HESI RN Mental Health Exam Prep Questions & Knowledge Review

What are the symptoms of major depression? Select all that apply. 1. Apathy 2. Insomnia without fatigue 3. Mood swings with manic episodes 4. Guilt feelings 5. Sleep disturbances

1. Apathy 4. Guilt feelings 5. Sleep disturbances Apathy, guilt feelings, and sleep disturbances are symptoms of major depression. Insomnia without fatigue and mood swings with manic episodes are symptoms of bipolar affective disorder.

Without knocking, a nurse enters the room of a young male client with the diagnosis of panic disorder and finds him masturbating. What should the nurse do? 1. Apologize and leave the room 2. Tactfully assess why he needs to masturbate 3. In a calm, quiet manner say, "This behavior is inappropriate in the hospital." 4. Pretend not to have seen the masturbation and carry out whatever task needs to be done

1. Apologize and leave the room The client has the right to privacy; his behavior is acceptable in the privacy of his room. Masturbation is a sexual outlet; assessment is unnecessary unless the act is practiced to excess. Pretending not to have seen the client and carrying out whatever task needs to be done may cause needless embarrassment to the client and close off further communication. The behavior is not inappropriate; the client was in the privacy of his own room.

Which medication may be used to encourage abstinence in a client with alcoholism? 1. Disulfiram 2. Lorazepam 3. Methadone 4. Chlordiazepoxide

1. Disulfiram Rehabilitation helps an alcoholic client abstain from alcohol abuse. Disulfiram is a medication that may be administered to the alcoholic client to encourage abstinence. During detoxification of alcoholic clients, lorazepam and chlordiazepoxide are used to treat tremors, nervousness, and restlessness, but they are not used to promote abstinence. Methadone is a synthetic opioid that helps suppress withdrawal symptoms in clients addicted to morphine or heroin.

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what? 1. Attempts to minimize the illness 2. Lacks an emotional response to the illness 3. Refuses to discuss the condition with the client's spouse 4. Expresses displeasure with the prescribed activity program

1. Attempts to minimize the illness Attempting to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial. Lacking an emotional response to the illness indicates repression of affect rather than denial. Failure to communicate is insufficient evidence to diagnose denial; the marital relationship may be strained, or the client may be worried about upsetting the spouse. Expressing displeasure with the activity program usually indicates displacement of anger, not denial.

Which intellectual factor would the nurse find appropriate as a dimension for gathering data for a client's health history? 1. Attention span 2. Primary language 3. Coping mechanisms 4. Activity and coordination

1. Attention span Attention span is an intellectual dimension used to gather data for a health history. A social dimension for gathering health history includes primary language. A coping mechanism is considered to be a social subdimension used to gather a client's health history data. Physical and developmental subdimensions would include activities and coordination.

An antidepressant is prescribed for a depressed older client. After 1 week the client's son expresses concern that there does not seem to be much improvement. How should the nurse respond? 1. "Antidepressant therapy requires several weeks before it becomes effective." 2. "Antidepressant therapy will be more effective as the physical condition improves." 3. "Additional medications may be required before behavioral changes will be observed." 4. "Additional time is needed for the medication to become effective because of the prolonged depression."

1. "Antidepressant therapy requires several weeks before it becomes effective." The effects of antidepressants are cumulative; it may take 3 to 4 weeks before improvement is identified. Antidepressants do not become more effective as a client's physical condition improves. Antidepressants become effective after 3 or 4 weeks, regardless of the duration of the depression.

A client who was forced into early retirement is found to have severe depression. The client says, "I feel useless, and I've got nothing to do." What is the best initial response by the nurse? 1. "Tell me more about feeling useless." 2. "Volunteering can help you fill your time." 3. "Your illness is adding to your current feelings." 4. "Let's talk about what you'd like to be doing right now."

1. "Tell me more about feeling useless." An open-ended response encourages further discussion and allows exploration of feelings. Telling the client that volunteering will help pass the time ignores the client's feelings. The depression is not adding to the feelings; the feelings are causing the depression. Asking the client to talk about what the client would rather be doing ignores the client's feelings.

An older adult resident of a nursing home who has the diagnosis of dementia of the Alzheimer type, frequently talks about the good old days at the ranch. What is the most appropriate action by the nurse? 1. Allowing the resident to reminisce about the past and listening with interest 2. Involving the resident in interesting diversional activities with a small group 3. Reminding the resident that those "good old days" are past and that he or she should focus on the present 4. Introducing the resident to other residents with the same diagnosis so that they can share their past experiences

1. Allowing the resident to reminisce about the past and listening with interest Allowing the resident to reminisce about the past and listening with interest encourages verbalization, gives the resident a feeling of security, and decreases the client's sense of isolation. Involving the resident in interesting diversional activities in a small group discourages verbalization between the resident and the nurse. Reminding the resident that those "good old days" are past and that the focus should be on the present discourages verbalization of feelings and the life review task associated with older adulthood. It is the nurse's, not other residents', role to meet the emotional needs of this resident. Individuals with cognitive impairments are usually unable to facilitate discussion groups.

hat are the "four A's" for which nurses should evaluate clients with suspected Alzheimer disease? 1. Amnesia, apraxia, agnosia, aphasia 2. Avoidance, aloofness, asocial, asexual 3. Autism, loose association, apathy, affect 4. Aggressive, amoral, ambivalent, attractive

1. Amnesia, apraxia, agnosia, aphasia Neurofibrillary tangles in the hippocampus cause recent memory loss (amnesia); temporoparietal deterioration causes cognitive deficiencies in speech (aphasia), purposeful movements (apraxia), and comprehension of visual, auditory, and other sensations (agnosia). Avoidance, aloofness, asocial, and asexual are characteristics of the schizoid personality. Autism, loose association, apathy, and affect are characteristics of schizophrenia. Aggressive, amoral, ambivalent, and attractive are characteristics of an antisocial personality.

A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors? 1. Bipolar disorder, manic phase 2. Antisocial personality disorder 3. Obsessive-compulsive disorder 4. Chronic undifferentiated schizophrenia

1. Bipolar disorder, manic phase This kind of hyperactive behavior is typical of the manic flight into reality associated with mood disorders. The behaviors are more indicative of a mood disorder than a personality disorder. Ritualistic, not manic, behavior is indicative of obsessive-compulsive disorder. A flat affect and apathy are more indicative of a schizophrenic disorder.

A resident in a nursing home recently immigrated to the United States from Italy. How does the nurse plan to provide emotional support? 1. By offering choices consistent with the client's heritage 2. By ensuring that the client understands American beliefs 3. By assisting the client in adjusting to the American culture 4. By correcting the client's misconceptions about appropriate health practices

1. By offering choices consistent with the client's heritage Adherence to a plan of care is enhanced by the nurse's providing choices consistent with the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and biases should not influence or interfere with the implementation of appropriate care. Helping the client adjust to the American culture is not the priority at this time; care should be adapted to the client's needs and culture. The person's cultural practices should not be addressed unless they are detrimental to the person's health.

A nurse counseling a female client on the inpatient psychiatric unit responds to a statement made by the woman by stating, "I'm confused about exactly what is upsetting you. Would you go over that again, please?" What is the nurse using? 1. Clarifying 2. Structuring 3. Confronting 4. Paraphrasing

1. Clarifying Clarifying is an attempt to better understand the message intended by the client. It is utilized to gain a clearer understanding of what another person has stated. Structuring is an attempt to create order and thereby allow a client to become aware of problems. Confronting examines a discrepancy between what a person is saying and what a person does. It requires careful attention to nonverbal communication, as well as the discrepancies between the nonverbal and verbal message. Paraphrasing allows the speaker to share how one person perceives and hears another's information. The nurse is not paraphrasing but instead is attempting to better understand the client.

A nurse should reassess an older adult client's needs and current plan of care when the client's behavior indicates the development of what symptom? 1. Confusion 2. Hypochondriasis 3. Additional complaints 4. Increased socialization

1. Confusion The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring. Hypochondriasis and additional complaints do not indicate that the plan needs to be changed unless the client's history demonstrates no prior use of these defenses. Increased socialization is a positive response to the plan of care that does not require reassessment.

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

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

A 30-year-old woman reports to the mental health clinic on the recommendation of her primary health care provider. She has been unable to carry out everyday activities because of increased pain in her lower back and legs. Numerous neurological and orthopedic workups indicate that her symptoms seem excessive when compared with the physical problems shown on physical examination and repeated MRIs and x-rays. She says that no one understands how difficult it has been to care for her 32-year-old husband, who has an inoperable brain tumor and is undergoing chemotherapy. In light of the history and symptoms, what disorder should the nurse suspect? 1. Conversion 2. Malingering 3. Referred pain 4. Body dysmorphic

1. Conversion Clients with conversion disorder have physical symptoms caused by psychological conflicts and stressors. It is the most common of the somatoform disorders and is initiated or exacerbated by significant psychological stressors. Malingering is a type of manipulation in which false or exaggerated symptoms are used to obtain a specific result, such as avoiding work or jail. Referred pain originates in one area of the body and is experienced (referred) in another part of the body that is not receiving the noxious stimulus directly. Body dysmorphic disorder is when a person believes that his or her body is deformed in some manner that is not readily observed by others.

Which of these are symptoms of depression commonly observed in older adults? Select all that apply. 1. Fatigue 2. Sadness 3. Agitation 4. Increased sleep 5. Increased appetite

1. Fatigue 2. Sadness 3. Agitation Symptoms of depression that are often observed in older adults include fatigue, sadness, and agitation. Insomnia is more likely than increased sleep to occur in depressed older adults. Anorexia, rather than increased appetite, is more likely to occur in depressed older adults.

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

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

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

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

A nurse is planning to teach a client about self-care. What level of anxiety will best enhance the client's learning abilities? 1. Mild 2. Panic 3. Severe 4. Moderate

1. Mild Mild anxiety motivates one to action, such as learning or making changes. Higher levels of anxiety tend to blur the individual's perceptions and interfere with functioning. Attention is severely reduced by panic. The perceptual field is greatly reduced with severe anxiety and narrowed with moderate anxiety.

What drug should a nurse anticipate that the health care provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose? 1. Naloxone 2. Methadone 3. Epinephrine 4. Amphetamine

1. Naloxone Naloxone is a narcotic antagonist that displaces opioids from receptors in the brain, thereby reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will add to the problem of overdose. Epinephrine and amphetamine will have no effect on respiratory depression related to opioid overdose.

A client with major depression that includes psychotic features tells the nurse, "All of my relatives have been killed because I've been sinful and need to be punished." What is the primary focus of nursing interventions? 1. Protecting the client against any suicidal impulses 2. Supporting the client's interest in the outside world 3. Helping the client manage the concern for family members 4. Reassuring the client that past behaviors are not being punished

1. Protecting the client against any suicidal impulses Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress; the client's safety is the focus of nursing interventions. Supporting the client's interest in the outside world is of very low priority. The client is focusing on the current personal situation, not the outside world. Helping the client manage the concern for family members is a secondary concern. Reassurance will not change the client's belief.

A client with the diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine drug. When the psychiatric daycare center plans a fishing trip, it will be important for the nurse to take which action? 1. Provide the client with sunscreen. 2. Caution the client to limit exertion during the trip. 3. Give the client an extra dose of medication to take after lunch. 4. Take the client's blood pressure before allowing participation in the outing.

1. Provide the client with sunscreen. Phenothiazines commonly cause a photosensitivity that can be controlled with sunscreen. Limiting activity is not a necessary precaution when phenothiazines are prescribed. The medication must be administered as prescribed. Participating in the outing should not negatively affect the client's blood pressure.

A 17-year-old client is found to have anorexia nervosa. The psychiatrist, in conjunction with the client and the parents, decides to institute a behavior modification program. What does the nurse recall is a major component of behavior modification? 1. Rewarding positive behavior 2. Reducing necessary restrictions 3. Deconditioning fear of weight gain 4. Reducing anxiety-producing situations

1. Rewarding positive behavior In behavior modification, positive behavior is reinforced, and negative behavior is neither reinforced nor punished. Reducing the number or complexity of necessary restrictions, deconditioning the fear of weight gain, and reducing the number of anxiety-producing situations may all be part of the program, but none is a major component.

A client on treatment for depression visited the primary healthcare provider with a complaint of blurred vision and constipation. Which drugs are responsible for these adverse effects? Select all that apply. 1. Phenelzine 2. Amoxapine 3. Maprotiline 4. Desipramine 5. Amitriptyline

2. Amoxapine 4. Desipramine 5. Amitriptyline Amoxapine, desipramine, and amitriptyline are first-generation antidepressants drugs with potential adverse effects of blurred vision and constipation. Phenelzine is a monoamine oxidase inhibitor. Dizziness and dyskinesias are the adverse effects of this drug. Maprotiline is a second-generation antidepressant drug with potential adverse effects of drowsiness and abnormal dreams.

What is the priority nursing intervention in the planning of nursing care for an adolescent client with anorexia nervosa? 1. Rewarding weight gain by increasing privileges 2. Discussing the importance of eating a balanced diet 3. Encouraging the client to include high-calorie foods in the diet 4. Family therapy focusing on the influence of the client's behavior on the family

1. Rewarding weight gain by increasing privileges Behavior modification programs are helpful treatment modes for many clients with anorexia nervosa. Discussing the importance of eating a balanced diet is ineffective. The person with anorexia nervosa is more concerned with losing weight than with eating a balanced diet. A well-balanced diet should be encouraged, but actual weight gain is critical and must be reinforced. Although family therapy may be helpful, emphasis on the anorexia may reinforce the negative behavior. Also, family therapy will not be a priority until the client gains weight.

A nurse enters the room of an agitated, angry client to administer the prescribed antipsychotic medication. The client shouts, "Get out of here!" What is the nurse's best approach? 1. Say, "I'll be back in 15 minutes, and then we can talk." 2. Get assistance and give the medication by way of injection 3. Explain why it is necessary to comply with the practitioner's order 4. Tell the client, "You have to take the medicine that's been prescribed for you."

1. Say, "I'll be back in 15 minutes, and then we can talk." Saying, "I'll be back in 15 minutes, and then we can talk" allows the agitated, angry client time to regain self-control; telling the client that the nurse will return will decrease possible guilt feelings and implies to the client that the nurse cares enough to come back. Getting assistance and giving the medication by way of injection does not respect the client's feelings; it may decrease trust and increase feelings of anger, helplessness, and hopelessness. An agitated, angry client will not be able to accept a logical explanation. Continued insistence may provoke increased anger and further loss of control.

Which medication is effective in treating eating disorders? 1. Sertraline 2. Clozapine 3. Benztropine 4. Chlorpromazine

1. Sertraline Medications such as sertraline are helpful in treating eating disorders. Clozapine is used in the treatment of resistant forms of schizophrenia. Benztropine is an antiparkinsonian medication. Chlorpromazine is an antipsychotic agent.

A client who has been battling cancer of the ovary for 7 years is admitted to the hospital in a debilitated state. The healthcare provider tells the client that she is too frail for surgery or further chemotherapy. When making rounds during the night, the nurse enters the client's room and finds her crying. Which is the most appropriate intervention by the nurse? 1. Sit down quietly next to the bed and allow her to cry. 2. Pull the curtain and leave the room to provide privacy for the client. 3. Explain to the client that her feelings are expected and they will pass with time. 4. Observe the length of time the client cries and document her difficulty accepting her impending death.

1. Sit down quietly next to the bed and allow her to cry. Sitting down quietly next to the bed and allowing her to cry demonstrates acceptance of the client's behavior and provides an opportunity for the client to verbally express feelings if desired. Pulling the curtain and leaving the room to provide privacy for the client may make the client feel that the behavior is wrong or is annoying others. Also, it abandons the client when support is needed. Explaining to the client that her feelings are expected and they will pass with time closes off communication and does not provide an opportunity for the client to talk about feelings. Also, it provides false reassurance. The length of time she cries is unimportant at this time. Assuming that she is having difficulty accepting her impending death is a conclusion without enough information.

A nurse encourages a client to join a self-help group after being discharged from a mental health facility. What is the purpose of having people work in a group? 1. Support 2. Confrontation 3. Psychotherapy 4. Self-awareness

1. Support Members of a self-help group share similar experiences and can provide valuable understanding and support to one other. Although confrontation and self-awareness may occur, these are not the primary purposes of self-help groups. Self-help groups provide an opportunity for people to interact, not to engage in professional psychotherapy.

What is the most important tool a nurse brings to the therapeutic nurse-client relationship? 1. The self and a desire to help 2. Knowledge of psychopathology 3. Advanced communication skills 4. Years of experience in psychiatric nursing

1. The self and a desire to help The nurse brings to a therapeutic relationship the understanding of self and basic principles of therapeutic communication; this is the unique aspect of the helping relationship. Knowledge of psychopathology, advanced communication skills, and years of experience in the field all support the psychotherapeutic management model, but none is the most important tool used by the nurse in a therapeutic relationship.

When communicating with a client with a psychiatric diagnosis, the nurse uses silence. How should clients feel when silence is used in therapeutic communication? 1. Unhurried to answer 2. It is their turn to talk 3. The nurse is thinking about the interaction 4. The nurse expects that further communication is unnecessary

1. Unhurried to answer Silence is a tool employed during therapeutic communication that indicates that the nurse is listening and receptive; it allows the client time to collect thoughts, gain control of emotions, or speak without hurrying. Silence should be comfortable and should not create pressure to talk. The client should feel that he or she has an opportunity to think about the interaction. The client's perception that the nurse expects that further communication is unnecessary will close communication.

Which often-abused medication is not hallucinogenic? 1. Ketamine 2. Barbiturates 3. Phencyclidine 4. Lysergic acid diethylamide

2. Barbiturates Barbiturates are one of the most often abused sedative-hypnotic medications, but they are not hallucinogens. Ketamine, phencyclidine, and lysergic acid diethylamide are hallucinogens.

A client with the diagnosis of an antisocial personality disorder responds to limit-setting by a nurse by saying, "You sure do look messy today." What is the most appropriate response by the nurse? 1. "Don't you feel well today?" 2. "I get the feeling you're angry with me." 3. "I really didn't think anyone would notice." 4. "Do you think that was a nice thing to say to me?"

2. "I get the feeling you're angry with me." The response "I get the feeling you're angry with me" helps the client focus on feelings rather than emphasizing the current unacceptable behavior. The response "Don't you feel well today?" gives the client an alibi for unacceptable behavior. By saying "I really didn't think anyone would notice," the nurse is becoming defensive rather than dealing with the problem directly. The response "Do you think that was a nice thing to say to me?" points out the behavior in a negative way.

A client who has been taking the prescribed dose of zolpidem for 5 days returns to the clinic for a follow-up visit. When interviewing the client, the nurse identifies that the medication has been effective when the client makes which statement? 1. "I have less pain." 2. "I have been sleeping better." 3. "My blood glucose is under control." 4. "My blood pressure is coming down."

2. "I have been sleeping better." Zolpidem is a sedative-hypnotic that produces central nervous system depression in the limbic, thalamic, and hypothalamic areas of the brain. Zolpidem is not an analgesic, antidiabetic, or antihypertensive medication.

What type of disorder is anorexia nervosa? 1. Mood disorder 2. Eating disorder 3. Sexual disorder 4. Thought process disorder

2. Eating disorder The eating disorder anorexia nervosa is a severe form of self-starvation that can result in death. Mania is a mood disorder. Fetishism is a sexual disorder in which an object, usually an article of clothing, is used to achieve arousal. Schizophrenia is a thought process disorder.

A nurse is counseling a client who abuses cocaine. The nurse recognizes that this drug is representative of which drug category? 1. An opioid 2. A stimulant 3. A barbiturate 4. A hallucinogen

2. A stimulant Cocaine is classified as a stimulant. It is inhaled in its powdered form or smoked as crack; its use creates experiences similar to but more intense than those experienced with the amphetamines, and its withdrawal results in a deeper crash. Opioids and barbiturates are central nervous system depressants. Hallucinogens produce cerebral excitation that can yield a state similar to psychosis.

Which subtype of schizophrenia may have good prognosis with treatment? 1. Residual 2. Paranoid 3. Catatonic 4. Disorganized

2. Paranoid The prognosis of paranoid schizophrenia is good with treatment. The residual subtype of schizophrenia may have a poor prognosis. The prognosis of the catatonic subtype of schizophrenia is fair. The prognosis of disorganized schizophrenia is poor with treatment.

A client with schizophrenia is started on a regimen of chlorpromazine. After 10 days a shuffling gait, tremors, and some rigidity are apparent. Benztropine mesylate 2 mg by mouth daily is prescribed. What does the nurse remember when administering these medications together? 1. Both medications are cholinesterase inhibitors. 2. Both medications have a cholinergic-blocking action. 3. The antipsychotic effects of chlorpromazine will be decreased. 4. The synergistic effect of these medications will cause drooling.

2. Both medications have a cholinergic-blocking action. Both medications block central acetylcholine receptors. Neither medication inhibits cholinesterase; neostigmine (Prostigmin) acts in this manner. Although benztropine mesylate can cause mental confusion when given in large doses, it does not reduce the antipsychotic effect of chlorpromazine. Both medications cause dry mouth.

Which treatment strategy is beneficial for a client with panic disorder? 1. Milieu therapy 2. Debriefing technique 3. Confrontation therapy 4. Electroconvulsive therapy

2. Debriefing technique The debriefing technique is often used to treat panic disorder. Milieu therapy is used to treat clients with schizophrenia. Confrontation therapy is not generally used to treat mental health disorders. Electroconvulsive therapy is used to treat affective disorders.

A client with cancer is told by a health care provider that the cancer has metastasized to other organs and is untreatable. The client tells the nurse, "I think they made a mistake. I don't think I have cancer. I feel too good to be dying." Which stage of grief does the nurse conclude that the client is experiencing? 1. Anger 2. Denial 3. Bargaining 4. Acceptance

2. Denial The client has difficulty accepting the inevitability of death and attempts to deny the reality of it. In the anger stage the client strikes out with statements such as "Why me?" and "How could God do this to me?" The client is angry at life and is still angrier to be removed from it by death. In the bargaining stage the client attempts to bargain for more time; the reality of death is no longer denied, but the client tries to manipulate and extend the remaining time. In the acceptance stage the client accepts the inevitability of death and quietly awaits it.

The grieving spouse of a client who has just died says to the nurse, "We should have spent more time together. I always felt that my work came first." What should the nurse conclude that the spouse is experiencing? 1. Displaced anger 2. Feelings of guilt 3. Shame for past behavior 4. Ambivalent feelings about the spouse

2. Feelings of guilt The spouse is expressing the typical feelings of guilt associated with the death of a loved one; often there is initial guilt over what might have been. No evidence supports the displaced anger conclusion. The spouse is expressing guilt, not shame. No evidence supports the ambivalent feelings about the spouse conclusion.

An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? Select all that apply. 1. Demonstrating concern for the injured child 2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 4. Asking questions about the injury and the child's prognosis 5. Giving an explanation of how the injury occurred that is not consistent with the injury

2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 5. Giving an explanation of how the injury occurred that is not consistent with the injury The child is often made the scapegoat in the situation; the parents blame the child because they have unrealistic expectations of the child. Discrepancies or inconsistencies in the history result from attempts to present a story that is not based in fact. Discrepancies between the parental explanation for the child's injuries and the physical findings or discrepancies in the history that each parent gives are common because the information that is being provided is not based in fact. Abusive parents usually do not ask questions about the injury or prognosis and demonstrate little or no interest in their child's well-being.

Which addictive drug may cause the dependent user to think that he or she has the ability to fly? 1. Cocaine 2. Hallucinogens 3. Amphetamines 4. Opioid analgesics

2. Hallucinogens Hallucinogens affect various parts of the brain, altering perception and thinking; a chronic user of these drugs may think he or she has the ability to fly. Use of the other drugs has other results. Chronic overdose of cocaine may lead to cardiorespiratory distress and seizures. Amphetamines strongly stimulate the central nervous system and may induce hallucinations and paranoia. Acute opioid overdose may cause severe respiratory depression, pinpoint pupils, and stupor or coma.

A married male client with three children has lost his job and states that he feels useless. He is tearful, upset, and embarrassed. What is an appropriate objective of care for this client? 1. Limiting tearfulness 2. Increasing self-esteem 3. Controlling feelings of sadness 4. Promoting acceptance by others

2. Increasing self-esteem The loss of a job can precipitate negative feelings about the self and decrease self-esteem. Feelings should be expressed, not limited; attempting to decrease a client's crying often ends up worsening it. Crying is not necessarily an expression of sadness; other feelings are involved. The focus should be on the client's self-acceptance, not acceptance by others.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1. Dementia 2. Multiple losses 3. Declines in health 4. A milestone birthday 5. An injury requiring hospitalization

2. Multiple losses 3. Declines in health Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client? 1. Projection 2. Repression 3. Suppression 4. Rationalization

2. Repression Repression is coping with overwhelming emotions by blocking awareness or memory of the stressful event. Projection is attributing one's own unacceptable feelings and thoughts to others. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Rationalization is the attempt to mask unacceptable feelings or behaviors by providing excuses and explanations.

Which condition is a physical condition in an alcoholic client? 1. Social isolation 2. Risk for poisoning 3. Ineffective impulse control 4. Risk for compromised human dignity

2. Risk for poisoning Risk for poisoning is a physical condition that may be exhibited in an alcoholic client. Social isolation, ineffective impulse control, and risk for compromised human dignity are psychosocial conditions that may be exhibited in alcoholic clients.

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care? 1. Physical contact will increase dependency needs. 2. Routines provide stability for clients with dementia. 3. Regressive behavior should be interrupted immediately. 4. Procedures do not have to be explained to clients with dementia.

2. Routines provide stability for clients with dementia. Rituals and routines in activities of daily living provide a framework and structure for clients with dementia, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood.

A 44-year-old client has been unable to function since her husband asked for a divorce 2 weeks ago. She is brought to the crisis intervention center by a friend. What type of crisis is this situation? 1. Social 2. Situational 3. Maturational 4. Developmental

2. Situational Situational crises involve an unanticipated loss, such as a divorce, that is threatening to the client. Social crises involve multiple losses such as those occurring during major disasters. Maturational crises occur in response to stress experienced as one struggles with developmental tasks. Developmental (maturational) crises are associated with developmental tasks; divorce is not a developmental task.

Which emotional condition may be apparent in a client with an addiction? 1. Insomnia 2. Social isolation 3. Acute confusion 4. Functional urinary incontinence

2. Social isolation Social isolation is an emotional condition that may be apparent in a client with an addiction. Insomnia, acute confusion, and functional urinary incontinence are physical, not emotional, conditions that may be apparent in clients with addiction.

Which type of caregiver is the most frequent abuser of older adults? 1. Adult child 2. Spouse 3. Family friend 4. Nonrelated professional caregiver

2. Spouse Caregivers are most often the clients' spouses, and spouses are frequently the perpetrators when an older adult is the victim of abuse. A client's adult child, family friend, or nonrelated professional caregiver may perpetrate abuse as well, but this occurs less often.

An executive, busy at work, receives a phone call from a friend relating bad news. The woman makes a conscious effort to put this information out of her mind and continues to work at the task at hand. The next day she remembers that her friend telephoned her but is unable to recall the message. Which defense mechanism does this behavior represent? 1. Regression 2. Suppression 3. Passive aggression 4. Reaction formation

2. Suppression Suppression is the voluntary exclusion from awareness of anxiety-producing feelings, ideas, and situations. In regression, a person returns to an earlier and more comfortable developmental level. Passive aggression is the use of behaviors such as passivity, procrastination, and inefficiency that negatively affect others. Reaction formation is a conscious behavior that is the opposite of an unconscious feeling.

A client with newly diagnosed multiple myeloma asks, "How long do you think I have to live?" What is the most appropriate response by the nurse? 1. "Let me ask your primary healthcare provider for you." 2. "I can understand why you are worried." 3. "Tell me about your concerns right now." 4. "It depends on whether the tumor has spread."

3. "Tell me about your concerns right now." The response "Tell me about your concerns right now" encourages the client to review facts and provides an opportunity to talk about feelings. The response "Let me ask your primary healthcare provider for you" suggests the nurse does not want to discuss the subject; it abdicates the nurse's responsibility to explore the issue with the client. Although it is an empathic answer, the response "I can understand why you are worried" does not encourage the client to explore feelings; it may increase anxiety. Although the statement "It depends on whether the tumor has spread" is true, the response does not encourage the client to examine feelings.

Which statement about addiction needs correction? 1. Alcoholism is an example of addiction. 2. Addiction is excessive use or abuse of a substance. 3. A person can have only a single addiction at one time. 4. Addiction can be characterized by a display of psychological disturbance

3. A person can have only a single addiction at one time. A person can have more than one addiction at the same time. The other statements are correct: Alcoholism is an example of addiction. Addiction is excessive use or abuse of a substance, and it can be characterized by a display of psychological disturbance.

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

3. "Tell me what you're thinking about yourself." Encouraging the client to focus on the self will facilitate communication and foster self-perception. Stating that God will not punish the client denies the client's feelings and provides false reassurance. Stating that the voices are fantasy denies the client's experience. Stating that the client is not wicked denies the client's feelings and provides false reassurance.

A nurse on the psychiatric unit of the hospital has been assigned four clients for the shift. The assignment includes an 84-year-old client who is severely depressed, a 73-year-old client who is being discharged, a 53-year-old client who was admitted for lithium toxicity, and a 48-year-old client who has panic attacks. Which client should the nurse evaluate first after receiving report? 1. 84-year-old client 2. 73-year-old client 3. 53-year-old client 4. 48-year-old client

3. 53-year-old client The 53-year-old client should be evaluated first because of the severity of adaptations associated with lithium toxicity. A severely depressed client has a low energy level and is not at the greatest risk at this time. A client who is stable enough to be discharged does not need immediate attention. Clients with panic attacks usually seek immediate attention when it is needed.

A client who is dying jokes about the situation even though the client is becoming sicker and weaker. Which is the most therapeutic response by the nurse? 1. "Why are you always laughing?" 2. "Your laughter is a cover for your fear." 3. "Does it help to joke about your illness?" 4. "The person who laughs on the outside cries on the inside."

3. "Does it help to joke about your illness?" The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always laughing?" is too confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear" is too confrontational and an assumption by the nurse. The response "The person who laughs on the outside cries on the inside" is too judgmental, an assumption, and a stereotypical response.

Many people control anxiety with the use of ritualistic behavior. What must the nurse do when caring for these clients? 1. Avoid mentioning the ritual 2. Explain the meaning of the ritual 3. Allow them time to carry out the ritual 4. Prevent them from carrying out the ritual

3. Allow them time to carry out the ritual Allowing the client who uses a ritual time to carry out the ritual reduces the client's anxiety. Clients prevented from using ritualistic behavior to control anxiety are being deprived of a defense and will not be able to relieve tension. The client's behavior should never be ignored; it is important to accept and support these clients during this time. Explaining the meaning of the ritual will not decrease the use of the behavior. Preventing a ritualistic behavior will probably increase the client's anxiety.

What is the most commonly experienced type of hallucination? 1. Visual 2. Tactile 3. Auditory 4. Olfactory

3. Auditory Auditory hallucinations are the most commonly experienced type of hallucinations. Visual, tactile, and olfactory hallucinations are less commonly experienced compared to auditory ones.

Two 20-year-old female clients on the psychiatric unit have become very much attached to each other and are found in bed together. They become angry and sarcastic when the nurse asks one of them to return to her own bed. How can the nurse best address this situation? 1. By asking the health care provider to transfer one of the clients to another unit 2. By limiting their privileges for several days because their behavior is undesirable 3. By adopting a matter-of-fact, nonjudgmental attitude and setting limits on the behavior 4. By supervising them carefully and separating them when possible throughout the day and always at night

3. By adopting a matter-of-fact, nonjudgmental attitude and setting limits on the behavior Everyone has the right to his or her sexual orientation and preferences, but limits must be set on acting-out behavior on a psychiatric unit. Helping clients deal with their sexuality in a more appropriate manner is more therapeutic than continuous separation by the staff. Punishment is inappropriate.

A nurse is aware that after the administration of alprazolam (Xanax) is started, it is important to observe the client for side effects. What is the nurse's initial action? 1. Measuring the client's urine output 2. Examining the client's pupils daily 3. Checking the client's blood pressure 4. Monitoring the abdomen for distention

3. Checking the client's blood pressure Orthostatic hypotension is a common side effect of alprazolam (Xanax) that occurs early in therapy. Central nervous system depression is not an early side effect, but it may occur after prolonged use. An alteration in urine output is not a common side effect, but it may occur after prolonged use. Distention is not a common side effect, but distention from constipation may occur after prolonged use.

Which disorders are complications associated with alcoholism? Select all that apply. 1. Rhinitis 2. Sinusitis 3. Delirium tremens 4. Korsakoff psychosis 5. Wernicke encephalopathy

3. Delirium tremens 4. Korsakoff psychosis 5. Wernicke encephalopathy Delirium tremens, Korsakoff psychosis, and Wernicke encephalopathy are associated with alcoholism. Rhinitis and sinusitis are associated with chronic abuse of cocaine by snorting.

A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing? 1. Hallucination 2. Error in judgment 3. Delusion of persecution 4. Self-accusatory delusion

3. Delusion of persecution A delusion of persecution is a fixed and firm belief or a feeling of being harassed, in danger, or at the mercy of others. Hallucinations are perceived experiences that occur in the absence of actual sensory stimulation. An error in judgment is poor decision-making, not a distortion of reality like a delusion. In a self-accusatory delusion the person accepts blame for an act that never was committed.

The parents of an overweight adolescent girl tell the nurse that they are concerned that their daughter feels inferior to her sister, who is an attractive, successful college senior. They ask the nurse what they can do about this problem. What should the nurse do? 1. Suggest that they appear to be creating a problem where none exists 2. Tell them to avoid talking about their older child's accomplishments 3. Encourage the parents to give the adolescent recognition for her strong points 4. Advise the parents to tell the adolescent to view her sister's success as a challenge

3. Encourage the parents to give the adolescent recognition for her strong points Encouraging the parents to give the adolescent recognition for her strong points will help the parents foster improved self-esteem in the younger daughter. A problem does exist; their child is overeating. The parents cannot avoid talking about the sibling, but they should avoid any comparisons. The child already is viewing the sister's success as a challenge, and it has diminished her self-esteem.

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

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

A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client? 1. Helping the client enter into group recreational activities 2. Convincing the client that the hospital staff is trying to help 3. Helping the client learn to trust the staff through selected experiences 4. Arranging the client's contact with others so it is limited while she is in the hospital

3. Helping the client learn to trust the staff through selected experiences Demonstrating that the staff can be trusted is a vital initial step in the therapy program. The client is not ready to enter group activities yet and will not be until trust is established. Even proof will not convince the client with a schizoid personality that feelings of distrust are false. Arranging the client's contact with others is not realistic even if it is possible; limiting contact with other clients will not enhance trust.

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

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

A nurse is caring for a client with a diagnosis of catatonic schizophrenia. What clinical finding does the nurse expect the client to exhibit? 1. Crying 2. Self-mutilation 3. Immobile posturing 4. Repetitive activities

3. Immobile posturing Clients with catatonic schizophrenia exhibit rigidity and posturing behaviors. Most clients with catatonic schizophrenia are unable to express feelings and would be unlikely to cry. Self-mutilation is associated with depression. Repetitive activities are associated with obsessive-compulsive disorders.

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

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

A nurse is caring for a client who is angry and agitated. What is the best approach for the nurse to use with this client? 1. Confronting the client about the behavior 2. Turning on the television to distract the client 3. Maintaining a calm, consistent approach with the client 4. Explaining to the client why the behavior is unacceptable

3. Maintaining a calm, consistent approach with the client Consistency ensures an approach that is known and less frightening than the unknown. A calming approach can decrease agitation. Confronting the client about the behavior may escalate the client's anger and agitation. Environmental stimulants should be decreased, not increased. An agitated client is not capable of comprehending logical explanations; the nurse must avoid criticisms and arguments with the client.

A health care provider prescribes divalproex (Depakote). What does the nurse consider an appropriate indication for the use of this drug? 1. Control of acute agitation of schizophrenia 2. Treatment of the agitated phase of a paranoid state 3. Management of manic episodes of bipolar disorder 4. Modification of the depressive phase of major depression

3. Management of manic episodes of bipolar disorder Although divalproex (Depakote) is an antiepileptic, it is used to control the manic phase of a bipolar disorder. Divalproex is not the drug of choice for schizophrenia; nor is it used for agitated paranoid states. Divalproex is not used for major depression, except with a history of at least one manic episode or a family history of manic disorders.

Which qualities are traits of an addictive personality? Select all that apply. 1. Confusion 2. Illogical thinking 3. Negative self-image 4. Feelings of insecurity 5. Low tolerance for stress

3. Negative self-image 4. Feelings of insecurity 5. Low tolerance for stress Negative self-image, feelings of insecurity, and low tolerance for stress are traits of the addictive personality. Confusion and illogical thinking are alcohol withdrawal symptoms.

Which tool is used to standardize and measure nursing treatments? 1. Nursing Outcomes Classification (NOC) 2. NANDA-I Approved Nursing Diagnoses 3. Nursing Interventions Classification (NIC) 4. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

3. Nursing Interventions Classification (NIC) Nursing Interventions Classification (NIC) is a tool that helps to define nursing interventions, as well as helps to standardize and measure the nursing care provided. Nursing Outcomes Classification (NOC) helps measure the outcome of the nursing interventions implemented to the patient. NANDA-I Approved Nursing Diagnoses are used to identify and describe the patient needs, serving as a basis for planning care. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is a guidebook for diagnostic and treatment codes for mental disorders.

A nurse understands that when a client is a member of a different ethnic community it is important to do what? 1. Ensure that the nurse's biases are understood by the family 2. Make plans to counteract the client's misconceptions about therapies 3. Offer a therapeutic regimen compatible with the lifestyle of the family 4. Recognize that the client's responses will be similar to other clients' responses

3. Offer a therapeutic regimen compatible with the lifestyle of the family The client cannot be expected to accept or even respond to a plan that is incompatible with the family's lifestyle. The family should not have to adjust to the nurse's biases; the nurse must self-identify biases and ensure that they do not interfere with nursing care. There is no evidence that misconceptions will occur. All individuals respond differently to situations.

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

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

Which therapy is long-term and intense and enables a client to bring unconscious thoughts to the surface? 1. Hypnosis 2. Play therapy 3. Psychoanalysis 4. Cognitive therapy

3. Psychoanalysis Psychoanalysis is an intense long-term form of therapy that enables a client to bring unconscious thoughts to the surface. Hypnosis helps a client recover deeply repressed emotions. Play therapy helps children express themselves with the use of toys such as puppets as their "spokespeople" for feelings. Cognitive therapy is focused on breaking negative thought patterns and developing positive feelings about memories or thoughts.

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

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

A client with schizophrenia is taking benztropine (Cogentin) in conjunction with an antipsychotic. The client tells a nurse, "Sometimes I forget to take the Cogentin." What should the nurse teach the client to do if this happens again? 1. Take 2 pills at the next regularly scheduled dose. 2. Notify the health care provider about the missed dose immediately. 3. Take a dose as soon as possible, up to 2 hours before the next dose. 4. Skip the dose, then take the next regularly scheduled dose 2 hours early.

3. Take a dose as soon as possible, up to 2 hours before the next dose. Taking a dose as soon as possible is the advised intervention when a dose is missed; interruption of the medication may precipitate signs of withdrawal such as anxiety and tachycardia. Taking 2 pills at the next regularly scheduled dose will provide an excessive amount of the medication at one time. Notifying the health care provider about the missed dose immediately is unnecessary. Skipping a dose is not advised if the next regularly scheduled dose is due within 2 hours.

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine or trihexyphenidyl in conjunction with the phenothiazine-derivative neuroleptic medications? 1. They reduce postural hypotension. 2. They potentiate the effects of the neuroleptic drug. 3. They combat the extrapyramidal side effects of the neuroleptic drug. 4. They ameliorate the depression that may accompany schizophrenia.

3. They combat the extrapyramidal side effects of the neuroleptic drug. Benztropine and trihexyphenidyl control the extrapyramidal (parkinsonian) manifestations associated with the neuroleptics and are classified as antiparkinsonian drugs. These drugs do not reduce postural hypotension, nor do they potentiate phenothiazine derivatives or have an effect on depression.

A male client with the diagnosis of antisocial personality disorder takes a female nurse by the shoulders, kisses her, and shouts, "I like you." What is the most appropriate response by the nurse? 1. "Thank you. I like you, too." 2. "I wish you wouldn't do that." 3. "Don't ever touch me like that again. I don't like it" 4. "Your behavior is inappropriate. Don't do that again."

4. "Your behavior is inappropriate. Don't do that again." Telling the client that his behavior is inappropriate and instructing him not to do it again accepts the client while rejecting and setting limits on the behavior the client is using. Thanking the client and telling him that she likes him, too, encourages this type of behavior instead of setting limits. Saying that she wishes the client wouldn't do that or telling the client not to touch her like that again and that she doesn't like it makes it appear that it is the nurse's preference, not the client's behavior, that is the issue.

A nurse tells the family member of an alcoholic client, "This condition occurs in individuals who have developed physiologic dependence on alcohol and then quit drinking abruptly." To which condition is the nurse referring? 1. Korsakoff psychosis 2. Fetal alcohol syndrome 3. Wernicke encephalopathy 4. Alcohol withdrawal syndrome

4. Alcohol withdrawal syndrome Alcohol withdrawal syndrome occurs in individuals who have developed a physiologic dependence on alcohol and then quit drinking abruptly. Korsakoff psychosis and Wernicke encephalopathy are brain disorders; they may occur in clients with chronic alcoholism. Fetal alcohol syndrome is a congenital anomaly that results from maternal use of alcohol during pregnancy. These conditions are not associated with abrupt cessation of alcohol use.

A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped, and I don't want to be bothered." What is the best response by the nurse? 1. "You won't feel better unless you make the effort to get up and get dressed." 2. "I know you'll feel better again if you just make an attempt to help yourself." 3. "Everyone feels this way in the beginning as they confront their feelings. I'll sit with you." 4. "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started."

4. "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started." The statement "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started" acknowledges the client's feelings, offers hope, and helps the client to a higher level of function. The statement "You won't feel better unless you make the effort to get up and get dressed" ignores the client's feelings and may not be true. The statement "I know you'll feel better again if you just make an attempt to help yourself" denies the client's feelings, and feeling better cannot be guaranteed. The statement "Everyone feels this way in the beginning as they confront their feelings. I'll sit with you" minimizes the client's feelings; also the client is not interested in how others feel.

A client who has been attending a day treatment facility for 1 month with the diagnosis of major depression is to be discharged in a week. Because the nurse and the client are aware of this, what is the most appropriate comment by the nurse? 1. "We have just a few sessions left. I'm really pleased at your progress." 2. "Your discharge date has been set for next week. That's wonderful news." 3. "We have five sessions remaining. We need to start making plans to end our sessions." 4. "I understand that your discharge is set for next week. I'm wondering how you feel about that."

4. "I understand that your discharge is set for next week. I'm wondering how you feel about that." Plans for termination that take emotional needs into account are best made after exploration of the client's thoughts and feelings about discharge. Noting that there are just a few sessions left and expressing pleasure at the client's progress acknowledges the future termination but focuses on the nurse's, not the client's, feelings. Noting that the client's discharge date has been set for next week and calling this wonderful news acknowledges the future termination but suggests that the client should feel wonderful about the discharge, which may or may not be true. Although noting that the client and nurse have five sessions remaining and that the two need to start making plans to end the sessions acknowledges the future termination, plans for termination should be made after a discussion of the client's emotional response to the pending discharge.

A client who consented to electroconvulsive therapy (ECT) is being prepared for the second session. The client tells the nurse, "I've decided that I don't want this treatment." What is the best response by the nurse? 1. "It's too late to stop the treatment now." 2. "We'll discuss the advantages after the treatment." 3. "You need more than one treatment for it to be successful." 4. "I'll tell your psychiatrist that you don't want the treatment."

4. "I'll tell your psychiatrist that you don't want the treatment." A client has the right to revoke consent for treatment at any time; continuing treatment is a violation of the client's rights. "It's too late to stop the treatment now" is incorrect, and continuing with the treatment would be an act of battery. Teaching about the advantages and disadvantages of therapy should be conducted before, not after, the treatment; giving the client treatment without consent is an act of battery. A statement such as "You need more than one treatment for it to be successful" is considered coercion; continuation of treatment after the client's refusal would be an act of battery.

A client with generalized anxiety disorder says to the nurse, "What can I do to keep myself from overreacting to stress?" What is the best response by the nurse? 1. "Work on developing more positive relationships." 2."Improve your time-management skills." 3. "Ignore situations that you cannot change." 4. "Work on identifying and developing coping strategies."

4. "Work on identifying and developing coping strategies." Identifying and developing a wide variety of coping strategies increases the individual's ability to cope with stress; different defenses can be used in various situations. Developing positive relationships may help the patient, but this is not the most significant step the patient can take to address stressful situations. Improved time-management skills may or may not be helpful. People should not ignore situations that affect them.

A client who has been admitted to the hospital for an elective prostatectomy is extremely anxious and has hand tremors. The client's partner informs the nurse that the client has been drinking heavily for the past 5 years. While the client is unpacking his items from home, the nurse sees him hiding a bottle of whiskey in the rear of a drawer. How should the nurse respond initially to this behavior? 1. Try to catch the client drinking the alcohol 2. Confiscate the alcohol when the client is not looking 3. Wait for the client to bring up the subject of drinking 4. Ask the client how much alcohol he consumes in a week

4. Ask the client how much alcohol he consumes in a week Asking the client how much alcohol he consumes in a week will reveal the client's level of alcohol abuse through direct questioning and will open the way to a conversation about the importance of not drinking during his hospital stay. Trying to catch the client drinking the alcohol is a judgmental approach that involves manipulation and will decrease the client's self-esteem. Confiscating the alcohol when the client is not looking is not straightforward and will decrease trust. The client probably will not bring up the subject, because denial is often used to cope with alcohol abuse.

A 6-year-old child recently started school but has been refusing to go for the past 3 weeks. What does the nurse determine is an appropriate intervention for this child? 1. Explain that school is a place to have fun 2. Delay the return to school for several months 3. Enroll the child in a special education program 4. Develop a behavior modification program with the child

4. Develop a behavior modification program with the child A behavior modification program tailored for and developed with the individual child is the most appropriate approach at this time. School may or may not be a place to have fun. The child may not like school and may not think that it is fun, but having fun is not the purpose of school. Delaying the child's return to school for several months serves no purpose and may be viewed by the child as a reward for the behavior. There are no data to indicate that the child is in need of special education.

A nurse administers prescribed anxiolytics to clients with severe emotional disorders. What is the goal of this treatment? 1. Reduces antisocial symptoms 2. Limits secondary complications 3. Prevents destructiveness by the client 4. Makes the client more amenable to psychotherapy

4. Makes the client more amenable to psychotherapy Anxiolytics reduce the anxiety level and make clients more open to new strategies when coping with stress. Anxiolytics do not ease antisocial symptoms. They cannot prevent secondary complications. Preventing destructiveness by the client is not the major reason for their administration.

What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion? 1. Informing the client's family 2. Monitoring pharmacological interventions 3. Completing a denial-of-rights form and forwarding it to the administrative officer 4. Documenting both the client's behavior and the reason that specific rights were denied

4. Documenting both the client's behavior and the reason that specific rights were denied Seclusion and restraints are special procedures for dealing with aggressive acting-out behavior for the protection of the client and others; clear documentation is essential when the client's rights are restricted. Informing the client's family is not necessary because the use of seclusion or restraints is included in the general consent form that is signed on admission. Pharmacological intervention should be monitored for all clients. There is not a typical form; however, documentation is required to justify the need for seclusion or the use of restraints.

The nurse observes biting, rocking, sucking, and lags in intellectual development in a child. She also concludes the child is suffering from sleep disorders. What could be the reason for the child's condition? 1. Physical neglect 2. Sexual abuse 3. Physical abuse 4. Emotional abuse

4. Emotional abuse The child may be neglected if the parent is having a mental illness such as psychosis. Sleep disorders, feeding disorders, biting, rocking, sucking, and lags in intellectual development are behavioral findings associated with emotional abuse. Physical neglect, sexual abuse, and physical abuse manifest in different sets of signs and symptoms.

An adolescent client with an antisocial personality disorder has been admitted to the hospital because of drug abuse and repeated sexual acting-out behavior. Which client behavior supports the nurse's conclusion that actions directed toward modifying the behavior of this client have been successful? 1. Promises never to take drugs again 2. Discusses the need to seduce other adolescents 3. Recognizes the need to conform to society's norms 4. Identifies the feelings underlying the acting-out behavior

4. Identifies the feelings underlying the acting-out behavior Identifying the feelings underlying the acting-out behavior demonstrates the development of some insight and a willingness to begin looking at the underlying causes of behavior. A promise to never take drugs will probably have little meaning to the client. Discussing the need to seduce other adolescents reflects a continuation of the client's behavior before being hospitalized. Agreeing to conform to society's norms is not sufficient motivation for lasting change.

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

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

A nurse is assessing a middle-aged client whose children have left home in search of work. The client is trying to adjust to these family changes. Which family life-cycle stage is the client going through? 1. Family in later life 2. Family with adolescents 3. Unattached young adult 4. Launching children and moving on

4. Launching children and moving on The client is adjusting to a reduction in family size after the adult children have left home in search of work. The client is going through the launching children and moving on stage of the family life-cycle stage. An individual going through the family in later life stage deals with retirement and the loss of a spouse, siblings, or other peers. The family in the adolescents stage of the family lifecycle involves establishing flexible boundaries to accommodate the growing child's independence. An individual experiencing the unattached young adult stage begins to differentiate themselves from his or her family of origin. The young adult establishes him or herself at work while the young adult's parents experience the launching children and moving on stage.

Which drugs are considered neuroleptics? Select all that apply. 1. Asenapine 2. Lurasidone 3. Aripiprazole 4. Thioridazine 5. Chlorpromazine

4. Thioridazine 5. Chlorpromazine First-generation antipsychotic drugs are also known as neuroleptics. Thioridazine and chlorpromazine are neuroleptics. Asenapine, lurasidone, and aripiprazole are second-generation drugs, which are considered as atypical antipsychotic drugs.

On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery." Which side effect does the nurse suspect that the client is experiencing? 1. Akathisia 2. Torticollis 3. Tardive dyskinesia 4. Parkinsonian syndrome

Akathisia, a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation. Torticollis is characterized by a stiff neck (wry neck). Tardive dyskinesia is characterized by gross involuntary movements of the extremities, tongue, and facial muscles that develop after prolonged therapy. Pseudoparkinsonism is characterized by motor retardation, rigidity, and tremors; the reaction resembles Parkinson's syndrome but usually responds to decreasing the dose, the administration of an antidyskinetic medication, or discontinuation of the haloperidol.

Which class of drugs is frequently prescribed for a client with bipolar disorder to induce sedation? 1. Antipsychotics 2. Antidepressants 3. Benzodiazepines 4. Mood stabilizers

Benzodiazepines are frequently used to sedate clients with bipolar disorder (BPD). BPD is treated with three major classes of drugs which include mood stabilizers, antipsychotics, and antidepressants.

A depressed client has been receiving venlafaxine (Effexor) 25 mg three times a day by mouth. The health care provider increases the dose to 37.5 mg three times a day by mouth. The pharmacy supplies scored 25-mg tablets of Effexor. How many tablets should the nurse administer? Record your answer using one decimal place. _________ tablets

Solve the problem by using ratio and proportion. Desire 37.5 mg x tablets ------------------- = --------- Have 25 mg 1 tablet 25x = 37.5 x = 37.5 ÷ 25 x = 1.5 tablets.

A client is agitated and threatening staff and other clients with physical harm. The nurse prepares to administer the prescribed PRN haloperidol (Haldol) after other means to deescalate the behavior have failed. The prescription calls for the administration of 5 mg of haloperidol intramuscularly PRN for severely agitated/aggressive behavior. The haloperidol is available in a vial labeled "2 mg/mL." How many milliliters of solution should the nurse administer? Record your answer rounding to one decimal place. __________ mL

Use ratio and proportion to solve this problem. Desire 5 mg x mL ---------------- = ------- Have 2 mg 1 mL 2x = 5 x = 5 ÷ 2 x = 2.5 mL

A client comes to the mental health clinic for a monthly intramuscular 37.5 mg fluphenazine decanoate injection. Fluphenazine decanoate is available 25 mg/mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place. __________ mL

Use the "desired over have" formula of ratio and proportion. Desire 37.5 mg x mL ------------------- = ------ Have 25 mg 1 mL 25x = 37.5 x = 37.5 ÷ 25 x = 1.5 mL