HESI Module 4
A student calls the campus crisis hotline and tells the nurse, "I went out to a sorority party last week and drank too much. Someone raped me, but when I told my folks about it, they acted like it was my fault. I feel so dirty and used." Which statement by the nurse would be most therapeutic? "Would you come in to talk with me in the strictest confidence?" "I believe that you can feel a lot better about yourself. Won't you come in to see me tomorrow?" "Parents always feel that their daughters could never be raped. I could talk to them for you, if you'll let me." "You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"
"You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"
A client with schizophrenia attending a support group held by a clinic nurse says to the nurse and the group, "I've been laid off from my job at the factory, and so have 300 other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be most therapeutic at this time? "It seems that the stock market is responsible for mass unemployment in our factory-based city." "I'm sorry to hear that you've lost your job. Why not make an appointment to come in and talk with me this week?" "How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?" "Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."
"Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."
The nurse is providing information to a group of nursing staff members about caring for suicidal clients. What should the nurse tell the group? Discussing suicide with a client is not harmful Those clients who talk about suicide never actually try it Depressed clients are the only people who commit suicide When a person makes suicide threats, the only thing the person wants is attention
Discussing suicide with a client is not harmful
A furious and aggressive client is put in restraints and told that the restraints will be removed once the she regains control. At which time is removal of the restraints by the nurse appropriate? When medication that has been administered has taken effect When the client apologizes and tells the nurse that it will never happen again When the nurse explores with the client the reasons for the angry and aggressive behavior When no acts of aggression are observed in the hour following the release of two extremity restraints
When no acts of aggression are observed in the hour following the release of two extremity restraints
Family members awaiting the outcome of a suicide attempt are tearful. Which response by the nurse would be most therapeutic to the family at this time? "I can see that you are worried." "You have nothing to worry about." "You can see your loved one soon." "Everything possible is being done."
"I can see that you are worried."
The nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client makes which statement? "I need to go to the bathroom." "I'm no longer a threat to myself or others." "I want to be alone for a while in my own room." "I can't breathe in here. The walls are closing in on me."
"I'm no longer a threat to myself or others."
The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? "No, I wasn't, but I am now, thanks to you." "I hadn't thought of that, but I can see that you are." "Of course not, but there are days when I think that I should be." "What is suicide going to do for me except get me excommunicated from the church?"
"No, I wasn't, but I am now, thanks to you."
A 2-year-old child has injuries consistent with child abuse and the nurse is interviewing the child's parent. Which statement by the parent indicates the possibility of child abuse? "My child can't be expected to learn everything at once." "I can expect my child to talk using some words at this age." "I expect my child to try doing some things without my help." "When I tell my child to do something, I don't expect to have to repeat myself."
"When I tell my child to do something, I don't expect to have to repeat myself."
A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, "Well, I'm feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney." Which response by the nurse is most appropriate? "Good grief! You don't look organized to me." "Okay, what are you up to today? Your behavior is not appropriate." "You talk about getting organized. Are you thinking of killing yourself?" "If you keep behaving like this, you know that I'll have to tell the health care provider, and we'll have to seclude you."
"You talk about getting organized. Are you thinking of killing yourself?"
Which client is at the highest risk for suicide? A 24-year-old man who is angry with his family A 71-year-old man with mild depression and social withdrawal A 75-year-old woman with severe depression and debilitating arthritis A 30-year-old newly divorced woman who has custody of her children
A 75-year-old woman with severe depression and debilitating arthritis
An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of which type of crisis? A situational crisis An individual crisis A maturational crisis An adventitious crisis
A maturational crisis
The home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic antidepressant lying near the client. What action must the nurse take immediately? Inducing vomiting Calling an ambulance Administering syrup of ipecac Counting the pills remaining in the bottle
Calling an ambulance
A client with schizophrenia says, "I'm away for the day ... but don't think we should play or do we have feet of clay?" Which alteration in the client's speech does the nurse document? Neologism Word salad Clang association Associative looseness
Clang association
The nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should have which focus? Follow-up appointments Providing the hospital phone number Contracts and immediate available crisis resources Encouraging the family to always be with the client
Contracts and immediate available crisis resources
The nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. Which action should the nurse take? Informing the client that everything is all right Speaking to the nursing assistant immediately, while in the client's room, to solve the problem Explaining to the nursing assistant that yelling in the client's room is tolerated only if the client is talking loudly Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation
Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation
The nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD). Which should be the nurse's primary focus? Group therapy Recreational therapy Goals and objectives The client's medical diagnosis
Goals and objectives
The nurse brings a meal tray to a client with psychosis in his hospital room. The client refuses the meal and says, "I'm not eating any more poisoned food while I'm vacationing here. I'm starting on a fast to stay healthy and alive." Which nursing intervention would be most appropriate initially? Taking the tray away and canceling all meals until further notice Having the client eat with other clients in the community dining room Eating some of the food from the client's tray to prove that it isn't poisoned Telling the client that the psychiatrist will be called for a prescription for a tube feeding
Having the client eat with other clients in the community dining room
A client with schizophrenia is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing? Defensive coping Inability to cope effectively Sensory perception alterations Inability to communicate effectively
Inability to communicate effectively
The nurse is working with an older client who has been hospitalized and the client's family to formulate a plan for discharge. In guiding the discussion with the client and family, which living arrangement should the nurse promote? Alone With their children In long-term care facilities Independently but close to their children
Independently but close to their children
The nurse is explaining the plan of care to family members of an older client with a diagnosis of depression. Which explanation should the nurse provide to the client and family members? Older clients do not commit suicide Depression in an older person is never treatable Depression in an older person will not cause physical manifestations Indications of dementia may be present in an older client with depression
Indications of dementia may be present in an older client with depression
A client and her newborn have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time? Describe the stages of and treatments for HIV Listen quietly while the mother talks and cries Discuss with the mother how she might have gotten HIV Call an HIV counselor and make an appointment for the woman
Listen quietly while the mother talks and cries
The nurse is preparing to provide nursing unit information to a client who does not speak English who is being admitted to the mental health unit. Which action is best for the nurse to take to ensure that the client understands the information? Asking a family member to translate for the client Obtaining a hospital interpreter to communicate with the client Asking a hospitalized client who speaks the same language as the client to translate Providing the client with a pamphlet that explains the nursing unit information in the client's language
Obtaining a hospital interpreter to communicate with the client
The nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. The nurse is likely to note which aspect of the disorder? Social contacts are important. The client is not concerned about food and meal planning. Personal relationships tend to become more superficial and distant. The client with anorexia will usually keep his or her weight near normal weight.
Personal relationships tend to become more superficial and distant.
A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relations are poor. He then tells the nurse that the symptoms started after his best friend was killed in the terrorist attack at the World Trade Center. The nurse plans the client's care, as the client is likely experiencing which disorder? Social phobia Panic disorder Post-traumatic stress disorder Obsessive-compulsive disorder
Post-traumatic stress disorder
The nurse working in a mental health unit reads a client's medical record and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of which disorder? Depression Schizophrenia Post-traumatic stress disorder Obsessive-compulsive disorder
Post-traumatic stress disorder
A client with schizophrenia says, "I feel like I'm rotting away inside and all of my organs are rusting." Which type of delusion does the nurse identify in the client's statement? Somatic Jealousy Persecution Idea of reference
Somatic
The nurse caring for a client with schizophrenia is assessing the client's ability to control distorted thought processes. Which finding indicates a positive outcome? The client is able to identify when hallucinations or delusions are real. The client can describe in detail the frequency and context of the hallucinatory and delusional behavior. The client can describe the hallucinations and delusions in detail and is able to interact with others and share in their delusional systems. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations.
The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations.
The nurse working in the emergency department is performing an initial assessment on a client, and notes many physical injuries. The nurse suspects family-related violence. Which finding is specific to this type of violence? The client lives in an assisted living facility. The client is financially dependent on him or herself. The client relies on neighbors and friends for transportation to and from appointments. The client lives with one of their children and requires extensive assistance with activities of daily living.
The client lives with one of their children and requires extensive assistance with activities of daily living.
The nurse working with a survivor of sexual assault , is developing a plan of care for the client. Which short-term initial goal is most appropriate? The client will care for her own physical wounds. The client will verbalize her feelings about the event. The client will identify an appropriate treatment plan. The client will resolve feelings of fear and anxiety related to the rape trauma.
The client will verbalize her feelings about the event.
The nurse employed in an emergency department is assisting in caring for an adult client who is a survivor of family violence. Which priority instruction does the nurse include in the discharge plan? Calling the police Self-defense classes The locations of shelters The importance of leaving the violent situation
The locations of shelters
A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't know how in the world to do it." Based on the client's statement, what does the nurse determine? There is no suicide risk There is a minimal suicide risk Suicide has been attempted unsuccessfully The risk for suicide exists and continued assessment is needed
The risk for suicide exists and continued assessment is needed
The nurse employed in a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided? Day shift Weekdays Weekends 7 to 10 a.m.
Weekends
The nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which finding indicates that the client is at high risk for suicide? The client is impulsive. The client is disorganized. The client has a history of suicide attempts. The client has an immediate plan for a suicide attempt.
The client has an immediate plan for a suicide attempt.
The nurse collects data from an older client and monitors him for signs of abuse. Which psychosocial factor does the nurse recognize as placing the client at risk for abuse? The client lives alone. The client is independent. The client shows signs and symptoms of depression. The client is completely dependent on family members for food and medicine.
The client is completely dependent on family members for food and medicine.
A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and states, "My priest assaulted me when I was an altar boy, and my dad just found out. He's got a gun, and he's driving over to the church rectory. I don't know what to do." Which response by the nurse is most appropriate initially? "How did your dad learn of your abuse by clergy?" "Call the police immediately and then call the priest to warn him that your dad has a gun." "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police." "You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened."
"Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police."
A client in halo traction says to the nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which response by the nurse is therapeutic? "No one ever gets used to that thing! It's horrible." "If I were you, I'd have had the surgery rather than suffer like this." "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move." "Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don't you think?"
"Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move."
A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem worth it anymore. Why shouldn't I just end it all?" Which statement should the nurse use to gather additional data from the client? "Did you sleep at all last night?" "Tell me what you mean by that." "I know you've had a stressful night." "I'm sure that your family is worried about you."
"Tell me what you mean by that."
A client with schizophrenia exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic? "Got it. The 'blinks' are 'taking over' the 'bumpers.'" "I can't understand what you're saying. You have to talk more clearly!" "This morning you are participating in the tree-decorating ceremony for the unit." "I can't understand you. Are you asking me to stay with you while you eat supper?"
"This morning you are participating in the tree-decorating ceremony for the unit."
A client who has twice attempted suicide says, "If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do." Which response should the nurse give to the client? "Of course you can't be left alone to get on with what you want to do." "Okay, go ahead and do whatever you want to do. Human beings have free will." "You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?" "Sounds like you're angry with people for caring enough about you to try to keep you from hurting yourself."
"You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?"
The nurse in the emergency department is helping care for a young female survivor of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors as which type of reaction? Signs of depression Common reactions to a devastating event Indicative of the need for hospital admission Evidence that the client is at high risk for suicide
Common reactions to a devastating event
A resident of a long-term care facility who has Alzheimer's disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which should the nurse consider when approaching the client about this behavior? This resident is a dangerous individual. Individuals with Alzheimer's disease are likely to be child molesters. This resident probably had an unfortunate experience while singing and dancing in his own youth. Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine.
Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine.
The nurse observes that a client is pacing back and forth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels "out of control!" Which intervention is most appropriate initially to maintain a safe environment? Restraining the client Placing the client in seclusion Continuing to monitor the client Moving the client to a quiet room and talking about her feelings
Moving the client to a quiet room and talking about her feelings
A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of the highest priority? Fear Anxiety Distorted body image Risk for impaired breathing
Risk for impaired breathing
A nurse notices a client's glaring eyes during a conversation with the client. The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be beneficial? Allowing the client to pace Escorting the client to a quiet room Changing the conversation to a less threatening subject Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings
Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings
A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, "The voice in my head is telling me that you're cheating." Which response by the nurse is therapeutic? "Is the voice telling you to do anything?" "I don't believe that you are hearing voices." "It isn't possible for people to hear voices in their head." "I do not hear any voices. Has the voice said anything else?"
"I do not hear any voices. Has the voice said anything else?"
A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most important? "Have you been having any thoughts of hurting your baby?" "Do you think that something physically wrong is causing your baby to cry?" "Do you think that your baby cries so frequently because he's not getting enough nourishment from breastfeeding?" "You say that he doesn't seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?"
"Have you been having any thoughts of hurting your baby?"
A client with schizophrenia says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my health care provider told me to." Which intervention would the nurse suggest as a distraction technique? "Pretend that you're on the phone and talk to the voices." "Have you tried to count back from 100 or listen to music?" "The next time this happens, try telling the voices to go away." "Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening."
"Have you tried to count back from 100 or listen to music?"
A client says to the nurse, "I'm really phobic about flying, so my husband and I always drove or took the train everywhere. Now he's been offered a big job in Europe, and if I don't get over this and fly with him, he says we're done. I'll be left to bring up our three children by myself." Which statement by the nurse would be therapeutic? "No problem. You can be hypnotized to sleep through your trip." "I'm interested that it took his threat of leaving you to motivate you to seek help." "You seem more anxious and afraid of raising three children alone than of flying." "I can teach you strategies to help master your panic. An antianxiety medicine would also help you."
"I can teach you strategies to help master your panic. An antianxiety medicine would also help you."
A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse observes the client for compulsive behavior involving which repetative element? Fears Actions Thoughts Delusions
Actions
The nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the client's discharge outcomes, the most positive outcome is that the client states that he or she will perform which action? Learn to play tennis Take a painting class Start an exercise program Continue to attend Alcoholics Anonymous meetings
Continue to attend Alcoholics Anonymous meetings
A client with obsessive-compulsive disorder who continually cleans her room with paper towels becomes enraged with her roommate for throwing the package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which action would the nurse take first? Restraining the client Filling out an incident report Removing both clients to safe locations Calling the hospital's risk-management department
Removing both clients to safe locations
The nurse is working with a new nurse employee who has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. The new nurse employee has developed a plan of care for the client. The nurse realizes the new nurse employee requires additional instruction if which aspect is included in the plan of care? Initiating confinement measures Acknowledging the client's behavior Assisting the client to an area that is quiet Maintaining a safe distance with the client
Initiating confinement measures
The nurse is caring for a client who has been identified as a survivor of physical abuse by a family member. Which action is the priority as the nurse plans care for the client? Notifying the caseworker of the situation Adhering to mandatory abuse reporting laws Removing the client from any immediate danger Obtaining treatment for the abusing family member
Removing the client from any immediate danger
A client with moderate depression, who was admitted to the mental health unit 2 days ago, suddenly begins smiling and reports that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan in which manner? Suggesting a reduction of medication Allowing increased in-room activities Increasing the level of suicide precautions Allowing the client off-unit privileges as necessary
Increasing the level of suicide precautions
The nurse plans outcomes for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment? Evaluation of neurological status Use of directive communications with the client Administration of acute psychotropic medications Keeping the client active with hobbies, exercise, and work
Keeping the client active with hobbies, exercise, and work
The nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially? Making a "no suicide" contract with the client Telling the client that anger should be suppressed Providing a peaceful place for the client to meditate Helping the client control expression of his feelings
Making a "no suicide" contract with the client
An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad told me he had to marry Mom because she got pregnant." Which response by the nurse would be therapeutic? "You're feeling that your folks didn't want you, but they chose to marry and have you." "You feel that you were a burden and not wanted? Let's talk with your parents to see whether you're right." "Let's speak with your parents about what you've just told me. Let's ask whether you were truly unwanted." "Sounds like your father was very inappropriate, but I'm certain that he didn't mean that you were a burden to him."
"You're feeling that your folks didn't want you, but they chose to marry and have you."
A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The nurse plans care knowing that this condition is referring to which aspect of the disorder? Mutism Verbigeration Pressured speech Poverty of speech
Mutism
An acutely ill client with schizophrenia says to the nurse, "He keeps saying that he likes you, and I keep telling him you're married, but he won't listen, and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriatestatement? "Try not to listen to the voices right now so that I can talk with you." "I think that you can help him stop his behavior if you concentrate." "Tell him I said to mind his p's and q's or I'll call the police on him." "I think that you're trying to share your own feelings toward me, but you're shy."
"Try not to listen to the voices right now so that I can talk with you."
A client with schizophrenia in the psychiatric inpatient unit is yelling, "The CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." Based on the client's statement, which clinical manifestation should the nurse document in the client record? Demonstrates paranoia Exhibits ideas of reference Evidence of persecutory delusions Evidence of ideas of somatic delusions
Evidence of persecutory delusions
The nurse is teaching a group of new employees ways to deescalate aggressive behavior exhibited by a client with schizophrenia. After the course employees state several actions they would take if a client with schizophrenia became increasingly aggressive. Which comment causes the nurse to realizes further instruction is required? Being assertive with the client Negotiating options with the client Maintaining a nonaggressive posture Standing close to the client and telling the client that the behavior is unacceptable
Standing close to the client and telling the client that the behavior is unacceptable
A client brought to the emergency department by the police after being mugged is extremely agitated, trembling and hyperventilating. What is the appropriate initialnursing action? Staying with the client Teaching the client how to relax Asking the client questions about the mugging Allowing the client to be alone in a room at the end of the emergency department corridor, where it is quiet
Staying with the client
The nurse is working with a new nurse employee who is creating a care plan for an adolescent is returning home after an acute psychiatric hospitalization for a suicide attempt. The nurse should suggest a revision of the plan of care if the new nurse includes which intervention? Encouraging the sharing of feelings Suggesting that the client's mother quit her job Identifying the family's strengths and weaknesses Offering and providing the family options and resources
Suggesting that the client's mother quit her job
A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on which client factor? Sources of support The object of the crisis The client's coping mechanisms The physical condition of the client
The physical condition of the client
A person who has overdosed on heroin is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are constricted. Which intervention does the nurse anticipate that the emergency department health care provider will prescribe? Gastric lavage Intravenous fluid Naloxone Ammonium chloride
Naloxone
A client experiencing homelessness, with an antisocial disorder, is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, "I need to be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which nursing intervention would be therapeutic? Sending the client to the psychiatric hospital intake center immediately for evaluation Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide
Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide
A woman is brought to the emergency department after an assault. She presents with complaints of dizziness, dyspnea, visual disturbance, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client's presentation? Mild Panic Severe Moderate
Severe
A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse planning care for this client to understand that the client is afflicted with which disorder? Paranoia Depression Schizophrenia Somatization disorder
Somatization disorder
The nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic? "I can see that this isn't a good time to visit." "You seem to be having a very difficult time." "Do you think your wife would want you to behave like this?" "What are you doing? How much are you drinking, and how long has this been going on?"
"You seem to be having a very difficult time."
A client in a mental health unit gets into a fight with another client over the use of the public telephone on the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which intervention by the nurse would be most therapeutic? Taking telephone privileges away from both clients for the day and giving them time-outs in their rooms Saying to the clients, "Okay, this is the last straw. Neither of you may use the telephone until tomorrow, and then only with a nurse timing you." Saying to the clients, "Go to your rooms, both of you. I don't want to hear anything more about the telephone on this unit for at least 2 hours." Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?"
Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?"
The mother of a child who is taking methylphenidate hydrochloride(HCL) tells the school nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which response by the nurse would be appropriate? "His cough could be a side effect of the methylphenidate HCL." "Your son should never take any medicine, even if it's OTC." "You may administer a small amount of OTC cough syrup without a problem, but not for more than 3 days." "I think that you should stop giving this medicine to your son until I can check its content with the pharmacy."
"I think that you should stop giving this medicine to your son until I can check its content with the pharmacy."
The mental health nurse is conducting the initial assessment of an client who is obese. The client confides that she was sexually molested at age 7 and began putting on weight thereafter. The nurse determines that the client's symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents which? Satisfaction with self A form of functional coping Protection from the risk of intimacy Long-term lack of compliance with weight programs
Protection from the risk of intimacy
Which step should be included in the care of a 13-year-old hospitalized child who has been abused? Encouraging the child to avoid the abuser Providing a caring environment that fosters the development of trust Teaching the child to make intelligent choices when confronted with an abusive situation Having the child identify the abuser if that person should visit while the child is hospitalized
Providing a caring environment that fosters the development of trust
A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for the rest of my life." Which response by the nurse is therapeutic? "What are you saying? Sounds like you need to pull yourself together and go back to school." "Having faith in yourself is one thing, but looking at your alternatives realistically is another." "You seem to be saying that your choices are final and that you've lost any other opportunities." "Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get."
"You seem to be saying that your choices are final and that you've lost any other opportunities."
A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! I'm the one who's dying." Which response by the nurse would be most therapeutic? "Have you shared your feelings with your family?" "Well, it sounds like you're being pretty pessimistic." "I think we should talk more about your anger with your family." "You're feeling angry that your family continues to hope for you to be cured."
"You're feeling angry that your family continues to hope for you to be cured."
A client says to the nurse, "I'm worried about my husband. He's talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose — but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is appropriate? "Yes, he's too intelligent to end it all." "I'm not sure. I don't know him that well." "Most people who talk about ending it all are just looking for attention." "Your husband is displaying behaviors that indicate a risk for self-harm."
"Your husband is displaying behaviors that indicate a risk for self-harm."
A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes this as an example of which speech pattern? Echolalia Tangential speech Clang associations Loosened associations
Clang associations
Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective? "I no longer have to lose weight." "I won't starve myself anymore." "I'll eat until I don't feel hungry." "I went out to lunch today with my cousin."
"I went out to lunch today with my cousin."
A client with schizophrenia arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client's hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate? Saying nothing and contacting the psychiatrist to sign a commitment order Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?" Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit Asking, "Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?"
Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?"
A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time? Reflecting back to the client that he appears upset Letting the client have some time alone to grieve the impending loss of the limb Reminding the client that the injury was a result of alcohol abuse and referring him for counseling Informing the health care provider of the client's depression and requesting medication to assist the client in coping with the diagnosis
Reflecting back to the client that he appears upset
A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. What is the priority nursing intervention? Remain with the client at all times Request that a family member remain with the client at all times Remove the client's clothing and dress the client in a hospital gown Place the client in a seclusion room from which all potentially dangerous articles have been removed
Remain with the client at all times
A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which intervention should the nurse implement? Restricting visitors Placing the client in a private room and locking the bathroom door Removing perfume, shampoo, and other toiletries from the client's room Placing flowers brought to the client in a small glass vase and putting them in the client's room
Removing perfume, shampoo, and other toiletries from the client's room
A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention should the nurse implement? Placing the client in a private room and locking the client's closets and bathroom Placing the client in a private room and removing all knives and glass from the client's meal tray Allowing the client to go out on pass as long as the client is accompanied by a responsible adult Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times
Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times
A client says to the nurse, "I don't do anything right. I'm such a loser." What is the appropriate response? "Everything will get better." "You don't do anything right?" "You do things right all the time." "You are not a loser; you are sick."
"You don't do anything right?"
A client with mania who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite.'" Which statement by the nurse would be most therapeutic? "When you can speak to me without yelling and being aggressive, I'll be happy to speak with you." "Just get your anger out with me, because we're not going to allow you be discharged until you calm down." "Do threats and name-calling usually work for you? Do people tend to listen to you and do as you order them to?" "I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."
"I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."
A client with schizophrenia is seen seemingly talking to someone who isn't there. Which nursing statement would be most therapeutic initially? "Today is my birthday. Would you like to go on an outing with my family?" "You need to wash up and get ready to go to supper in the cafeteria with the other clients now." "I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices." "You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?"
"I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices."
A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication." Which response by the nurse is appropriate? Telling the parents, "Medication noncompliance is the most frequent reason that people with this diagnosis relapse." Telling the parents, "Well, it's his decision to take his medicine, but it's yours to have him live with you if he stops the medication." Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?" Saying to the parents, "Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication."
Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?"
A 24-year-old client with schizophrenia says, "I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester." Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client's return to college? Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle Telling all friends about the illness so that they support the client's avoidance of alcohol and drugs and help the client maintain a balanced lifestyle Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization Compliance with treatment, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and socialization with one supportive friend
Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle
The nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client? Providing authority and action Displaying an attitude of detachment and efficiency Providing hope and reassurance that the crisis is temporary Demonstrating confidence in the client's ability to deal with the crisis
Providing authority and action
The nursing instructor enters a classroom to begin class and finds two students yelling and physically assaulting each other. Which intervention by the instructor would be most appropriate? Walking out of the classroom and asking the secretary to call security, then telling all of the students to leave and go to the nursing laboratory Getting the class to leave with her and sending everyone to the nursing laboratory, then calling security to the classroom and reentering to observe what is happening with the two students. Telling the class, "Take a break. I'll come and get you to restart class as soon as I can," then closing the classroom door, refusing to let anyone else in, and asking a passing instructor to get security Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats
Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats
A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through." Which statement by the nurse would be most therapeutic? "The voices will disappear in a few weeks as your hormones stabilize." "This must be very distressing to you. Can you tell me more about the voices?" "It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices." "You will want to tell the health care provider about them when you visit him next week. He is very interested in these voices and will want to help you with them."
"It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices."
A client in skeletal traction says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me she had other patients besides me! I'm very sick, but the nurses don't care!" Which response by the nurse would be therapeutic? "You poor thing! I'm so sorry this happened to you. That nurse should be reported!" "I think you're being very impatient. The nurses work very hard and come as quickly as they can." "It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?" "I can hear your anger. That nurse had no right to speak to you that way. I will report her to the director. It won't happen again."
"It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?"
A client says to the nurse, "It's over for me — the whole thing is over." Which response by the nurse would be therapeutic? "What do you mean, 'The whole thing is over'?" "Over? Well, that sounds pretty drastic to me. Let's discuss this in the strictest confidence." "Can you tell me more about why it's over for you? I'll keep your thoughts strictly confidential." "Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."
"Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."
. An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic? "Milk thistle aside, you still need to stop using alcohol. You have a severe drinking problem." "If milk thistle is so effective, I wonder why the liquor industry isn't lobbying to put it in alcohol?" "Milk thistle is used in Europe this way, but research findings are limited, so I'd stop drinking if I had a problem like you do." "Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."
"Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."
The nurse is caring for an older adult client who says, "I don't want to talk with you — you're only a nurse. I'll wait for my health care provider." Which response by the nurse would be therapeutic? "I'll leave you now and call your health care provider." "So you're saying that you want to talk to your health care provider?" "I'm angry with the way you've dismissed me. I am your nurse!" "I'm assigned to work with you. Your health care provider placed you in my hands."
"So you're saying that you want to talk to your health care provider?"
A client who is an alcoholic, has been admitted to the mental health unit states to the nurse, "The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled me over in my car." Which statement by the nurse is most appropriate? "Did you ask the judge to clarify his decision to make you come here?" "This limit means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level." "Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don't you agree?" "This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."
"This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."
A client in a retirement center rings the night alarm and says to the nurse, "Look at this old man! He keeps breaking into my apartment! You've got to get him to stay out of here so I can sleep." Which statement by the nurse would be most therapeutic? "Why not just throw him out yourself and lock up once and for all?" "Now, you know that you're always seeing things and people at night who aren't there." "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest." "I'm sure you're very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he'll leave your apartment."
"This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest."
A client says to the nurse, "I came in to see you because I've been off my medication for 4 years but I feel as though I may be getting depressed again. I've been despondent again and thinking I should have ended it. That's why I'm here to get help." Which response by the nurse would be therapeutic? "Well, you really have had a good long drug-free time, but it sounds as if the health care provider needs to reorder your medication at once." "If you've been able to be drug free all this time, you probably don't need to restart the medicine. You probably just need some therapy to help you manage stress." "Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?" "Well, it's similar to when a client is battered — things have to boil over before the police can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before the health care provider can restart the medication."
"Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?"
A client with major depression says to the nurse, "I should have died. I've always been a failure." Which response by the nurse is therapeutic? "I see a lot of positive things in you." "You still have a great deal to live for." "Feeling like a failure is part of your illness." "You've been feeling like a failure for some time now?"
"You've been feeling like a failure for some time now?"
The nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the mental health unit observes the client for certain characteristic behaviors. Which characteristic behavior will the nurse likely observe? Hostility Inflexibility Adaptability Extreme fear
Inflexibility
