

A nurse is assigned to care for an adolescent who has been admitted to the psychiatric hospital with a diagnosis of anorexia nervosa. What should the nurse's initial intervention be? 1 Scheduling an endocrinology consult because of amenorrhea 2 Confronting those behaviors that reflect an inflated self-importance 3 Arranging for psychotherapy sessions to help develop a desire to accommodate others 4 Developing a contract to achieve a weekly weight gain, with consequences for nonachievement

4 Treatment usually includes a contract for weight gain, signed by the client, whereby privileges are revoked if the weight is not gained; the diet and the amount of food eaten are not the focus of care. Menstruation usually ceases because of severe malnutrition, not because of endocrine pathology. These clients have a low self-esteem and usually do not feel important.

What should the nurse keep in mind about rituals when planning care for a client who uses ritualistic behavior? 1 They help the client control anxiety. 2 They are under the client's conscious control. 3 They are used by the client primarily for secondary gains. 4 They help the client focus on the inability to deal with reality.

1 The rituals used by a client with obsessive-compulsive disorder help control the anxiety level by maintaining a set pattern of action. The client cannot consciously control the ritual. Rituals are used primarily to handle feelings of anxiety and generally are seen by the client as illogical; they provide few secondary gains. Rituals are a means of diverting attention from feelings of anxiety.

When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly at what point in their routine? 1 Before meals 2 After going to bed 3 During group activities 4 While watching television

2 Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing environmental stimuli.

A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? 1 Threats 2 Ideation 3 Gestures 4 Attempts

3 A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.

A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? 1 Undoing 2 Projection 3 Suppression 4 Intellectualization

3 Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.

A nurse is intervening with a client who is having a crisis. What is the nurse's concern after the initial crisis issues have been addressed? 1 Nature of the precipitating factor 2 Impact of the situation on significant others 3 Client's ability to cope with successive crises 4 Client's potential to perform activities of daily living

4 Assessment of the client's current status and ability to perform activities of daily living is the priority because it will influence the choice of an appropriate therapeutic regimen. Although the nature of the precipitating factor is significant, this is not the priority at this time and should already have been addressed. Concern now is for the client, not for how the client's behavior affects others. The current crisis must be dealt with first rather than successive crises.

What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment? 1 Reality orientation 2 Behavioral confrontation 3 Reflective communication 4 Reminiscence group therapy

1 Reality orientation is generally helpful for clients exhibiting mild cognitive impairment; these clients are aware of their impairment, and orientation then reduces anxiety. Behavioral confrontation is not therapeutic because it may cause frustration and increase psychomotor agitation in a client with cognitive impairment. Reflective communication is a technique in which the nurse restates or repeats the client's statements; it can be used to clarify thoughts but may also lead to frustration when the approach is overdone. Reminiscence group therapy is helpful with severely confused, disorganized clients because it reinforces identity, acknowledges what was significant, and often compensates for the dullness of the present.

The nurse is caring for a client with newly diagnosed schizophrenia. What factor in the client's history indicates a greater potential for recovery? 1 Vague prepsychotic symptoms 2 Brain abnormalities on PET scan 3 Insidious onset of the client's illness 4 A relative who also has schizophrenia

1 The presence of vague prepsychotic symptoms is associated with decreased morbidity related to schizophrenia. Brain abnormalities on PET scan, insidious onset of the client's illness, and a relative who also has schizophrenia tend to contribute to a poor prognosis.

A salesman with a history of heavy drinking is on a detoxification unit. He asks the nurse's permission to skip the Alcoholics Anonymous (AA) meeting held each day. What is the nurse's initial response? 1 "What are your feelings about going to AA meetings?" 2 "What is it that you dislike about going to AA meetings?" 3 "It's all right to wait until you feel like going to AA meetings." 4 "An important part of your treatment is attending AA meetings."

1 The question "What are your feelings about going to AA meetings?" forces the client to face what going to AA meetings means to the client. The question "What is it that you dislike about going to AA meetings?" focuses the client on negative aspects; also, the client may be unable to answer this question. The response "It's all right to wait until you feel like going to AA meetings" reinforces avoidance, which delays dealing with the problem; the client may never feel like going to AA meetings. Although the response "An important part of your treatment is attending AA meetings" is true, it does not explore the client's feelings.

The nurse is involved in a therapeutic relationship with a depressed client. Which question and/or statement by the nurse is appropriate for stage 1 of this relationship? Select all that apply. 1 "I'm here to talk with you about how you've been feeling." 2 "How do you feel about keeping a journal regarding how you are feeling?" 3 "Are you experiencing any suicidal or homicidal thought?" 4 "Are you open to the prospect of being prescribed antidepressant medication?" 5 "What we talk about will be shared only with your treatment team."

1, 3, 5 Stage 1, the orientation phase of the therapeutic relationship, involves the nurse learning about the client and their initial concerns and needs. Discussing how the client feels is an initial focus of the communication. Assessing for specific problems, such as suicidal thoughts, is appropriate because it addresses this client's safety needs. Assuring confidentiality helps build trust and so is appropriate for this stage. Discussions concerning treatment techniques, such as journaling and medication, are reserved for stage 2 of the working phase of the relationship.

An older widow with lung cancer is now in the terminal stage of her illness. Her family is puzzled by her mood changes and apparent anger at them. The nurse explains to the family that the client is doing what? 1 Trying to avoid her situation 2 Coping with her impending death 3 Attempting to reduce family dependence on her 4 Hurting because the family will not take her home to die

2 Anger is associated with one of the stages of dying; understanding the stages leading to the acceptance of death may help the family accept the client's moods and anger. Avoiding the situation reflects the stage of denial, when the reality of the situation is not being acknowledged; anger is not common in this stage. There are not enough data to indicate that the client is trying to reduce her family's dependence on her or that she wants to go home to die.

Which intervention will the nurse implement when assisting a child with a history of aggressive behavior to regain control in the triggering phase of an assault cycle? 1 Discuss alternative behaviors to substitute for aggression. 2 Provide the child with a quiet, low-stimulus environment. 3 Speak to the child in a calm but firm manner. 4 Administer medication as needed (PRN) to facilitate de-escalation.

2 In the triggering phase, the client's behavior is nonthreatening and poses no danger to others. Minimizing environmental stimuli and providing a calm, nonthreatening environment likely will serve to help the client de-escalate and regain control. Discussion of substitute behaviors is effective only once the crisis is over (postcrisis phase). As the client escalates, the nurse needs to begin to assume control by presenting a calm but firm tone of voice and demeanor. It is at this time that appropriate oral PRN medications may be helpful.

After caring for a terminally ill client for several weeks, a nurse becomes increasingly aware of a need for a respite from this assignment. What is the best initial action by the nurse? 1 Requesting a few days' vacation time 2 Seeking support from colleagues on the unit 3 Withdrawing emotional involvement with the client 4 Staying with the client while trying to work through the feelings

2 Talking with colleagues who face or who have faced the same problems may provide constructive help with the situation. Requesting vacation time is an avoidance technique; these feelings must be addressed. Withdrawing emotional involvement with the client does not address the needs of the nurse and may interfere with a productive nurse-client relationship. Staying with the client while trying to work through the feelings does not address the needs of the nurse and may interfere with a productive nurse-client relationship.

A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and concludes that the relationship with the husband was probably what? 1 Loving 2 Long-term 3 Ambivalent 4 Subservient

3 If the relationship was ambivalent, the surviving spouse now has feelings of both anger and guilt to resolve. A loving relationship evokes fewer feelings of guilt and is followed by a less complicated grieving process. The length of the relationship seems to have little to do with the ease or difficulty in completing the grieving process. Individuals in the subservient role usually have learned to accept directions and either find a new director or are relieved to have a chance to express their own feelings.

When a diagnosis of child abuse is established, what is the priority of nursing care? 1 Promoting bonding with the child 2 Staying with the parents while they visit 3 Protecting the total well-being of the child 4 Teaching methods of discipline to the parents

3 Management of the abused child places protection of the child's total being above consideration of parents' rights or wishes. Protecting the child, not promotion of parental attachment, is the priority at this time. Supervision may be necessary, but it is only part of maintaining the child's well-being. Teaching methods of discipline is not appropriate at this time.

A client with cyclothymic disorder with hypomanic symptoms is admitted to the psychiatric unit. The client has progressively lost weight and does not take the time to eat the provided food. How can the nurse best respond to this situation? 1 By providing a tray in the client's room 2 By assuring the client that food is deserved 3 By ordering food that the client can hold and eat while moving around 4 By pointing out that the client must replace the energy burned by eating

3 The client with hypomanic symptoms cannot tolerate sitting still long enough to eat an adequate meal; handheld foods will help meet the client's nutritional needs and do not require the client to sit down. This client will most likely ignore the tray. Unworthy feelings are related to a depressive, not manic, episode. It is unlikely that this client will understand or care about the need to replace energy with food.

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? 1 Speaking aloud at weekly meetings 2 Promising to attend at least 12 meetings yearly 3 Maintaining controlled drinking after 6 months 4 Acknowledging an inability to control the problem

4 A major premise of AA is that to be successful in achieving sobriety, clients with alcohol abuse problems must acknowledge their inability to control their drinking. There are no rules about speaking at meetings, although members are encouraged strongly to do so. There are no rules of attendance at meetings, although members are encouraged strongly to attend as often as possible. Maintaining controlled drinking after 6 months is not part of AA; this group strongly supports total abstinence for life.

Shortly after the death of her husband after a long illness, a woman visits the mental health clinic complaining of malaise, lethargy, and insomnia. The nurse, knowing that it is most important to help the wife cope with her husband's death, should attempt to determine which information? 1 Age of the wife 2 Timing of the husband's death 3 Socioeconomic status of the couple 4 Adequacy of the wife's support system

4 Support is most important when coping with the crisis of death; the client must rely on the support system to cope with the loss. The client's age may play a role in coping, but it is not the most important factor. The timing may be important if the death is just one of multiple stresses, but it is not the most important factor in helping a client cope. Socioeconomic status may be important in long-term planning, but it is not the most important factor in the grieving process.

A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate? 1 Loss of appetite 2 Postural hypotension 3 Total memory loss 4 Confusion immediately after the treatment

4 The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of appetite, postural hypotension, and total memory loss are not usual or expected side effects. Memory loss is usually restored after a few months of treatment.

A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child? 1 Keeping the child from inflicting any self-injury 2 Helping the child improve communication skills 3 Helping the child formulate realistic ego boundaries 4 Providing the child with opportunities to discharge energy

1 All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority.

he nurse would recognize which behavior as being characteristic of the panic phase of crisis behavior? 1 Being physically immobile 2 Sobbing for no apparent reason 3 Reporting great difficulties falling asleep 4 Startling easily to loud noises and being touched

1 Being unable to physically move is a psychomotor characteristic of extreme panic, which is a characteristic of crisis behavior. Sobbing for no apparent reason, reporting great difficulties falling asleep, and startling easily to loud noises and being touched are behaviors seen in lesser degrees of anxiety.

A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 1 2 years 2 6 years 3 6 months 4 1 to 3 months

1 By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.

Relatives of the victims of a home invasion in which several family members were killed receive crisis intervention services. Which therapy is most beneficial after the immediate event has passed? 1 Grief 2 Family 3 Psychoanalytical 4 Psychoeducational

1 Grief therapy provides guidance as one completes the tasks of successful mourning; its goal is to prevent unresolved and dysfunctional grief. Family therapy focuses on the family as a system rather than on just one individual's problem; the goals of family therapy are to foster the self-worth of all members, promote clear and honest communication among members, create guidelines for interaction that are realistic and flexible, and link individuals and family with society in ways that are open and hopeful. No data in the scenario indicate that the family became dysfunctional after the tragedy. Psychoanalytic therapy is generally not used to explore unresolved grief. Psychoanalysis helps the individual become aware of repressed emotional conflicts, analyze their origin, and, through the process of insight, bring them into consciousness, so maladaptive behavior can be altered. Psychoeducational therapy is focused on teaching clients and family members about disorders, treatments, and resources with the goal of empowering them to participate in their own care once they have the knowledge. No evidence in the scenario indicates that the families need psychoeducational therapy.

What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit? 1 Projection 2 Regression 3 Repression 4 Rationalization

1 Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid type, in which the delusional system is well systematized. Repression, or unconscious forgetting, is not a major defense used by clients with schizophrenia; if it were, they would not need to break with reality. Rationalization, in which the individual blames others for problems and attempts to justify actions, is seldom used by clients with schizophrenia.

While leading a group session, what should the nurse do when occasional silence occurs? 1 Accept silence with reflection or affirmation. 2 Be willing to sit indefinitely to wait out the silence. 3 Call on specific members to talk when silence occurs. 4 Require each member to talk by going around the group.

1 The nurse can feel pressured to fill the silence or can interpret the silence as a failure in achieving group goals. It can be therapeutically beneficial to allow clients to sit and reflect on their thoughts while being a supportive presence. The nurse can communicate support, understanding, and acceptance with gentle reflections and affirmations. Some examples include: "This is really hard for you to process." or "Take all the time that you need." The group sessions are typically scheduled and must work within time limits, so an indefinite silence is unrealistic. Calling out clients and/or requiring them to talk by going around the group can cause increased anxiety and poor participation.

During a therapy group session, a female client begins to cry and tells the other group members that her husband has told her that he wants a divorce. What is the most appropriate initial response by the nurse? 1 Observing how the group responds to her statement 2 Asking her to explore the reasons that he wants a divorce 3 Suggesting that she and her husband seek marital counseling 4 Staying with the client outside the room until she stops crying

1 The nurse should not intervene at this time because the client made the statement to the group. Initially the nurse should observe how the group responds to the client's statement. Next the nurse should nurture a supportive response by group members. Asking her to explore the reasons that he wants a divorce may be perceived as confrontational and intimidate the client and other group members. Suggesting that she and her husband seek marital counseling is inappropriate at this time. The group should focus on the client's current feelings. Staying with the client outside the room until she stops crying is unnecessary because the client is not a danger to herself or others. Also, it gives the message that feelings of sadness cannot be shared with the group.

A school nurse is asked to present an educational program on attention deficit-hyperactivity disorder (ADHD) to the staff of an elementary school. What should the nurse emphasize about this disorder? 1 It becomes evident before 4 years of age. 2 Its major clinical manifestation is easy distractibility. 3 It occurs more frequently in lower socioeconomic groups. 4 It causes affected children to sleep more than unaffected children.

2 A major clinical manifestation is distractibility. The stimuli may come from external sources or internal sources. Children frequently demonstrate immaturity relative to chronologic age. Selective attention is often seen, in which the child has difficulty attending to "nonpreferred" tasks, such as completing chores or finishing homework. This problem usually becomes evident around 6 to 7 years of age and is noted in at least two different settings (e.g., school and home). Socioeconomic factors do not play a major role in the occurrence of this disorder. Children with ADHD have less need for sleep than do children without ADHD.

The nurse explores the possibility of joining Narcotics Anonymous (NA) with a client who has a history of drug abuse. What is a major reason that NA is helpful in treating addictive behavior? 1 More change will take place within the group. 2 Group members are supportive of one another's problems. 3 Group members share a common background and history. 4 Addiction problems are dealt with more effectively in a group.

2 Although members of the group may become impatient with one another's problems at times, the group is usually supportive. Members share common goals, and the opportunity is available to test out new patterns of behavior. The rate and degree of change are individually based variables. People with addiction problems have varied backgrounds; the only common denominator may be the addiction. Although many clients function well in a group, some clients cannot.

A hospitalized older depressed client tells the nurse that life is no longer worth living. What is the best response by the nurse? 1 "Why do you want to die?" 2 "Are you having thoughts about suicide?" 3 "You must be very depressed to feel that way." 4 "Let's focus on something positive in your life."

2 Asking direct questions about suicidal intent helps the client verbalize, because it demonstrates to the client that the topic is one that can be discussed. It also provides essential information needed to plan care. Asking the client the reason for wanting to die is not the priority; the client has already said that life is not worth living and may not be able to elaborate further. Stating that the client must be very depressed is judgmental and may put the client on the defensive and block communication. By moving the focus to finding something positive to talk about, the nurse is avoiding discussing the issue; this statement may block further communication.

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? 1 Write down conversations to facilitate the recall of information. 2 Monopolize conversations about the anxiety being experienced. 3 Redirect the conversation with the nurse to physical symptoms. 4 Start a conversation asking the nurse to recommend palliative care.

3 Clients with somatoform disorders are preoccupied with the symptoms that are being experienced and usually do not want to talk about their emotions or relate them to their current situation. Clients with somatoform disorders do not seek opportunities to discuss their feelings. Memory problems are not associated with somatoform disorders. These clients want and seek treatment, not palliative care.

A client confides to the nurse that she enjoys engaging in sex with multiple male adult sex partners simultaneously. What is the most appropriate response by the nurse? 1 "I recommend that you seek counseling for this problem." 2 "Don't you think that having sex with multiple partners is immoral?" 3 "These men are abusing you, and you should go to the police to report them." 4 "What are you using for birth control and protection from sexually transmitted infections?"

4 Adults may have consensual sex as desired, but the nurse should encourage the use of birth control and protection from sexually transmitted infections. The nurse is interjecting personal values by stating that the client should seek counseling for this behavior or that the client's behavior is immoral. If the sex is consensual, it is not abusive.

During a period of hyperactivity a client on the psychiatric unit demands to be allowed to go downtown to shop. The client does not currently have privileges. How should the nurse respond? 1 "You can't leave the unit, because you're too sick." 2 "You'll have to ask your primary healthcare provider for permission to go." 3 "You'll have to wait, because no staff member is available to go with you." 4 "You don't have privileges to leave, but we can look through this new catalog."

4 Clients who are hyperactive are easily diverted. It is best to use distraction rather than precipitate a confrontation. Telling the client that leaving will not be allowed ignores the client's wishes and offers no alternative behavior. Telling the client that the primary healthcare provider will have to be called shifts responsibility to the primary healthcare provider; the nurse should know that a shopping trip is unrealistic at this time. Telling the client that no one is available to accompany the client does not deal with reality and only postpones the need to address the problem directly.

After speaking with the parents of a child dying of leukemia, the primary healthcare provider gives a verbal do-not-resuscitate order but refuses to put it in writing. What should the nurse do? 1 Follow the order as given by the primary healthcare provider. 2 Refuse to follow the primary healthcare provider's order unless the nursing supervisor approves it. 3 Ask the primary healthcare provider to write the order in pencil on the child's chart before leaving the room. 4 Determine whether the family is in accord with the primary healthcare provider while following hospital policy.

4 Determining whether the family is in accord with the primary healthcare provider while following hospital policy verifies family and provider agreement and uses institutional policy developed by the ethics committee. Neither the nurse nor the nursing supervisor should accept this inappropriate order. The order must be present in ink on the written record.

A client is experiencing hallucinations. What therapeutic intervention should the nurse plan to help the client cope with the hallucinations? 1 Reinforcing the perceptual distortions until the client develops new defenses 2 Providing an unstructured environment and assigning the client to a private room 3 Avoiding helping the client make connections between anxiety-producing situations and hallucinations 4 Distracting the client's attention by providing a competing stimulus that is stronger than the hallucinations

4 Distracting the client by providing a competing stimulus that is stronger than the hallucinations is helpful in easing hallucinations. Connections should be made to decrease the use of hallucinations. Reinforcing the distortions, providing an unstructured environment, and assigning the client to a private room will foster the hallucinations.

According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to which earlier developmental stage? 1 Trust versus mistrust 2 Industry versus inferiority 3 Identity versus role confusion 4 Generativity versus stagnation

4 Erikson theorized that how well people adapt to the current stage depends on how well they adapted to the stage immediately preceding it—in this instance, adulthood. Although Erikson believed that the strengths and weaknesses of each stage are present in some form in all succeeding stages, their influence decreases with time.

A nurse in a hospice program cares for clients and family members who are coping with imminent loss. What is the most important factor in predicting a person's potential reaction to grief? 1 Family interactions 2 Social support system 3 Emotional relationships 4 Earlier experiences with grief

4 How a person has handled grief in the past provides clues to how he or she will cope with grief in the present. Although family interactions, social support system, and emotional relationships are all important, none is the paramount predictor of a client's reaction to grief.

A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks she is pregnant even though she has had intercourse only once, more than a year ago. What is the most appropriate inference for the nurse to make about the student? 1 Using magical thinking 2 Submitting to peer pressure 3 Lying about the last time she had intercourse 4 Lacking knowledge that anorexia can cause amenorrhea

4 The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data are available to support the fact that the client is using magical thinking, which is characterized by the belief that thinking or wishing something can cause it to occur; in light of the client's diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this type of concern. Although the nurse should question the timeline again, the client's nutritional status should be explored first.

What does a nurse expect to determine about a child with a diagnosis of reactive attachment disorder? 1 Has been physically abused 2 Tries to cling to the mother on separation 3 Is able to develop just superficial relationships with others 4 Has a more positive relationship with the father than with the mother

3 Children who have experienced attachment difficulties with primary caregivers are not able to trust others and therefore relate superficially. Physical abuse is a possibility but not a necessity for this diagnosis. The child probably will not cling or react when separated from the mother. Attachment will not occur with either parent.

A depressed client whose spouse recently died attends an inpatient group therapy session in which the nurse is a co-leader. When another client talks about being divorced and the resulting feelings of abandonment, the nurse notices that tears are running down the depressed client's face. What should the nurse do to support this client? 1 Ask group members to return to discuss this client's feelings. 2 Have another client stay and spend time talking with the client. 3 Observe the client's behavior carefully during the next several hours. 4 Accompany the client to his or her room and encourage a discussion of his or her feelings.

4 Helping a client cope with unresolved grief involves assisting the client in expressing thoughts and feelings about the lost object or person as a necessary part of grief work. Asking group members to return to discuss this client's feelings is too threatening; at this point the client needs therapeutic one-on-one interaction. Having another client stay and spend time talking with the client is the responsibility of the nurse; another client does not have the expertise to help this client. The current nonverbal behavior indicates that the client is dealing with feelings; an opportunity should be provided for a verbal exploration rather than merely observing the client.

The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? 1 Apraxia 2 Agnosia 3 Aphasia 4 Amnesia

2 Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting on clothing properly.

A nurse is assessing several depressed clients. Which behavior should alert the nurse to closely monitor a client for a suicide attempt? 1 When the client does not eat 2 If the client describes a plan for suicide 3 If the client cannot list any future goals 4 When the client's depression appears to deepen

2 The development of a plan means that the client has moved past the questioning phase and into the acting-out phase of suicide. The client may stop eating if the depression is deepening; this may signal a decrease in motivation and a decrease in suicide potential. The client may not have any identifiable goals and still want to live. The client's depression appearing to deepen is not a gauge of the potential for suicide by itself; more information is required.

A nurse is assessing a young adult for evidence of achievement of the age-related developmental stage set forth in Erikson's developmental theory. What developmental crisis is associated with this age group? 1 Trust versus mistrust 2 Intimacy versus isolation 3 Industry versus inferiority 4 Generativity versus stagnation

2 The major task of young adulthood is centered on human closeness and sexual fulfillment; lack of love results in isolation. The trust-versus-mistrust stage is associated with infancy. The industry-versus-inferiority stage is associated with middle childhood (school age). The generativity-versus-stagnation stage is associated with middle adulthood.

Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia? 1 Continual pacing 2 Suspicious feelings 3 Inability to socialize with others 4 Disturbed relationship with the family

2 The nurse must consider the client's suspicious feelings and establish basic trust to promote a therapeutic milieu. Continual pacing is not a problem, because the nurse can walk back and forth with the client. Inability to socialize with others and disturbed relationship with the family may be of long-range importance but have little influence on the nurse-client relationship at this time.

A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? 1 They affect their inherited traits. 2 They have little effect on their lives today. 3 They are important in assessment of their values. 4 They establish personal interactions throughout life.

3 Past experiences are important and must be recognized because they set the parameters for the individual's enduring values throughout life. Past experiences do not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds over a lifetime; new experiences continue to influence future responses.

A 65-year-old man is admitted to a mental health facility with a diagnosis of substance-induced persisting dementia resulting from chronic alcoholism. When conducting the admitting interview, the nurse determines that the client is using confabulation. What does the nurse recall precipitates the client's use of confabulation? 1 Ideas of grandeur 2 Need for attention 3 Marked memory loss 4 Difficulty in accepting the diagnosis

3 A client with this disorder has a loss of memory and adapts by filling in areas that cannot be remembered with made-up information. Ideas of grandeur do not occur with this type of dementia. The use of confabulation is not attention-seeking behavior; the individual is attempting to mask memory loss. This person is not coping with the diagnosis; when confabulating, the individual is attempting to mask memory loss.

Windows in the recreation room of the adolescent psychiatric unit have been broken on numerous occasions. After a group discussion one of the adolescents confides that another adolescent client broke them. What should the nurse do when using an assertive intervention instead of aggressive confrontation? 1 Confront the adolescent openly in the group, using a controlled voice and maintaining direct eye contact. 2 Knock on the door of the adolescent's room and ask whether the adolescent would come out to talk about the situation. 3 Approach the adolescent when the client is alone and, after making direct eye contact, inquire about the involvement in these incidents. 4 Use a trusting approach toward the adolescent and imply that the staff doubts the adolescent's involvement but requests a denial for the record.

3 A private confrontation with presentation of reported facts allows verification; a calm, direct manner is most assertive. Confronting the adolescent openly in the group, using a controlled voice and maintaining direct eye contact, is aggressive confrontation, not assertive intervention. Knocking on the door of the adolescent's room and asking whether the adolescent would come out to talk about the situation places control in the hands of the client rather than the nurse, and this may lead to aggressive confrontation. Using a trusting approach toward the adolescent and implying that the staff doubts the adolescent's involvement but requests a denial for the record is not assertive intervention; it is manipulation and is not truthful.

A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? 1 Ideas of grandeur 2 Confusing illusions 3 Persecutory delusions 4 Auditory hallucinations

3 The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate? 1 Echolalia 2 Neologisms 3 Flight of ideas 4 Loosening of associations

4 Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships.

A nurse in a long-term care facility is caring for a bedridden client with multiple chronic illnesses. Although usually continent, the client expresses anger through urinary incontinence. What should the nurse do to best address this situation? 1 Offer the client a bedpan every 2 hours. 2 Encourage the client to watch more television. 3 Decrease the client's fluid intake in the evening. 4 Assist the client in setting realistic short-term goals.

4 People with chronic illnesses often feel helpless and powerless. This can turn into anger and acting-out behaviors against those providing care. Helping the client set and achieve realistic short-term goals fosters client independence and hope. Because the client is able to control elimination, frequent toileting is not the problem. Although distraction is important, it should be varied and the client's preferences taken into consideration. Radio and television do not promote interaction. As a means of preventing urinary stasis and dehydration, fluid intake should be encouraged. Also, restricting fluid intake will not prevent intentional incontinence.

After a child's visit to a healthcare provider, the parent tells the nurse, "I'm so upset! The doctor prescribed an antidepressant!" What is the best response by the nurse? 1 "Tell me more about what's bothering you." 2 "Weren't you told why your child needs an antidepressant?" 3 "You need to speak with the healthcare provider about your concerns." 4 "Are you sure it's an antidepressant and not a drug for attention deficit disorder?"

1 "Tell me more about what's bothering you" provides an opportunity to explore the parent's feelings. It is the nurse's responsibility, not the healthcare provider's, to assess the parent's concerns before planning further interventions. "Weren't you told why your child needs an antidepressant?" is a confrontational response that may put the parent on the defensive. "Are you sure it's an antidepressant and not a drug for attention deficit disorder?" is a judgmental, nontherapeutic response that may worsen the parent's concerns.

When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? 1 Checking on the client frequently 2 Keeping the client's room lights dim 3 Addressing the client in a loud, clear voice 4 Restraining the client during periods of agitation

1 During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others.

A nurse is working with children who have been sexually abused by a family member. What overwhelming feelings do these children usually express? Select all that apply. 1 Guilt 2 Anger 3 Revenge 4 Disbelief 5 Self-blame

1, 2, 5 Sexually abused children often have nonsexual needs met by their abuser and are powerless to refuse; ambivalence results in self-blame and guilt. Anger may exist, especially toward the nonabusive parent who is not protecting the child. Disbelief or a desire for revenge may exist, but neither is the overwhelming feeling reported.

A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client? 1 The illness is very real to the client and requires appropriate nursing care. 2 Although the client believes that there is an illness, there is no cause for concern. 3 There is no physiological basis for the illness; therefore only emotional care is needed. 4 Nursing intervention is needed even though the nurse understands that the client is not ill.

1 Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.

A 13-year-old who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for further testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. Which is the best response by the nurse? 1 Refer the mother to the psychiatrist. 2 Explain to the mother the results of the tests. 3 Suggest that the mother call the psychologist. 4 Teach the mother about the tests that were administered.

1 It is the responsibility of the psychiatrist, who is the primary healthcare provider, to discuss the test results with the mother. Explaining to the mother the results of the tests is beyond the scope of the nurse's role. The mother should be referred to the psychiatrist, not the psychologist, because the psychiatrist is the leader of this health team. Teaching about the tests should have been done before, not after, the tests were administered. It is important that this student get the testing and counseling needed since the future problems of bullies include a higher risk for conduct problems, hyperactivity, school dropout, unemployment, and participation in criminal behavior. Chronic bullies seem to continue their behaviors into adulthood, negatively influencing their ability to develop and maintain relationships.

What does a nurse recall that language development in the autistic child resembles? 1 Echolalia 2 Stuttering 3 Scanning speech 4 Pressured speech

1 The autistic child repeats sounds or words spoken by others, which is echolalia. Stuttering is a speech disorder in which the same syllable is repeated, usually at the beginning of a word. Scanning speech is associated with neurological disorders, not autism. Pressured speech is rapid, tense, and difficult to interrupt. This is associated with anxiety, not autism.

Unsatisfied needs create anxiety that motivates an individual to action. What should the nurse identify as the purpose for this action? 1 Reducing tension 2 Denying the situation 3 Minimizing physical discomfort 4 Problem-solving and focusing on the problem

1 The primary purpose for action when a client is anxious is the reduction of emotional tension and prevention of escalation of the anxiety. When tension is reduced, anxiety is diminished, and the person feels more comfortable, safe, and secure. When acting to reduce anxiety, the person is extremely aware of the presence of anxiety and is not attempting to deny its existence. When anxiety becomes severe, the client is unable to focus on or solve the problem. Emotional tension, not physical discomfort, needs to be reduced. Minimizing the escalation of anxiety has an effect on psychological, rather than physical, discomfort.

According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage? 1 Trust 2 Identity 3 Initiative 4 Autonomy

1 Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense of self; this results in identity diffusion and confusion. Without initiative, the individual will experience the development of guilt and feelings of inadequacy. Without autonomy, the individual has little self-confidence, develops a deep sense of shame and doubt, and learns to expect defeat.

A nurse is assigned to lead a relaxation group. Which techniques should the nurse incorporate? Select all that apply. 1 Meditation 2 Mental imagery 3 Token economy 4 Operant conditioning 5 Deep-breathing exercises

1, 2, 5 Meditation lowers heart and blood pressure rates, decreases levels of adrenal corticosteroids, improves mental alertness, and increases a sense of calmness and peace. Imagery is the internal experience of memories, dreams, fantasies, and visions that serves as a bridge connecting the body, mind, and spirit; its distractive ability decreases adrenal corticosteroids, promotes muscle relaxation, and increases a sense of calmness and peace. Deep breathing increases oxygenation and releases tension in the muscles of the neck, shoulders, and torso. Token economy is a behavioral theory that acknowledges acceptable behavior with a reward (token) that can be redeemed for something that has a perceived value (e.g., a desirable activity). Operant conditioning, a behavioral therapy, is the learning of a particular type of behavior followed by a reward.

What characteristic of anxiety is associated with a diagnosis of conversion disorder? 1 Free-floating 2 Relieved by the symptom 3 Consciously felt by the client 4 Projected onto the environment

2 The client's anxiety results from being unable to choose psychologically between two conflicting actions. The conversion to a physical disability removes the choice and therefore eases the anxiety. The anxiety is not free floating or diffuse but rather localized and converted to a physical disability. The conversion of the anxiety to a physical disability occurs on an unconscious level; the original anxiety no longer exists, and the client generally is not anxious about the physical disability. The anxiety is internalized into a physical symptom, not projected onto the environment.

An emergency department nurse assesses a male client brought in by a law enforcement officer. The client was in jail and tried to hang himself with his shirt. Physically the client is stable, but emotionally he continues to state that he wants to die. The nurse identifies factors indicating a high risk of suicide. What is the risk factor that is considered the most "lethal?" 1 History of alcohol and drug abuse 2 Previous high-risk suicide attempts 3 History of withdrawal from friends and coworkers 4 Recent family disorganization due to his incarceration

2 A history of high-lethality attempts at suicide confirms that the individual has attempted suicide in the past and therefore may attempt to commit suicide in the future. Although the correlation between substance abuse, particularly alcohol, and suicide is high, this is of lesser concern at this time because of the client's incarceration. Isolation from friends and coworkers is of less significance than having an unstable, dissatisfying life with family members or having a history of prior suicide attempts. Although both of these events may cause stress, numerically they receive a lesser rating than having a history of multiple high-risk suicide attempts.

A nurse is interviewing a mother accused of physical child abuse. When speaking with this mother, what does the nurse expect her to do? 1 Attempt to rationally explain her behavior. 2 Reveal the belief that her child needed to be disciplined. 3 Offer a detailed explanation of how her child was injured. 4 Ask how she can arrange to visit her child on the pediatric unit.

2 An abusive parent often indicates that he or she was trying to improve the child's behavior with physical consequences for behavior the parent considered unacceptable. Such parents usually do not admit their behavior, so they do not have a need to rationalize it. These parents offer many vague explanations of how the child was injured; rarely is the explanation detailed. Asking how she can arrange to visit her child on the pediatric unit is an unusual request because the abusive parent usually does not ask to see the child.

A client leaves group therapy in the middle of the session. The nurse finds the client obviously upset and crying, and the client tells the nurse that the group's discussion was too much to tolerate. What is the most therapeutic initial nursing action at this time? 1 Request kindly but firmly that the client return to the group to work out conflicts. 2 Suggest that the client accompany the nurse to a quiet place so that they can talk about the situation. 3 Ask the group leader what happened in the group session and base interventions on this additional information. 4 Respect the client's right to decline therapy at this time and report the incident to the rest of the health team members.

2 Asking the client to discuss the situation privately incorporates the principles of starting where the client is and helping the client verbalize feelings; it also facilitates the collection of additional data. The client is not ready to return to the group. Asking the group leader what happened in the group session should be done later, after the more appropriate nursing action is completed. Respecting the client's right to decline therapy accepts the client's right not to be forced back into the group; however, direct nursing intervention should be attempted at this time.

A nurse approaches a depressed client who has just been admitted to the psychiatric unit and says, "Hello! I'm Andrea, your nurse. I'll introduce you and help you settle in with the others here. We'll also talk about anything that concerns you." How do these statements establish the nurse-client relationship? 1 They provide a theme. 2 They define boundaries. 3 They identify problems. 4 They initiate the working phase

2 Boundary development and maintenance, safety, and the development of trust are the three basic concepts of an initial therapeutic relationship. Boundaries define and separate the self from the client and indicate one's responsibilities in relation to the other individual. Themes are recurring patterns of interaction with others throughout life. The identification and clarification of problems, the client's position and understanding of the problems, and the nurse's understanding of the problems take place in the working phase of the therapeutic relationship. After boundaries and a sense of safety are developed, trust must be developed; only then can the working phase begin. However, there is no clear delineation between the end of the orientation phase and the beginning of the working phase.

A disturbed client starts to repeat phrases that others have just said. How should the nurse document this speech? 1 Alogia 2 Echolalia 3 Neologism 4 Echopraxia

2 Echolalia is repetition of another person's remarks, words, or statements. It occurs when individuals are fearful of saying their own words and therefore echo the words of others. Alogia is limited speech. Neologism is when new words are coined or old words take on private symbolic meanings. Echopraxia involves reflecting observed movements rather than speech.

The parents of a client in a psychiatric hospital send an unwrapped birthday gift to the unit for their daughter but do not stay to visit with her. The client responds to this situation by crying. What is the best response by the nurse? 1 Limit her contact with the parents. 2 Discuss her parents' behavior with her. 3 Distract her by engaging her in an activity. 4 Take her to the coffee shop for a birthday treat.

2 Helping the client understand the meaning of the parents' behavior can reduce the parents' emotional control over her. Limiting her contact with the parents is a temporary measure and does not reduce the emotional conflict with the parents. Distraction is not a therapeutic way to cope with realistic feelings. Taking her to the coffee shop for a birthday treat ignores the necessity of clarifying her parents' behavior.

A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating? 1 Feeling undeserving of the food 2 Too busy to take the time to eat 3 Wishes to avoid others in the dining room 4 Believes that there is no need for food at this time

2 Hyperactive clients frequently will not take the time to eat because they are overinvolved with everything in their environment. Feeling undeserving of the food is characteristic of a depressive episode. The client is unable to sit long enough with the other clients to eat a meal; this is not conscious avoidance. The client probably gives no thought to food because of overinvolvement with the activities in the environment.

A male nurse is caring for a client. The client states, "You know, I've never had a male nurse before." What is the best reply by the nurse? 1 "Does it bother you to have a male nurse?" 2 "How do you feel about having a male nurse?" 3 "There aren't many male nurses; we're a minority." 4 "You sound upset. I'll get a female nurse to care for you."

2 Inquiring neutrally about the client's feelings about having a male nurse encourages the client to express and explore feelings in an open, nonjudgmental way. Asking the client whether having a male nurse is disturbing puts the client on the defensive. Stating that there aren't many male nurses does not encourage further conversation, and the client will not have the opportunity to express feelings; this response is focused on the nurse rather than on the client. Immediately volunteering to get a female nurse puts the client on the defensive rather than encouraging verbalization of feelings.

The husband of a woman who has been sexually assaulted arrives at the hospital after being called by the police. After reassuring him about his wife's condition, the nurse should give priority to what? 1 Arranging for the rape counselor to meet with the wife 2 Discussing with him his own feelings about the situation 3 Helping him understand how his wife feels about the situation 4 Making him comfortable until the practitioner has finished examining his wife

2 Partners may themselves feel angry and abused; these feelings should be quickly and openly discussed. Arranging for the rape counselor to meet with the wife should not be done yet; rape counselors work with the victim and partner together. The partner's feelings must be resolved before the partner can help the client, and the nurse may not fully know the wife's feelings. Making him comfortable until the practitioner has finished examining his wife may be reassuring, but it leaves the partner alone to deal with his feelings.

A client on the psychiatric unit is undergoing a pretreatment evaluation for electroconvulsive therapy (ECT). Because of the client's profoundly depressed behavior, the nurse doubts that the client can provide informed consent. What should the nurse's initial intervention be? 1 Consulting with the hospital's legal staff and following their recommendation 2 Having the client verbalize understanding and the outcomes of the procedure 3 Asking the client to sign the consent form, because the client has not been declared incompetent 4 Suggesting to the primary healthcare provider that a family member sign the consent form for the client

2 The client's understanding should be assessed first. Depressed clients are often cognitively stable and capable of providing legal consent. Consultation with the hospital's legal staff may eventually be necessary, but it is not the initial intervention. The client's rights are not protected if the nurse elicits consent for a procedure when the nurse believes that the client does not comprehend the information; just because the client has not legally been determined to be incompetent, it does not mean that the client is competent; further assessment is necessary. Unless the client has legally granted the family member authority to make decisions, or the family member has been appointed as the client's guardian by the court, having a family member sign the consent is illegal.

Two 14-year-old girls are best friends and always eat lunch together at school. One of the girls eats rapidly and then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do? 1 Confront her friend with her suspicions. 2 Talk to the school nurse about her concerns. 3 Inform the girl's mother about her daughter's behavior. 4 Watch a while longer before doing anything that might ruin the friendship.

2 The adolescent is exhibiting signs of bulimia nervosa. The school nurse is an appropriate resource for the friend and has the responsibility for intervening, because purging can lead to malnutrition and electrolyte imbalances, which are life threatening. The friend does not have the expertise to intervene. Waiting any longer may jeopardize the health of her friend.

A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to assess? 1 Weight gain 2 Dehydration 3 Hyperactivity 4 Hyperglycemia

2 The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.

A woman who is emotionally and physically abused by her husband calls a crisis hotline for help. The nurse works with the client to develop a plan for safety. What should be included in the safety plan? Select all that apply. 1 Limiting contact with the abuser 2 Determining a safe place to go in an emergency 3 Memorizing the domestic violence hotline number 4 Obtaining a bank loan to finance leaving the abuser 5 Arranging for a family member to assist her in leaving

2, 3 It is important that the client have a safe place to go and a plan for getting there. The client needs to know the hotline number if there is an emergency. It is best to memorize the number because if it is written down the abuser may find it. Any change, especially one in which the abuser becomes angry, may cause the woman to experience more abuse. Although the client will require money to leave the abusive situation, it is best to save money a little at a time rather than try to obtain a loan and alert the abuser of the desire to leave. It is not advisable to tell a family member about the plan to leave because the person may tell the abuser.

A young client who has just lost her first job comes to the mental health clinic very upset and says, "I just start crying without any reason and without any warning." How should the nurse respond initially? 1 "Do you know what makes you cry?" 2 "Most of us need to cry from time to time." 3 "Crying unexpectedly can be very upsetting." 4 "Are you having any other problems at this time?"

3 The response "Crying unexpectedly can be very upsetting" identifies the client's feelings. Asking, "Do you know what makes you cry?" is an unrealistic question; the cause of anxiety may not be known. "Most of us need to cry from time to time" moves the focus away from the client. "Are you having any other problems at this time?" disregards the client's comment; it is a direct question that may impede communication.

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? 1 Shutting the client's door during the night 2 Applying a vest restraint when the client is in bed 3 Leaving a dim light on in the client's room at night 4 Administering the client's prescribed as-needed sedative medication

3 A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.

A nurse is counseling clients who are attending an alcohol rehabilitation program. Which substance poses the greatest risk of addiction for these clients? 1 Heroin 2 Cocaine 3 Nicotine 4 Marijuana

3 Although polysubstance abuse is common, clients undergoing rehabilitation from alcohol dependence are more likely to use or develop a dependence on nicotine, another legal substance, than on an illegal substance such as heroin, cocaine, or marijuana.

A nurse is interviewing an 8-year-old girl who has been admitted to the pediatric unit. Which statement by the child needs to be explored? 1 "Wow! This place has bright colors." 2 "Is my mother allowed to visit me tonight?" 3 "Those boys are so cute. I hope their room is next to mine!" 4 "I'm scared about being here. Can you stay with me awhile?"

3 An 8-year-old child should be more concerned with same-gender relationships. A child who demonstrates a strong attraction to opposite-gender relations should be questioned further to explore the possibility of sexual abuse. A statement such as "Wow! This place has bright colors" is not unusual because 8-year-old children are usually attracted to colorful environments. A statement such as "Is my mother allowed to visit me tonight?" or "I'm scared about being here. Can you stay with me awhile?" is not unusual because 8-year-old children will want the support of a trusted person when experiencing stress.

When a person who wishes to be athletic is uncoordinated but also successful in a musical career, what defense mechanism might this be related to? 1 Sublimation 2 Transference 3 Compensation 4 Rationalization

3 Compensation is replacing a weak area or trait with a more desirable one. Sublimation is rechanneling unacceptable desires and drives into those that are socially acceptable. Transference is the unconscious tendency to assign to others in the current environment feelings and attitudes associated with another person. Rationalization is the use of justification to make tolerable certain feelings, behaviors, and motives.

A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client? 1 Rigidity and a narrowing of perception 2 Alternating episodes of fatigue and high energy 3 Diminished pleasure in activities and alteration in appetite 4 Excessive socialization and interest in activities of daily living

3 Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.

A mother brings her 7-year-old son into an outpatient clinic for a follow-up appointment. The mother appears angry and agitated with the boy. Looking at the boy's medical chart, the nurse notes that the boy has a diagnosis of encopresis. What is the primary symptom of encopresis? 1 Practicing self-mutilation 2 Practicing self-induced vomiting 3 Passing feces either voluntarily or involuntarily into inappropriate places 4 Passing urine either voluntarily or involuntarily into inappropriate places

3 Encopresis is the passage of feces into inappropriate places such as clothing, closets, floors, or toy boxes, either voluntarily or involuntarily. It may severely limit a child's social development and results in parental disapproval and rejection. Encopresis does not involve self-induced vomiting or self-mutilation. The passage of urine into inappropriate places is called enuresis.

A client tells the nurse, "I'm a terrible, evil person. The voices are telling me that God needs to punish me." What is the most therapeutic initial response by the nurse? 1 "God is loving and won't punish you." 2 "Those voices you're hearing are a fantasy." 3 "Tell me what you're thinking about yourself." 4 "You aren't wicked—both God and I love you."

3 Encouraging the client to focus on the self will facilitate communication and foster self-perception. Stating that God will not punish the client denies the client's feelings and provides false reassurance. Stating that the voices are fantasy denies the client's experience. Stating that the client is not wicked denies the client's feelings and provides false reassurance.

After a traumatic event, a client is extremely upset and exhibits pressured and rambling speech. What therapeutic technique can the nurse use when a client's communication rambles? 1 Touch 2 Silence 3 Focusing 4 Summarizing

3 Focusing is indicated when communication is vague; the nurse attempts to concentrate or focus the client's communication on one specific aspect. Touch invades the client's space and will not help focus the client's communication. Silence prolongs the rambling communication; the client needs to be focused. Until the concern is identified and explored, summarizing is impossible.

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask the client to do to assess orientation to place? 1 Explain a proverb. 2 Give the state where the client was born. 3 Identify the name of the clinic's town. 4 Recall what the client ate for breakfast.

3 Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person is part of the assessment of cerebral functioning. Asking the client the name of the town the clinic is in assesses this. Explaining a proverb requires abstract thinking, which involves a higher integrative function than does orientation to place. Having the client state where the client was born helps the nurse assess remote memory, not orientation. Having the client recall what was eaten for breakfast helps assess recent memory, not orientation.

Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse? 1 A 25-year-old man who is mimicking the use of a machine gun in front of the nurse's station 2 A 45-year-old man who is sitting quietly in the corner, watching the movements of other clients 3 A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients 4 A 33-year-old woman who wanders aimlessly around the unit, saying, "I just don't know what to do. I feel so lost."

3 The pacing client is demonstrating increased agitation and poses an immediate threat to the safety of other clients. The behavior requires immediate nursing intervention to prevent injury to herself or others. Although the client mimicking the use of a gun is probably hallucinating, he poses no immediate threat to himself or others. Although the quiet, watchful client may be suspicious, the data given do not indicate that he presents a danger to himself or to others. Although anxious, the client who expresses a feeling of being lost does not represent a threat to herself or others.

A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect? 1 Altruism 2 Catharsis 3 Universality 4 Transference

3 Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.

A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse? 1 "Do you want me to get someone else to change you?" 2 "You shouldn't be embarrassed; this is part of my job." 3 "I'll be back in a little while; why don't you rest until then?" 4 "While I'm bathing you I'll start teaching you about bowel training."

4 A matter-of-fact approach eases embarrassment and then focuses on a method of helping the client regain control. The response "Do you want me to get someone else to change you?" ignores the issue, and with it the nurse is abandoning responsibility. The response "You shouldn't be embarrassed; this is part of my job" lacks empathy and does not offer hope for improvement. The response "I'll be back in a little while; why don't you rest until then?" cuts off communication and ignores the client's need to be changed.

A nurse is working in the orientation phase of a therapeutic relationship with a client who has borderline personality disorder. What will be most difficult for the client at this stage of the relationship? 1 Controlling anxiety 2 Terminating the session on time 3 Accepting the psychiatric diagnosis 4 Setting mutual goals for the relationship

4 Clients with borderline personality disorder frequently demonstrate a pattern of unstable interpersonal relationships, impulsiveness, affective instability, and frantic efforts to avoid abandonment; these behaviors usually create great difficulty in establishing mutual goals. Although the client with a borderline personality disorder may have difficulty in the areas of controlling anxiety, ending sessions on time, and accepting the diagnosis, none is the most significant issue.

A client with a personality disorder is playing cards with another person in the lounge. When the other person cheats at cards, the client responds by aggressively scattering the cards around the room. What does the nurse conclude about the client's personality? 1 Poor reality testing 2 A violent personality 3 An antisocial personality 4 Inadequate impulse control

4 The client is angry and reacts impulsively; the action is unplanned and is not under the client's control. No data are provided to suggest that the client is out of contact with reality; the client is reacting to a real situation with anger. There is no identifiable cluster of behaviors to suggest that the client has a violent personality. There is no pattern of behavior to suggest an antisocial personality, which may or may not involve impulse control.

A hospice nurse is caring for a dying client and his wife. What factor will be a major determinant in the mourning outcome for the wife? 1 Duration of the relationship shared by the couple 2 Age of the wife at the time of the husband's death 3 Health of the surviving spouse at the time of the death 4 Importance of the deceased person as a source of support

4 The more dependent the client was on the deceased for support, the more difficult the grieving process will be. Emotional and financial considerations are major factors. The duration of the couple's relationship and the age of the wife at the time of the man's death are not major influences on the mourning outcome. The health of the surviving spouse at the time of the death may or may not be a major factor in the mourning outcome; the spouse may be healthy and still be dependent on the partner.

The husband of a young mother who has attempted suicide tells the nurse that he told his wife he would bring their 26-month-old daughter to visit his wife and asks if that would be possible. What is the best response by the nurse? 1 "Probably so, but you'd better check with her primary healthcare provider first." 2 "Of course! Children of all ages are welcome to visit relatives." 3 "It could be very upsetting for your child to see her mother so depressed." 4 "Tell me what your wife said when you offered to bring your child for a visit."

4 The nurse should determine whether the spouse has discussed the child visiting with the client before commenting further. The responses "Probably so, but you'd better check with her primary healthcare provider first" and "Of course! Children of all ages are welcome to visit relatives" assume that the client has consented to the visit; this assumption may be incorrect. The response "It may be very upsetting for your child to see her mother so depressed" makes an assumption that requires more data and discussion to validate.

The night nurse reports that a young client with paranoid schizophrenia has been awake for several nights. The day nurse reviews the client's record and finds that this client did not have an interrupted sleep pattern disorder before transfer from a private room to a four-bed room 3 days ago. What factor should the nurse identify as most likely related to the client's sleeplessness? 1 Fear of the other clients 2 Concern about family at home 3 Watching for an opportunity to escape 4 Trying to work out emotional problems

1 Because the client has paranoid feelings that other people are out to do harm, assignment to a four-bed room may be threatening. Concern about family at home seems unlikely, because the disruption appears to have started with the transfer to a four-bed room. Watching for an opportunity to escape is possible but unlikely; planning an escape is usually not part of a schizophrenic pattern of behavior. Trying to work out emotional problems is possible but not likely; clients with schizophrenia have difficulty solving problems.

During the eighth session of a therapy group, a member who talks frequently is interrupted by one who doesn't. When the interrupting person is finished talking, the one who usually contributes says, "I'm so glad that you feel like talking today." While saying this, the client sits rigidly and looks angry. How should the nurse respond? 1 Comment on the interrupted client's angry behavior and pleasant words. 2 State that it appears that these members of the group are not getting along. 3 Agree with the interrupted client that it is good to have the quiet client talk. 4 Ignore the comment and speak with the talkative member privately about being hostile.

1 For this to be a growth process for the group, feelings and behaviors must be explored. It is better to focus on behaviors and feelings than on personalities or the fact that they do not get along. Agreement ignores the covert message, which should be explored to help the client and the group. Commenting on the incongruent verbal and nonverbal behavior may lead to a growth experience for the client and the group.

A husband is upset that his wife's alcohol withdrawal delirium has persisted for a second day. What is the most appropriate initial response by the nurse? 1 "I see that you're worried. We're using medication to ease your wife's discomfort." 2 "This is expected. I suggest that you go home because there's nothing you can do to help." 3 "Are you afraid that your wife will die? I assure you, very few alcoholics die during the detoxification process." 4 "Are you worried that your wife is uncomfortable while she's going through withdrawal? I'm sure that she's not in pain."

1 Recognizing the spouse's feelings and giving simple factual information help to allay anxiety. Telling the husband that the prolonged delirium is expected, encouraging him to go home, and saying that there is nothing he can do discourages further verbalization of concerns and promotes feelings of isolation and helplessness. Asking whether the husband is afraid that his wife will die and assuring him that very few alcoholics die during the detoxification process is inappropriate, especially during this time of stress; it also gives little assurance to the husband. Asking whether the husband thinks that his wife is uncomfortable and assuring him that she is not constitutes false reassurance and does not allow the man to verbalize anxieties or fears.

An older retired client is visiting the clinic for a regularly scheduled checkup. The client tells the nurse about the great life he has lived and the activities that he enjoys at the senior center. According to Erikson, what developmental conflict has been resolved by this client? 1 Trust versus mistrust 2 Integrity versus despair 3 Generativity versus self-absorption 4 Autonomy versus shame and doubt

2 The tasks of older individuals are ego integrity, satisfaction with life, and acceptance of the future versus despair, remorse, and fear of the future. Trust versus mistrust is the conflict associated with infancy. Generativity versus self-absorption is the conflict associated with later adulthood. Autonomy versus shame and doubt is the conflict associated with early childhood.

An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms? 1 Delusions 2 Hallucinations 3 Posttraumatic stress disorder (PTSD) 4 Obsessive-compulsive disorder (OCD)

3 PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and urges of ritualistic behaviors that improve the affected person's comfort level.

A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual? 1 It demonstrates respect for the client's autonomy. 2 This behavior is viewed as a result of anger turned inward. 3 Denying this activity may precipitate an increased level of anxiety. 4 Successful performance of independent activities enhances self-esteem.

3 The repeated thought or act defends the client against severe anxiety; the client does not want to perform the ritual but feels compelled to do so to keep anxiety at a controllable level. Compulsive behaviors are not autonomous choices. The client is compelled to perform the activity to reduce anxiety. Anxiety reduction, not anger, is the motivation for performing the ritual. Rituals are not activities that enhance self-esteem; they control anxiety. The client may be ashamed of the rituals that cannot be stopped.