hesi mental health questions

A female client arrives in the clinic carrying a duffle bag and is wearing torn and dirty clothes. She tells the practical nurse (PN) she has no place to go. The PN takes her vital signs and observes leg ulcers on both lower extremities. What additional information should the practical nurse obtain to determine if she is homeless? A. Ask the client directly about her living arrangements B. Question whether the client brought someone with her C. Elicit her home address during the mental status exam D. Avoid discussing her living arrangements during care

A. Ask the client directly about her living arrangements rationale: If the PN suspects the client is homeless, the best way to obtain the information is to ask the client directly (A) so care and social services can be provided. (B, C, and D) do not obtain direct information from the client.

Which response should the practical nurse (PN) offer to express empathy to a female client who is depressed and continues to talk about her grief over recent losses? A. "Let's focus on topics today that have given you some happiness." B. " Tell me more about what you are feeling." C. "I lost my parents last year and still feel sad." D. "I had several family losses in one month and continued working."

B. " Tell me more about what you are feeling." rationale: (B) is the best response because it focuses on the needs of the client and indicates that the PN is interested in what the client has to say. (A) is an attempt to refocus the subject and dismisses the client's grief, which keeps the communication process superficial. (C and D) are self-focusing responses.

A client who is admitted for surgery seems to focus only on his immediate concerns and asks the practical nurse (PN) to repeat everything that is said over again. The client seems to follow directions but asks for assistance when filling out admission forms and checklists. He apologizes to the PN often and says he did not hear all of the instructions. This client is experiencing which level of anxiety? A. mild B. panic C. severe D. moderate

C. severe rationale: Severe anxiety (C) is characterized by a greatly narrowed perceptual field, difficulty with problem solving, selective attention (focus on one detail), and selective inattention (block out threatening stimuli). Mild to moderate levels of anxiety on the continuum are characterized by the client being alert, attentive, and a focused perception that facilitates as optimal state for problem solving and learning. This client is not exhibiting signs and symptoms of (A,B, or C).

A practical nurse (PN) is interacting with a female client who is discussing her divorce as a stressor. What areas should be explored with the client to gather the most relevant information? A. affective responses B. social responses C. physiological responses D. biopsychosocial responses

D. biopsychosocial responses rationale: Appraisal of a stressor is the processing and comprehension of stressful situations that takes place on many levels, specifically cognitive, affective, physiological, behavioral, and social (D). Limiting the client's self analysis (A,B,C) may omit an important variable that needs further intervention.

A confused male client who unexpectedly becomes agitated and combative, raises his fist and threatens a female practical nurse (PN) stating that he is going to bash in her face. What action should the PN take? A. Activate the de-escalation response team B. Administer a PRN antianxiety agent C. Tell the client his behavior is not acceptable D. Summon the in- house security guard

A. Activate the de-escalation response team rationale: A de-escalation response team (or call for help) should be called to the bedside to prevent anxiety transference and to protect others by showing a coordinated effort to gain control of a potentially violent situation (A). If the team are unable to help the client gain control, medication (B) may be the most effective choice in managing an emergency situation. Verbal redirection (C) is unlikely to be effective for acutely aggressive or agitated clients. Although (D) can be of assistance, sufficient personal are needed to help the client gain control.

The practical nurse (PN) is assessing a client who has been noncompliant with a prescribed diet and exercise regimen. This client is using which defense mechanism? A. Denial B. Projection C. Dissociation D. Displacement

A. Denial rationale: The client is using denial (A) to avoid the seriousness of the illness, which interferes with treatment. (B) occurs when an individual attributes his or her own unacceptable traits, ideas, or impulses to another. (C) occurs when an idea, thought, emotion, or other mental process is separated from the consciousness and thereby loses emotional significance. (D) occurs when one avoids emotional conflict and anxiety by transferring emotions, ideas, or wishes from one objects to a substitute that is less anxiety-producing.

The practical nurse (PN) is collecting admission data for a young man with a history of chronic mental illness who is admitted to the mental health unit. What client information is most important in guiding the PN in data collection? A. Displays aggressive and assaultive behavior B. Expresses denial to comply with treatment C. Requests to leave against medical advice D. States he knows how to fit his diagnosis

A. Displays aggressive and assaultive behavior rationale: When collecting admission data, it is most important to implement safety and staff protective measures for the client's display of aggressive and assaultive behavior (A). Although (B, C, and D) are supported by the client's basic rights and self-determination, the client's admission is likely related to a crisis state and emergency admission provides safety for the client until the healthcare provider can assess, diagnosis, initiate treatment, and legal judgements, if indicated.

A women arrives at the clinic with multiple bruises. The practical nurse (PN) who has carried for her on previous similar visits is concerned about her safety. Which question should the PN ask the client to determine if she is a victim of domestic violence? A. How are things in your home life? B. Why do you stay in your situation? C. What did you do that caused your partner to hit you? D. Do you feel it is healthy to remain a battered victim?

A. How are things in your home life? rationale: A general question be used to initiate the assessment and questions that imply judgement or blame should be avoided (A). Why questions (B), and terms that imply domestic violence, such as battered (C), which often carry a negative stigma, can be misinterpreted by the victim (D) and should be avoided.

A male client who is diagnosed with schizophrenia, catatonic type, is admitted to the mental health unit and does not verbally communicate to any of the staff. His wife states that he became increasingly anxious, withdrawn, and stayed in bed staring at the wall since his recent job promotion. Which nursing diagnosis should the PN implement of this client? A. Impaired verbal communication related to severe anxiety B. Personal identity disturbance related to workplace stress C. Fear of responsibility related to a promotional opportunity D. Ineffective individual coping related to unresolved conflict

A. Impaired verbal communication related to severe anxiety rationale: Impaired verbal communication can result from maladaptive neurobiological responses that results from a precipitating stressor, which is mostly likely severe anxiety aroused by this client's recent job promotion (A). (B, C, and D) do not address the concept of psych-cognitive functioning in schizophrenia

A client becomes confused, grabs a pair of scissors, and cuts his IV tubing and indwelling catheter. An emergency security code is called, and two security officers arrive in the client's room. What action should the practical nurse (PN) take next? A. Ask the security officers what the nurses should do B. Assign officers for a coordinated take-down maneuver C. Evacuate other staff members away from the area D. Distract the client and take away the scissors

B. Assign officers for a coordinated take-down maneuver rationale: The PN should coordinate the intervention and assign the officers in the take-down maneuver (B). Control of the situation should be retained by the licensed nurse, not non-healthcare professionals, such as security officers (A). Although staff should remain a safe distance away from the "weapon", others in the area should not be abandoned (C). To ensure the safety of the client and the staff, a team approach should be implemented with a "show of force" to defuse the client or initiate the take-down maneuver, not (D).

A male client who is hospitalized for an acute episode of schizophrenia is sitting in the dayroom of the mental health unit without any clothes on. He is telling everyone who looks at him that he is "the body beautiful." Which intervention should the practical nurse implement? A. Tell the client to put his clothes on immediately B. Cover the client while assisting him to his room C. Ignore the behavior to prevent the client's repetition of the behavior D. Seclude the client until he can regain control of impulsive behavior

B. Cover the client while assisting him to his room rationale: Sexual expression, such as public nudity by a client with schizophrenia, is socially unacceptable and intrusive to others. Although the client may not be able to control sexual thoughts or impulses, neutral and nonjudgmental nursing interventions should be implemented to project the client (B) from the social consequences of his own judgement. (A and C) do not provide the client with privacy and respect. Although (D) removes the client from the public view, the best action is to ensure the client's dignity and privacy immediately

A female client tells the practical nurse (PN) that she wants to lead a healthier, more balanced life style. She asks the PN how she should begin the process of self-exploration. Which message should the PN convey? A. If someone is a victim of circumstances, unhealthy coping is often beyond one's control. B. Each adult is responsible for one's own behaviors, including unhealthy behaviors. C. Significant life-style changes are easier followed if professional guidance is sought. D. The first step is to focus on changing attitudes and behaviors of significant others.

B. Each adult is responsible for one's own behaviors, including unhealthy behaviors. rationale: A principle of mental health is supported by an adult's ability to make choices and cope with the consequences of one's behaviors while effectively contributing to community and personal relationships. Learning new life-styles and coping mechanisms begins with self-exploration (self inventory) and taking responsibility for one's behavior (B), which fosters empowerment. (A,C, and D) do not focus on the concept of self, health, and wellness.

The practical nurse (PN) is assessing a newly admitted client with paranoid schizophrenia who is hypervigilant and who constantly scans the environment. The client tells the PN, "I saw those two doctors in the hall talking about me." What descriptive terminology should the PN document to describe the client's thought process? A. Echolalia B. Ideas of reference C. Delusions of infidelity D. Auditory hallucinations

B. Ideas of reference rationale: Ideas of reference (B) are misinterpretations of the verbalizations or actions of others that the client gives suspicious personal meanings to these behaviors. This behavior does not reflect (A,C or D).

Based on Maslow's hierarchy of needs, which nursing strategies should the practical nurse (PN) implement to promote a client's self-esteem? A. Supporting needs for intimacy B. Promoting physical appearance C. Assisting with obtaining financial help D. Identifying contributions of the person

B. Promoting physical appearance rationale: Promoting physical appearance (B) contributes to a client's self-esteem, which is Maslow's fourth level of needs. The need for intimacy (A) is reflected on the third level, love and belonging. The need for financial help (C) is on the second level, safety and security. Identifying contributions of the person (D) are reflected on level five, self-actualization.

A female client admits that she has been battered frequently by her live in boyfriend over the last year. She tells the practical nurse (PN) they plan to be married and she thinks things will be better since he is always sorry after the battering. What is the best action for the PN to take? A. Assist the client in enrolling in a self-defense class B. Provide information to develop an emergency plan C. Support the client's hope that the battering will end D. Emphasize battering usually remains the same

B. Provide information to develop an emergency plan rationale: The client should have information about available community resources that can provide emergency help because physical abuse and violence tend to escalate in severity and frequency. If the client feels she is in a life-threatening abusive situation, she should have an emergency plan (B). (A,C, and D) are not helpful.

A male client is admitted to a drug rehabilitation program for chronic cocaine abuse. Which nursing problem should the practical nurse consider is the client's highest priority? A. Risk for noncompliance related to chronic drug use B. Risk for self-violence related to suicidal depression C. Sensory perceptual alternation related to stimulant drug use D. Risk for other directed violence related to underlying personality disorder

B. Risk for self-violence related to suicidal depression rationale: Withdrawal of cocaine, a stimulant, results in lethargy and severe depression and can be accompanied by suicidal ideation, so risk for self-violence (B) is the priority. Although addressing the client's noncompliance (A) during the initial detoxification period could trigger an against medical advice (AMA) discharge, risk for suicidal actions are the priority. Psychotic features, including sensory perceptual alternations (C) and violent behaviors (D) should be addressed, but the client risk for self-directed life-threatening behavior is the higher priority

What approach is best for the practical nurse (PN) to use when establishing a relationship with a severely socially withdrawn male client diagnosed with schizophrenia? A. Read to the client from the daily newspaper to promote orientation B. Sit with the client in silence several times a day C. Ask the client questions about the thoughts that he is having D. Use therapeutic touch by placing a hand on the client's arm occasionally

B. Sit with the client in silence several times a day rationale: This severely withdrawn client should be accepted and met "at the client's own level," with silence. Short contact and the use of silence are helpful to minimize the client's anxiety (B). (A and C) may be ineffective. Touch (D) is often perceived as threatening and is not recommended.

A client was admitted with major depressive disorder 3 weeks ago and received a prescription for sertraline (Zoloft) on admission. Today the client self-reports feeling great. It is most important for the practical nurse (PN) to consider which information when implementing care for this client? A. The relationship between the depth of depression and suicide ideation exists B. The client may be at increased risk for suicide as the depression lifts C. The mediation takes 2 weeks to be effective, so the treatment is working well D. The client is improving, so discharge planning should be considered

B. The client may be at increased risk for suicide as the depression lifts rationale: Severely depressed clients may have suicidal ideation, but lack the cognitive ability to plan an attempt and the energy to implement a plan. As depression lifts, the client may be better able to plan a suicide attempt and may have sufficient energy to carry out a plan, so (B) is the most important consideration. (A,B, and C) are accurate considerations, but for this client (B) is the most important

A male client arrives at the mental health clinic complaining of insomnia, irritability, increased tension, and headaches. He tells the practical nurse that the symptoms began a week ago after he lost his job, and he is concerned that he may have to relocate his family. Which stressor is this client experiencing? A. an anxiety reaction B. a situational crisis C. a maturational crisis D. an adjustment disorder

B. a situational crisis rationale: A situational crisis occurs when a life event upsets an individual's psychosocial equilibrium. Loss of a job can give rise to a situational crisis (B). (A,C, and D) do not depict this client's situation.

A male client is admitted to the hospital with distorted sensory perceptions, disordered thoughts, and an increase in non-goal directed motor activity. The client does not respond to the practical nurse's (PN) calming efforts. What is the next intervention the PN should initiate? A. decrease environmental stimuli B. ensure the environment is safe C. respect the client's personal space D. encourage the client to express feelings

B. ensure the environment is safe rationale: Safety (B) is the highest priority for a client who is experiencing severe anxiety, which places him at high risk for self-injury related to the increased non-goal directed motor activity, distorted perceptions, and disordered thought. (A,C, and D) may be indicated, but the client's safety has the highest priority.

The practical nurse (PN) is inquiring about coping strategies with a male client who is admitted for alcohol abuse. The client tells the PN that his job skills and communication skills are his best assets and support. Which additional information should the PN obtain about maladaptive mechanisms? A. family support B. self indulgence C. financial security D. daily stressors

B. self indulgence rationale: Coping resources include economic assets, abilities, skills, defensive techniques, social supports, and motivation. Coping mechanisms can be defines as efforts directed at stress management and can be constructive (assets) or destructive (liabilities), such as alcohol abuse, which should be determined by the client's self assessment of amount and duration of alcohol abuse (B). (A,C,D) are incorrect.

The practical nurse (PN) is caring for a male client who is admitted for schizophrenia and observes that his thoughts do not flow logically and he uses invented words. How should the PN document this behavior? A. interacts with others using child like expressions B. uses neologisms and tangential expressions C. demonstrates rapid speech while anxious D. responds with defensive language to cope with others

B. uses neologisms and tangential expressions rationale: Documentation of the client's altered thought processes reflected in speech should be described as tangential ideas, circumstantially, loose associations, and neologisms, or "word salad" (B). (A,C, and D) are not accurate descriptors for this client.

A client with schizophrenia approaches the practical nurse (PN) and says, " The voices are bothering me. They're yelling and telling me I'm bad. Can't you hear them?" Which responses should the PN provide? A. "Do you hear the voices often?" B. "Have you been taking your medication regularly?" C. "I can't hear the voices, but I can see that you're upset." D. "Dismiss the voices and ask someone to play cards with you."

C. "I can't hear the voices, but I can see that you're upset." rationale: A response based in reality should be given in response to the client. Since the experience is real for the client, acknowledging the distress encourages the client to identify feelings associated with the experience (C). The client can't respond to (A or B) while in an agitated state. (D) is not therapeutic.

When the mother of a young child is diagnosed with HIV, she asks the practical nurse (PN), "who will take care of my children if I die soon?" What response is best for the PN to provide? A. " Surely you have a friend or family member who can help you in this time of need." B. "Where is the father of your children? Surely he will want to help with the care of his children." C. "This is an important consideration, but you may live until they are grown up or even longer." D. "I can see that you are very concerned. Would you like me to call the chaplain to talk to you?"

C. "This is an important consideration, but you may live until they are grown up or even longer." rationale: (C) is the best response because it offers a hope without dismissing the client's concern. (A) may not be realistic. (B) is presumptuous and does not offer hope. (D) dismisses the client's concern.

A male client is admitted with major depression and tells the practical nurse (PN) that he feels like a freak since he is being admitted to a psychiatric unit in the hospital. He feels like he is the only one with this problem. Which information should the PN provide the client? A. Mental illness runs in families and effects many family members B. Comparing yourself with others does not help you and only makes things worse. C. About 50% of the population between that age of 15 and 55 have had a psychiatric disorder. D. Remember you are not to blame for your psychiatric illness and hospitalization

C. About 50% of the population between that age of 15 and 55 have had a psychiatric disorder. rationale: Mental health disorders are common in the U.S. with about one in five adults diagnosed with a mental health disorder. Explaining the extent of mental illness (C) to the client may assist the client to understand his illness, offer hope, and reduce his feelings of isolation. (A) provides the client with some information for insight but may not be supportive. (B and D) are not supportive and do not offer information to help the client understand mental illness.

A client arrives at the urgent care clinic with complaints of pounding heart and feeling out of breath. The client takes lorazepram (Ativan) 1 mg PO twice daily as needed for panic attacks. What action is most important for the practical nurse (PN) to implement? A. Ask the client when the last dose of Ativan was taken B. Encourage the use of relaxation breathing techniques C. Attach electrocardiographic electrodes to the client's chest D. Determine the client's activity when the symptoms began

C. Attach electrocardiographic electrodes to the client's chest rationale: A client with dyspnea and heart palpitations, even with a history of panic attacks, should be assessed for acute coronary syndrome (ACS). The most important action for acute chest pain or symptoms of ACS is to obtain electrocardiographic changes, so the PN should attach the electrodes to the client's chest (C). (A,B, and D) should be implemented after (C)

A male client with dementia who lives in an extended care facility is placed in a wheelchair each day and positioned in the hall where he kicks people who walk past him. Which intervention should the practical nurse (PN) implement? A. Move him to a busier hall with more people B. Ask the client every half hour what he needs C. Call him by name until he focuses his attention D. Approach the client from behind to apply a restraint

C. Call him by name until he focuses his attention rationale: Obtaining the client's attention (C) is fundamental when intervening because he focuses on the nurse and excludes the surrounding distractions that contributing to his behavior. (A and B) are forms of stimulation that may increase his agitated behavior. (D) is not indicated.

An adolescent female who is admitted with bulimia tells the practical nurse (PN) that she does not have an eating disorder. Which finding should the PN report that is most indicative of long standing purging behaviors? A. Polyuria B. Excessive facial hair C. Dental enamel erosion D. Elevated blood pressure

C. Dental enamel erosion rationale: Dental enamel erosion (C) results from repeated exposure of the teeth to gastric hydrochloric acid in vomitus and is most characteristics of long standing purging behaviors seen in bulimia. Polyuria (A) related to diuretic use and facial hair (B) related to significant body fat loss and reduced estrogen production is more likely characteristic of anorexia nervosa. Hypotension, not elevated blood pressure (D), may be seen with bulimia.

A male client who is in a minor motor vehicle collision (MVC) while on the job is brought to the urgent care clinic. The healthcare provider prescribes a urine drug screen, but the client repeatedly refuses to provide a specimen. Which action should the practical nurse (PN) implement? A. Collect a urine specimen using a sterile catheter B. Detain the client in the clinic he cooperates C. Document the client's refusal in the medical record D. Palpate the pubic symphysis for urinary retention

C. Document the client's refusal in the medical record rationale: A client the right to refuse treatment, so the PN should document the client's refusal in the medical record (C). (A) can be considered assault or battery since the client refuses the procedure. (B) violates the client's rights to determine his choice in care. (D) is not indicated at this time.

A 35 year old male client is admitted after a suicide attempt, Which action should the practical nurse (PN) implement when interacting with the client? A. Redirect conversations that focus on the topic of suicide B. Recommend that the client focus on peers rather than self-absorption C. Encourage the client to express feelings rather than suppress them D. Discuss the impact that suicidal behaviors have on his family

C. Encourage the client to express feelings rather than suppress them rationale: Expressing feelings in a therapeutic environment decreases hopelessness, so encouraging the client to express any feelings (C), particularly suicidal thoughts, is the priority. Avoiding the discussion of suicide (A) impedes recognition and early intervention for suicidal ideations, such as detail and lethality of a suicidal plan. A client who is suicidal often finds it difficult to move from self-absorption to other's perspective (B and D) because of his own feelings of unworthiness, fear of rejection by others, and low self-esteem.

A client is ruminating over memories and thoughts of recent life losses and expresses feelings of hopelessness and worthlessness. Which area of the brain is related to cognitive restructuring techniques? A. Thalamus B. Motor strip C. Frontal lobe D. Temporal lobe

C. Frontal lobe rationale: Frontal lobe (C) functions are cognitive thoughts and memories that contribute to the development of feelings of hopelessness and worthlessness. (A, B, and D) are unrelated to cognitive and emotional cerebral functions.

The practical nurse (PN) is planning care for an adult client who is admitted with depression. According to Maslow, which needs should the PN prioritize in the client's plan of care? A. Safety B. Self-esteem C. Physiological issues D. Psychological issues

C. Physiological issues rationale: Physiological needs (C), such as the body's need for oxygen, food, and fluids, are the priority needs of the client according to Maslow. (A, B, and D) are needs that are met after the basic survival needs are addressed.

What is the primary purpose for the practical nurse (PN) to use therapeutic communication? A. Maintain relationships B. Mutually share information C. Promote growth and change in clients D. Offer advice, suggestions, and spontaneous messages

C. Promote growth and change in clients rationale: Promoting growth and change in clients (C) is a goal of therapeutic communication. Social communication includes the maintaining the social relationship (A), mutual sharing of information (B), and offering advice, suggestions, and spontaneous messages (D).

A client with delusions of persecution has been refusing all hospital meals for the last 3 days and tells the practical nurse that the food contains poison. What action should the PN implement? A. Taste a small portion of the food in front of the client B. Obtain a prescription for nasogastric nutrition C. Provide foods in the original closed containers D. Allow the client to place a food order for delivery

C. Provide foods in the original closed containers rationale: A client with delusions of persecution related to poisoning should be provided foods that are in original sealed containers (C) or packages or nuts in uncracked natural shells. (A and D) are often viewed suspiciously by the client. (B) is not indicated.

Which behavior should the practical nurse identify as aggressive in a client who is admitted to the mental health unit? A. Acts passive when personal rights are challenged B. Uses statements that express feelings of victimization C. Verbally attacks and demeans peers in group settings D. Addresses other with Mister or Misses before last name

C. Verbally attacks and demeans peers in group settings rationale: Aggressive behavior is characterized by a demeaning or attacking speech patterns (C). Passive behavior (A and B) is characterized by feelings of victimization and personal rights violations. Respect is implied with addressing others with salutations (D) and last names.

A woman tells the practical nurse (PN) that for the past 6 months she has been terrified of leaving home. Whenever she thinks about going outdoors her heart pounds, she shakes and cries, and feels dizzy. Based on these findings, which nursing diagnosis should the practical nurse (PN) consider when caring for this client? A. fear related to physiologic responses to leaving the home B. self-esteem disturbance related to inability to leave home C. social isolation related to avoidance behaviors as evidenced by inability to go out of doors D. altered thought processes related to panic attacks when she thinks of leaving the house

C. social isolation related to avoidance behavior as evidenced by inability to go out of doors rationale: When caring for this client, the PN should consider the nursing diagnosis, social isolations (C), which best describes the client's findings that are consistent with agoraphobic or fear of leaving home or going outdoors. (A,B, and C) are less accurate descriptions of the client's condition or symptoms.

A male client who believes he has a brain tumor after numerous diagnostic tests that indicate no evidence of organic disease tells the practical nurse (PN), "No one believes me! I have the symptoms: terrible headaches and episodes of blurred vision. Last week I felt weak and even vomited. I'm going to die." Which response by the PN fosters cognitive restructuring? A. "Tell me about your relationships with the significant women in your life" B. " Sharing your thoughts and feelings about death can be helpful." C." There are other possible explanations for your symptoms." D. " Based on your diagnostic tests results, your concern is unfounded."

C." There are other possible explanations for your symptoms." rationale: Clients with illness anxiety disorder often ignore and possibilities except those that support their distorted thinking, and questioning the evidence is a cognitive restructuring technique that can be effective. Learning that his symptoms can have causes other than a brain tumor can help the client restructure his beliefs about his health. Asking the client to examine his relationships (A) is an insight-oriented communication technique, not cognitive restructuring. (B) acknowledges the client's statement about his death but does not help the client's statement about his death but does not help the client reexamine his beliefs about his symptoms. (C) is confrontational and ineffective.

The practical nurse (PN) is answering questions for a family member whose parent has early Alzheimer's disease (AD). Which information should the PN provide? A. AD is a form of dementia that consists of progressive loss of recent memory and disorientation to time and place. B. AD is a form of chronic dementia that may improve with medication, diet, behavioral, and environmental management. C. AD is secondary dementia that is characterized by brain atrophy that causes progressive cognitive degeneration and inability to function D. AD is a primary, irreversible, and fatal dementia that is caused by deposits of beta amyloid protein causing senile plaques in the brain.

D. AD is a primary, irreversible, and fatal dementia that is caused by deposits of beta amyloid protein causing senile plaques in the brain. rationale: Alzheimer's disease is best described in (D). The client is most likely manifesting early symptoms of AD (A), so an explanation that clearly defines the irreversible and fatal progression of AD provides the family member with the best information. (B and C) are not accurate.

A debilitated, older female client with Alzheimer's disease who is admitted to the hospital is bewildered and begins to kick and push away an unlicensed assistive personal (UAP). What action should the practical nurse take? A. Orient the client to time, person, and place B. Remind the client that the staff members are available to help her C. Place soft restraints on the client to prevent injury D. Ask a person who is unfamiliar to the client to sit at the bedside

D. Ask a person who is unfamiliar to the client to sit at the bedside rationale: Clients with Alzheimer's disease are unable to engage in self care and have difficulty adapting to new environments and information. A familiar person (D) can provide comfort and distraction and can ease the client's transition to the hospital. The client is not able to understand or retain reorientation or teaching (A and B). Alternative measures, such as distraction, should be used before restraints (C), which often increase anxiety and combativeness.

The practical nurse (PN) is caring for a female client with borderline personality disorder and a history of self-mutilation. The client tells the PN that another staff member makes her feel angry and unimportant. What priority intervention should the PN implement? A. Tell the client that she will be secluded if she acts out B. Give the client a reward for expressing her anger C. Explain that she should cope by doing something physical D. Ask her if she feels like hurting herself when she is angry

D. Ask her if she feels like hurting herself when she is angry rationale: A client with borderline personality disorder uses splitting and self-inflicted trauma as attention seeking and coping behaviors. The client's history of impulsivity and self-mutilation indicates she is at risk for self injury, so the PN should first ask the client if she plans to hurt herself (D) so safety precautions and a contract for safety can be implemented. (A) may be indicated of the client is unable to control impulsive acts. (B and C) are alternative activities after determining if the client has thoughts of self-mutilation

Which nursing intervention is best to help a female client with progressive memory deficit? A. Promote the client's sense of humor by telling jokes and discussing cartoons B. Avoid frustrating the client by performing routine activities of daily living for her C. Stimulate the client intellectually by bringing new topics to her attention D. Assist the client to perform simple tasks by giving step by step directions

D. Assist the client to perform simple tasks by giving step by step directions rationale: When simple directions are given in a step by step fashion (D), a client with memory deficit can process information and perform simple tasks. Clients with memory or cognitive impairment should be encouraged to perform all tasks they are capable of doing for themselves, not (B). (A and C) may be frustrating and counterproductive for the client.

During a prenatal visit, a client who is in the second trimester of pregnancy tells the practical nurse (PN) that she is using cocaine. What information about cocaine is most important for the PN to provide the client? A. CNS stimulants increase fetal heart rate and intrauterine movement B. Eat foods high in iron and protein if a decrease in appetite occurs C. Counseling should be sought to learn alternative coping behaviors D. Cocaine can cause miscarriage or premature onset of labor

D. Cocaine can cause miscarriage or premature onset of labor rationale: Cocaine, a central nervous system (CNS) stimulant, use during pregnancy (D) increases the risk of uterine tonicity and preterm labor, which can result in miscarriage (D), abruptio placentae, and stillbirth. Although the client should understand other factors about cocaine use in pregnancy (A,B,C), the most important information is the risk of premature birth.

Which finding should the practical nurse (PN) identify in a 10-year-old client who is diagnosed with attention deficit hyperactivity disorder (ADHD)? A. Crying when separated from parents and siblings B. Refusing to pick up toys as instructed by parents C. Fascination with spinning and moving toys and objects D. Inability to concentrate long enough to complete school work

D. Inability to concentrate long enough to complete school work rationale: Attention deficit hyperactivity disorder (ADHD) is characterized by inattention, impulsivity, and hyperactivity in the school aged child who often has difficulty focusing on one tasks (D). With separation disorder, the child demonstrates clinging behavior (A). (B) is characteristic of oppositional defiant disorder. Children with pervasive mental disorders, such as autism, exhibit repetitive use of language and movement (C).

Which drug is commonly prescribed for a client with attention-deficit hyperactivity disorder (ADHD)? A. Haloperidol (Haldol) B. Impiramine (Tofranil) C. Fluphenazine (Prolixin) D. Methylphenidate (Ritalin)

D. Methylphenidate (Ritalin) rationale: A central nervous system stimulant, such as Ritalin (D), provides effective treatment for clients with ADHD. (A, B, and C) are not used with ADHD

An older male client who has vision and hearing problems is admitted after a combative incident with his caregivers. Which intervention should the practical nurse (PN) implement when providing basic care? A. Ask the healthcare provider for a prescription to use restraints B. Perform tasks quickly to reduce risks to caregivers C. Explain to the client that this is unacceptable behavior D. Obtain the client's attention and consent before starting care

D. Obtain the client's attention and consent before starting care rationale: Individuals with limited sensory ability may strike out because of fear or confusion. Taking time to make contact with the individual before starting care should reduce problems (D). Restraints (A) are not indicated. Performing tasks quickly (B) does ensure the client's cooperation. Explaining appropriate behavior (C) is ineffective.

When implementing the plan of care for a client who is recovering from an overdose of clomipramine (Anafranil), the practical nurse (PN) recognized that it is essential to monitor the client for which side effects? A. Excess salivation and drooling B. Muscle rigidity and restlessness C. Polyuria and extreme hand tremors D. Orthostatic hypotension and constipation

D. Orthostatic hypotension and constipation rationale: Clomipramine (Anafranil) is a tricyclic antidepressant with anticholinergic side effects, such as orthostatic hypotension and constipation (D). (A) are extrapyramidal syndrome side effects of some antipsychotic medications. (B) is indicative of neuroleptic malignant syndrome related to antipsychotic medications. (C) are signs of lithium toxicity.

A male client who has lost his job calls the clinic and tells the practical nurse (PN), "I feel so overwhelmed that I've decided to take a handful of sleeping medicine I bought over the counter at the drugstore. I wish I didn't have to do it, but there's no other way." The PN asks several questions and learns that his wife is in the next room. How should the PN respond? A. Convince him to drive himself to the hospital B. Go to his home address and take him to the hospital C. Keep him on the phone while another nurse calls the police D. Persuade him to call his wife to the phone

D. Persuade him to call his wife to the phone rationale: Most suicidal clients have some ambivalence. An attempt to have his wife come to the phone (D) and instructions to bring him to the hospital is the safest action. (A and B) are not practical bases on the client's suicidal intentions. (C) may be an option is the wife can't respond.

During the admission interview to an inpatient psychiatric unit, the practical nurse (PN) asks a male client who is admitted with depression about recent life events that precipitated his admission. The client remains silent, looks at the floor, and does not answer any of the PN's questions. Which intervention is best for the PN to implement? A. Initiate a conversation about the client's suicidal ideations and plans B. Describe diagnostic lab results to the client C. Ask the client if he would like to talk to another nurse D. Record these findings in the medical record under the DSM 5 Axis 5

D. Record these findings in the medical record under the DSM 5 Axis 5 rationale: The DSM Axis 5 includes psychosocial and environmental stressors that are directly or indirectly related to death of a family member, health problems in a family, inadequate social support, adjustment to life-cycle transition, inadequate finances, and or martial difficulties. It is best to record the observed client behaviors in the medical records as responses for the DSM 5 Axis 5 classification. (A,B, and C) are unlikely to yield any additional information until the client's condition improves

The mother of a young child involved in the motor vehicle collision is in the family room when she is told that her child has died as a result of the injuries. She screams, "You killed my child!" and starts to pace. What is the best action for the practical nurse to implement at this time? A. Assure the mother that the child received the best possible care B. Show sympathy and offer her a locket of the child's hair C. Place an arm around the mother to hold and comforts her D. Remain with the mother and sit quietly in the room near the door

D. Remain with the mother and sit quietly in the room near the door rationale: The mother is experiencing shock and disbelief to her child's unexpected death, which can be manifested by a parent's initial reaction to project blame and anger. The mother's response may be a pre-warning sign of agitation and acting out or violent behavior, so the safest action is to remain with the mother in a quiet presence in the room (D) near the door as she works through this stage. At this stage, (A,B, or C) are unlikely to be effective until the mother has calmed down

A male client is admitted to an inpatient psychiatric facility after taking hallucinogenic drugs. The client screams threats and begins hitting the unlicensed assistive personal who is assisting with this admission. Which action should the practical nurse (PN) implement? A. Place the client in a vest and soft restraints B. Attempt alternative means to calm the client C. Offer the client a chance to modify behaviors D. Report the client is a danger to self or others

D. Report the client is a danger to self or others rationale: The PN should report that the client is a danger to self or others (D) before emergency restraints are applied (A) for safety. Reactions of a client under the influence of hallucinogenic drugs are unpredictable, so (B and C) are unlikely to be effective.

A 20-year-old male client who is admitted to the mental health unit for an adjustment disorder is telling the practical nurse (PN) that he wants to find an apartment, but he is afraid he does not make enough money to move out of his parent's home. Using Erikson's theory of psychosocial development, which development stage should the PN explore with this client? A. Physical and social losses B. Feelings of guilt or frustration C. Mastery of physical motor skills D. Sense of freedom in the community

D. Sense of freedom in the community rationale: According to Erikson, the young adult is in the intimacy-versus-isolation stage of development. This is the time in which he can participate in the social role of young adulthood, so encouraging the client to talk about his sense of adult freedom and responsibility (D) addresses his adjustment in this stage of development. (A,B, and C) do not focus on the young adult's development tasks.

What is the most prevalent type of elder abuse? A. Neglect B. Physical abuse C. Financial abuse D. Emotional abuse

A. Neglect rationale: Neglect (A), whether intentional or unintentional, is the most prevalent type of elder abuse and occurs when caregiver fails to provide basic needs such as food, clothing, or assistance with ADLs. (B) accounts for approximately one fourth of elder abuse and is the result of bodily harm, such as hitting, burning, pushing, or molesting the older adult. (C) is more common than physical abuse and occurs when the older adult's property or resources are mismanaged or misused. (D) includes intentional use of threats, humiliation, intimidation, and isolation and occurs in more than one third of all cases of elder abuse

The mother of a child who is brought to the clinic unconscious is hysterical, yelling, becoming increasingly agitated, and throws her bottle of water on the floor. Which response should the practical nurse make? A. Use an authoritative approach to confront her to control her behaviors B. Inform her that this behavior is unacceptable in the clinic C. Call for security officers to assist her from the premises D. Step aside and reassure the mother that the staff is present to help

D. Step aside and reassure the mother that the staff is present to help rationale: The client is exhibiting excessive agitation, which has a potential for violence. To ensure a safe environment, the PN should maintain a distance that avoids the client's physical reach and reassure her that the staff are here to help (D). The mother is distressed and is not likely to be receptive to verbal instructions, which may further agitate her (A and B). Calling a show of force (C) may only increase her agitation and her child needs her presence while care is provided.

Which part of the client's plan of care is the practical nurse (PN) implementing when plans are used to increase a male client's participation in his own care and social environment? A. client autonomy B. the therapeutic community C. the nurse-client relationship D. the multidisciplinary mental health team

B. the therapeutic community rationale: a therapeutic community (B) provides ways to increase a client's utilization of the social environment by providing therapeutic milieu but do not best describe the client's engagement in therapeutic experiences.

A female client who is admitted to the outpatient surgical center for bilateral tubal ligation starts to cry while waiting to go to surgery. Which therapeutic statement should the practical nurse (PN) offer the client? A. "I'm here for you. Everything is going to be all right." B. " Can you tell me what is bothering you?" C. " Do you want your husband to come to the bedside?" D. " Don't be afraid. The procedure is safe."

B. " Can you tell me what is bothering you?" rationale: The goal of therapeutic communication is to focus on the client and her concerns. The therapeutic technique of clarification (B) assists the client to put into words the vague feelings or ideas that she is experiencing. (A and D) provide false reassurance and are non-therapeutic. (C) dismisses the client's feelings and anxiety which should be explored to allow the client to verbalize her immediate distress.

A male client arrives at the mental health clinic and tells the practical nurse (PN) that he is overwhelmed and does not know who to talk to about his life. Based on the client's comments, what aspect of the client's life should the practical nurse explore first with the client? A. Coping mechanisms B. Problem resolution C. Support system D. Perception of the event

C. Support system rationale: The client is alluding to the lack of support, so determining if the client has family, friends, clergy, or coworkers should be identified first (C). (A, B, and D) are other factors that should be explored after the nurse-client relationship is established

A male client who is hospitalized for depression ruminates over poor financial decisions that he made in the past and calls himself "stupid". Which strategy should the practical nurse (PN) implement to limit the amount of time the client spends on negative self-evaluation? A. assign client to dust and sweep unit floors B. have client write thoughts and feelings in a journal C. contract with client to focus only on positive topics D. schedule occupational therapy and unit activities for client

D. schedule occupational therapy and unit activities for client rationale: Distraction and engagement in productive tasks, such as occupational therapy (OT) and unit activities, provide opportunities for the client to socialize and interact with others and limits his time for self-absorption and self-criticism (D). (A, B, and C) are solo activities that allow the client time to ruminate over his past.

The practical nurse (PN) is caring for a client with bulimia who continues to deny purging. Which finding should the PN report to the RN? A. Amenorrhea B. Dental erosion C. Thin, brittle hair D. Clubbing of the fingers

B. Dental erosion rationale: A client with bulimia often denies binging and purging with induced vomiting that causes erosion of tooth enamel (B), which should be reported for evaluation by the treatment team. (A,C, and D) are more common with anorexia, not bulimia.

The practical nurse (PN) assesses a client with a poor self-concept. This client is most likely to demonstrate which behaviors? A. effective group functioning B. accurate, astute perceptions C. escalation of anxiety D. willingness to accept change

C. escalation of anxiety rationale: A client's weak self-concept provides inadequate tools for coping with anxiety, which causes anxiety to escalate quickly (C). (A,B, and D) are seen in individuals with strong self-concepts.

What is the most likely reason that a male adult with chronic mental illness tells the practical nurse that he drinks several alcoholic drinks every day? A. To gain attention B. For symptom relief C. As a suicide attempt D. To decrease inhiations

B. For symptom relief rationale: Individuals who have chronic mental illness frequently use alcohol and illegal drugs for symptom relief (B) related to noncompliance with psychotropic prescriptions. (A) is not the primary reason for addictive behaviors. Suicidal behaviors (C) are more likely related to underlying mental illness. Although alcohol or illegal drugs diminish inhibitions and impulse control (D), the client is most likely self-medicating.

Which finding should the practical nurse (PN) report immediately when talking with a new mother who is diagnosed with postpartum depression with psychotic features? A. thoughts of harming her infant B. personal hygiene C. outbursts of anger D. disinterest in her husband

A. thoughts of harming her infant rationale: thoughts of harming her infant (A) is consistent with postpartum depression and should be reported immediately. Although (B,C,D) may occur in postpartum depression, the major concern is the potential of harm to herself or to her infant.

The practical nurse (PN) is taking the blood pressure of a middle-aged male who is involved with his children's sports teams as a coach and referee. While establishing a nurse-client relationship, the client tells the PN that he hires and trains teenagers to work part-time in his restaurant. Which psychosocial development stage is the client experiencing? A. Identity B. Generativity C. Isolation D. Stagnation

B. Generativity rationale: Generativity (B) is a positive psychosocial outcome in adulthood that includes teaching and guiding the younger generation. (A) is a developmental task of adolescence. (C) occurs with the failure to develop intimate relationships. (D) results from not being involved in the lives of the younger generation.

An older client who is hospitalized with pneumonia becomes disoriented and confused 2 days after admission. Which factor should the practical nurse (PN) identify to differentiate that the client is experiencing delirium, not dementia? A. impaired memory B. clear awareness of surrounding C. unrelated to specific cause D. acute onset of symptoms

D. acute onset of symptoms rationale: Delirium has an acute onset (D) characterized by a reduced level of consciousness, not (B), disturbed sleep-wake patterns, disorientation and perceptual problems, and is often associated with drug cumulative effects, a medical condition, or hospitalization, not (C). Dementia has a slow, insidious onset of symptoms, which include impaired memory (A) with loss of abstract thinking, judgment, language and motor skills and is often not reversible.

A practical nurse (PN) is reinforcing the steps for a dressing change for a male client who has a leg ulcer. When the client tries to change the dressing, he says he is inadequate, incompetent, and feels helpless. Which problem should the PN recognize that the client is exhibiting? A. depersonalization B. personality fusion C. self-esteem disturbance D. personal identity disturbance

C. self-esteem disturbance rationale: Self-esteem disturbance (C) is expressed as having a negative self-evaluation or negative feelings about one's self or one's capabilities. Characteristics expressed by the client do not reflect the problems in (A,B, or D).

A female client is anxious about a scheduled diagnostic procedure and keeps asking the same question of every staff person. How should the practical nurse respond? A. Encourage the client to watch television as a distraction B. Reinforce with the client the need for the procedure regardless C. Affirm the client's anxiety and ask if she wants to talk D. Reassure the client that the procedure is performed for others every day.

C. Affirm the client's anxiety and ask if she wants to talk rationale: Understanding the client's anxiety and offering to talk about it (C) gives the client an opportunity to express her feelings and work through the anxiety. Although distraction (A), reinforcement (B), and reassurance (D) can be useful, they do not help the client cope with anxiety.

A client diagnosed with Stage 3 Alzheimer's disease is experiencing difficulty toileting appropriately. What instruction is best for the practical nurse (PN) to provide the family? A. Label the client's bathroom door B. Place the client in disposable diapers C. Make sure the client does not eat nonfood items D. Question the client often about the urge to void or defecate.

A. Label the client's bathroom door rationale: A client with Stage 3 (mild decline) Alzheimer's disease has memory loss that begins to interfere with activities of daily living and may benefit from the use of environmental cues such as labels to compensate for memory loss. (B,C, and D) do not address the concepts of client dignity, advocacy, and collarboration.

A client with a long history of alcoholism is admitted with pneumonia and begins to manifest fine tremors, tachycardia, hypertension, and confusion. Which additional finding is most important for the practical nurse (PN) to report immediately? A. Tactile hallucinations B. Amnesia with short term memory loss C. Confabulation and word substitution D. Ataxia and nystagmus

A. Tactile hallucinations rationale: Delirium tremens (DTs) is a serious, potentially fatal side effect of alcohol withdrawal, often causing alcoholic hallucinosis (false sensory perceptions), which stimulate the sympathetic nervous system (SNS) and contribute to cardiovascular changes. The PN should report the client is having tactile hallucinations (A), which cause significant discomfort, anxiety, and fear, and require medications to reduce SNS stimulation. Although signs of Korsakoff's Wernicke's encephalopathy (B, C, and D) should be reported, these are irreversible alcoholic dementias related to chronic alcohol abuse that don't respond to benzodiazepines used in alcohol detoxification.

A man who has been admitted numerous times for alcohol detoxification is found wandering in the street and is unable to identify himself or his home address. He is manifesting ataxia, nystagmus, and confusion and has a blood alcohol level (BAL) of 0.29%. Which prescribed medication should the practical nurse (PN) administer to prevent Korsakoff's psychosis? A. Thiamine B. Benzodiazepines C. Glucose solution D. Haloperidol (Haldol)

A. Thiamine Rationale: A BAL greater than 0.20% depresses the entire motor area of brain causing the client to stagger, lose conscious control of reason, and react in an unpredictable manner. The client's confusion and alcohol tolerance causing Wernicke's encephalopathy places the client at risk for Korsakoff's psychosis, a form of amnesia characterized by loss of short-term memory and precipitated by acute abstinence. Thiamine deficiency causes Wernicke-Korsakoff's syndromes, so thiamine (B) should be administered. (B,C,D) may be indicated during withdrawal but do not prevent alcoholic encephalopathies.

The practical nurse (PN) is caring for a female client with chronic psychosis who repeatedly tells the PN that her arm is missing and she can't participate in the group activities. Which response should the PN offer when providing reality validation with the client? A. I see your arm is right there. B. Let's not focus on that right now. C. If your arm is missing, how can you feed yourself? D. Do you mean, it feels like your arm is missing?

D. Do you mean, it feels like your arm is missing? rationale: (D) is the most therapeutic response because the nurse is asking the client to describe her feelings. (A and C) challenge the client's unrealistic beliefs, and the client may feel threatened. (B) is an attempt by the nurse to change the subject and ignores what the client is saying.

The nurse who is leading a group therapy session is called to manage a unit emergency and assigns the practical nurse (PN) as the leader of the group. During the therapeutic session, a client challenges the PN as the leader. Which response should the practical nurse (PN) communicate? A. You are saying that I should not be the leader? B. Let's vote and see who should be the leader. C. So, you do not like me or my leadership style? D. You will not be the group leader ever.

A. You are saying that I should not be the leader? rationale: The nurse leader should provide a safe place for group members to challenge authority. (A) allows exploration of how the client feels toward the PN's leadership. Although a democratic leadership style (B) may be used in groups, the leader should maintain control and not permit disruption of the therapeutic environment. (C and D) are confrontational and non-therapeutic.

The practical nurse (PN) is caring for a male client with schizophrenia who is exhibiting forgetfulness, disinterest in activities, and difficulty completing tasks. Which intervention should the PN implement? A. provide a structured schedule of activities on the unit B. direct the client to pay his own household bills C. encourage the client to go to the day room to work a puzzle D. enroll the client in three therapeutic group sessions each day

A. provide a structured schedule of activities on the unit rationale: The cognitive processes of an individual with schizophrenia are affected by disturbed thought processes that impair memory, ability to focus attention, judgement, and decision making. A structured schedule of activities (A) provides the client social engagement without requiring the client to plan or make decisions. (B, C, and D) are too stimulating or complex for this client.

A 19 year old calls the clinic and tells the practical nurse (PN) that since bringing her newborn infant home, she has felt apathetic, fatigued, and helpless. She states, " I don't know what's expected of me." What action is most important for the PN to take? A. tell the charge nurse to come to the phone and talk with the client B. direct the client to come to the clinic for mother baby care instructions C. ask the client if she has been experiencing any hallucinations D. determine if the client is feeling sad and having suicidal thoughts

A. tell the charge nurse to come to the phone and talk with the client rationale: The client is exhibiting signs of a maturational crisis related to the role changes required by the birth of the infant. Crisis intervention is indicated, so the PN should ask the charge nurse to talk with the client (A). (B,C, and D) could be considered if (A) proves ineffective.

A male client with depression is unresponsive and preoccupied with guilt and hopelessness. Which statement should the practical nurse (PN) use that provides therapeutic feedback to the client? A. "Everything will work out ok for you." B. "The group appreciated your comments today." C. "You will feel better as your comments today." D. "You need to help yourself by thinking positive."

B. "The group appreciated your comments today." rationale: The most therapeutic and positive statement provides feedback about the client's interactions with others (B), which tells the client that he is recognized and allows him to connect with the group in the here and now. (A and C) are clichés and are not therapeutic. (D) is advice giving, which is non-therapeutic.

The practical nurse (PN) is answering questions that the mother and her teenage daughter who is admitted with anorexia nervosa are asking about hospitalization. Which statement by the client's mother indicates to the PN that she understands this disease? A. My daughter just doesn't have much of an appetite right now B. She is trying to punish me for my recent divorce from her father C. She sees herself as being very fat even though she is severely underweight D. There really isn't anything to worry about since most girls want to be very thin

C. She sees herself as being very fat even though she is severely underweight rationale: An adolescent female with anorexia nervosa views herself as obese despite her extreme decrease in body mass index (BMI). (C) indicates an understanding of a disturbed body image. (A, B, and D) reflect inaccurate understanding of self, family, health, wellness, and illness.

What finding should the practical nurse (PN) report to the nurse concerning possible abuse of a child? A. A 4 month old infant with fever that can't be consoled B. A toddler who cries when the father enters the room C. An adolescent who refuses to speak to a parent D. A 3 year old who begins bed-wetting during hospitalization

B. A toddler who cries when the father enters the room rationale: Since toddlers usually struggle with stranger anxiety and welcome the presence of a parent, the PN should report a toddler who begins to cry when the father enters the room (B), which may indicate fear related to possible abuse. (A) is a common finding that is consistent with fever in an infant. Adolescents commonly struggle with independence and dependency, a development task, which may be characterized by refusal to speak to a parent (C). The stress of hospitalization can cause a previously toilet-trained child to wet the bed, especially at night (D).

A male client who learns his results for HIV is seropositive tells the practical nurse that he is experiencing constant heart palpitations, can't concentrate, and walks around trembling. What reaction to the diagnosis is the client demonstrating? A. Guilt B. Acute anxiety C. Suicidal ideations D. Disappointment

B. Acute anxiety rationale: Acute anxiety (B) is manifested by physiological responses, such as a fight or flight reaction, which includes increases in heart rate, vigilance, pacing, jitteriness, and a feeling of impending doom. (A,C, and D) do not demonstrate feelings of anxiety.

Which intervention should the practical nurse (PN) implement for a male client who is actively hallucinating? A. Use an authoritative stand to confront the client B. Ask for permission before touching the client C. Inform the client that no one else is in the room D. Place the client in soft restraints if he is violent

B. Ask for permission before touching the client rationale: A client who is hallucinating should be asked his permission before being touched (B) because the client may misinterpret the touch as part of the hallucination and react physically to the stimuli. Authoritative posturing is not indicated with a client who is agitated or has altered perceptions of the environment (A). Although reality validation should be given, the client's ability to understand reality during an active hallucination may cause more anxiety and agitation (C). Restraints are used to protect the client and others from injury, so alternative means, such as a secured room, should be tried before applying physical restraint (D).

The practical nurse (PN) is interacting with a male client who is worried about being admitted to the mental health unit. Which self-reported characteristic should the PN acknowledge as most indicative of the client's healthy boundary of self-concept? A. Lets others define his self-concept B. Takes responsibility to meet his own needs C. Gives to others for the sake of giving D. Believes others should anticipate his needs

B. Takes responsibility to meet his own needs rationale: The client who acts responsibly in meeting his own needs (B) best describes a client's healthy boundary, so acknowledging this self-appraised self-concept provides the best feedback. Giving as much as possible for the sake of giving (C), believing others can anticipate the client's own needs (D), and letting others define the client (A) are examples of unhealthy boundaries, rather than assertive behavior

The practical nurse is talking with a male client about his recent job loss. What is the most important factor to explore with the client? A. Importance of the job to the client B. Size of his support system C. Awareness of his options D. His family's feelings about the loss

A. Importance of the job to the client rationale: The client's perception of his loss is a key factor (A). What may be trivial to one person may seem overwhelming to another. If the client does not perceive the event as problematic, a crisis may be averted. (B,C, and D) are less relevant

During a routine prenatal clinic visit, the practical nurse (PN) is assessing a pregnant female client who expresses fears of spousal abuse. Which information should the PN provide to facilitate client disclosure? A. Provide her with a reflection of her apparent unhappiness and uncertainty about pregnancy. B. Tell her that spousal abuse can be supported by evidence of old fractures seen on x-rays. C. Encourage her to share incidents of past abuse so her personal safety can be addressed D. Share with client that her situation is not unique and abuse often increases with pregnancy.

D. Share with client that her situation is not unique and abuse often increases with pregnancy. rationale: Fear, guilt, and embarrassment prevent women from sharing information about family violence. Letting the client know that the experienced by others (D) may overcome the strong tendency to deny abuse. Although (B and C) provide factual information, it may threaten the client or increase her fear and minimize seeking help. The interpretation that the client is unhappy and unsure about her pregnancy (A), though possibly true, does not address the client's risk for abuse, which should be addressed directly.