Mental Health 3

An older adult client takes multiple medications daily. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What are these findings most characteristic of? a. delirium. b. dementia. c. amnestic syndrome. d. Alzheimer's disease.

A: Delirium Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The onset of dementia or Alzheimer's disease, a type of dementia, is more insidious. Amnestic syndrome involves memory impairment without other cognitive problems.

A client with fluctuating levels of awareness, confusion, and disturbed orientation shouts, "Bugs are crawling on my legs. Get them off!" Which problem is the client experiencing? a. Aphasia b. Dystonia c. Tactile hallucinations d. Mnemonic disturbance

C: Tactile hallucinations The client feels bugs crawling on both legs, even though no sensory stimulus is actually present. This description meets the definition of a hallucination, a false sensory perception. Tactile hallucinations may be part of the symptom constellation of delirium. Aphasia refers to a speech disorder. Dystonia refers to excessive muscle tonus. Mnemonic disturbance is associated with dementia rather than delirium

A depressed client says, "Nothing matters anymore." What is the most appropriate response by the nurse? a. "Are you having thoughts of suicide?" b. "I am not sure I understand what you are trying to say." c. "Try to stay hopeful. Things have a way of working out." d. "Tell me more about what interested you before you became depressed."

a. "Are you having thoughts of suicide?" The nurse must make overt what is covert; that is, the possibility of suicide must be openly addressed. The client often feels relieved to be able to talk about suicidal ideation. None of the other options assesses the client's thoughts regarding possible self-harm.

After one of their identical twin daughters commits suicide, the parents express concern that the other twin may also have suicidal tendencies. Which reply should the nurse provide? a. "Genetics are associated with suicide risk. Monitoring and support are important." b. "Apathy underlies suicide. Instilling motivation is the key to health maintenance." c. "Your child is unlikely to act out suicide when identifying with a suicide victim." d. "Fraternal twins are at higher risk for suicide than identical twins."

a. "Genetics are associated with suicide risk. Monitoring and support are important." Twin studies suggest the presence of genetic factors in suicide; however, separating genetic predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary interventions can be helpful in promoting and maintaining health and possibly counteracting genetic load. The incorrect options are untrue statements or an oversimplification.

During the initial interview at the crisis center, a client says, "I've been served with divorce papers. I'm so upset and anxious that I can't think clearly." Which comment should the nurse use to assess personal coping skills? a. "In the past, how have you handled difficult or stressful situations?" b. "What would you like us to do to help you feel more relaxed?" c. "Tell me more about how it feels to be anxious and upset." d. "Can you describe your role in the marital relationship?"

a. "In the past, how have you handled difficult or stressful situations?" The correct answer is the only option that assesses coping skills. The incorrect options are concerned with self-esteem, ask the client to decide on treatment at a time when he or she "cannot think clearly," and seek to explore issues tangential to the crisis.

A client says, "I get in trouble sometimes because I make quick decisions and act on them." What is the nurse's most therapeutic response? a. "Let's consider the advantages of being able to stop and think before acting." b. "It sounds as though you've developed some insight into your situation." c. "I bet you have some interesting stories to share about overreacting." d. "It's good that you're showing readiness for behavioral change."

a. "Let's consider the advantages of being able to stop and think before acting." The client is showing openness to learning techniques for impulse control. One technique is to teach the client to stop and think before acting impulsively. The client can then be taught to evaluate outcomes of possible actions and choose an effective action. The incorrect responses shift the encounter to a social level or are judgmental.

A nurse's neighbor says, "My sister has been diagnosed with bipolar disorder but will not take her medication. I have tried to help her for over 20 years, but it seems like everything I do fails. Do you have any suggestions?" What is the nurse's best response? a. "National Alliance on Mental Illness (NAMI) offers a family education series that you might find helpful." b. "Since your sister is noncompliant, perhaps it's time for her to be changed to injectable medication." c. "You have done all you can. Now it's time to put yourself first and move on with your life." d. "You cannot help her. Would it be better for you to discontinue your relationship?"

a. "National Alliance on Mental Illness (NAMI) offers a family education series that you might find helpful." NAMI offers a family education series that assists with the stress caregivers and other family members often experience. The nurse should not give advice about injectable medication or encourage the family member to give up on the client.

. A community health nurse visits a family with four children. The father behaves angrily, finds fault with the oldest child, and asks twice, "Why are you such a stupid kid?" The wife says, "I have difficulty disciplining the children. It's so frustrating." Which comments by the nurse will facilitate an interview with these parents? (Select all that apply.) a. "Tell me how you discipline your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." d. "Do you or your husband ever spank your children?" e. "Calling children 'stupid' injures their self-esteem."

a. "Tell me how you discipline your children." b. "How do you stop your baby from crying?" c. "Caring for four small children must be difficult." An interview with possible abusing individuals should be built on concern and carried out in a nonthreatening, nonjudgmental way. Empathetic remarks are helpful in creating rapport. Questions requiring a descriptive response are less threatening and elicit more relevant information than questions that can be answered by yes or no.

A client reports good results from taking an herb to manage migraine headache pain. The nurse confirms there are no hazardous interactions between the herb and the client's current prescription drugs. What is the nurse's best comment to the client? a. "Thanks for telling me. I'll make a note in your medical record that you take it." b. "You are experiencing a placebo effect. When we believe something will help, it usually does." c. "Self-management of health problems can be dangerous. You should have notified me sooner." d. "Research studies show that herbals actually increase migraine pain by inflaming nerve cells in the brain."

a. "Thanks for telling me. I'll make a note in your medical record that you take it." The nurse should reinforce the client for reporting use of the herb. Many clients keep secrets about use of alternative therapies. If it poses no danger, the nurse can document the use. The client may also get placebo effect from the herb, but it is not necessary for the nurse to point out that information. The distracters are judgmental and may discourage the client from openly sharing in the future.

Which statements most clearly indicate the speaker views mental illness with stigma? (Select all that apply.) a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." c. "Many mental illnesses are genetically transmitted. It's no one's fault that the illness occurs." d. "Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people." e. "People with mental illness are lazy. They get government disability checks instead of working."

a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." e. "People with mental illness are lazy. They get government disability checks instead of working." Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame. See related audience response question.

Family members ask the nurse, "What can we say when our loved one says, 'Death is coming soon?'" To promote communication, which response could the nurse suggest for family members? a. "We feel sad when we think about life without you." b. "We have not given up on getting you well." c. "We think you will be around for a long time yet." d. "Let's talk about the good memories we have."

a. "We feel sad when we think about life without you." The correct response is emotionally honest. It allows the family opportunities to express emotions, address issues in the relationship, and say farewell. The distracters are evasive.

A terminally ill client says, "I know I will never get well, but," and the patient's voice trails off. Select the most therapeutic response by the nurse. a. "What do you hope for?" b. "Do you have questions about what is happening?" c. "You are not going to get well. It is healthy that you accept that." d. "When you have questions, it is best to talk to the health care provider."

a. "What do you hope for?" This open-ended response is an example of following the patient's lead. It provides an opportunity for the client to speak about whatever is on his mind. The distracters are not therapeutic; they block further communication, refocus the conversation, give advice, or suggest the nurse is uncomfortable with the topic.

Which comment by the nurse would best support relationship building with a survivor of intimate partner abuse? a. "You are feeling violated because you thought you could trust your partner." b. "I'm here for you. I want you to tell me about the bad things that happened to you." c. "I was very worried about you. I knew you were living in a potentially violent situation." d. "Abusers often target people who are passive. I will refer you to an assertiveness class."

a. "You are feeling violated because you thought you could trust your partner." The correct option uses the therapeutic technique of reflection. It shows empathy, an important nursing attribute for establishing rapport and building a relationship. None of the other options would help the client feel accepted.

A nurse assesses five newly hospitalized clients. Which clients have the highest suicide risk? (Select all that apply.) a. 82-year-old white male b. 17-year-old white female c. 22-year-old Hispanic male d. 19-year-old Native American male e. 39-year-old African American male

a. 82-year-old white male b. 17-year-old white female d. 19-year-old Native American male Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for older adult males, adolescents, and young adults. Other high-risk groups include young African American males, Native American males, and older Asian Americans. Rates are not high for Hispanic males.

Which patients meet criteria for hospice services? (Select all that apply.) a. A 92-year-old diagnosed with acute pneumonia and late-stage Alzheimer's disease b. A 54-year-old diagnosed with glioblastoma and life expectancy of 8 to 10 weeks c. A 16-year-old with type 1 diabetes, multiple infections, and substance abuse d. A 74-year-old newly diagnosed with chronic obstructive pulmonary disease (COPD) and life expectancy of 2 years e. A 36-year-old diagnosed with multiple sclerosis complicated by major depressive disorder and pain associated with muscle spasms

a. A 92-year-old diagnosed with acute pneumonia and late-stage Alzheimer's disease b. A 54-year-old diagnosed with glioblastoma and life expectancy of 8 to 10 weeks Hospice services are available to patients with terminal illnesses and a life expectancy of less than 6 months. The client must choose hospice care, rather than curative treatments. Although patients with other health problems may experience complications, treatments focusing on cure would exclude them from hospice services.

For which client would it be most important for the nurse to urge immediate discontinuation of kava? a. A client with a comorbid diagnosis of cirrhosis. b. A client with a comorbid diagnosis of osteoarthritis. c. A client with a comorbid diagnosis of multiple sclerosis. d. A client with a comorbid diagnosis of chronic back pain.

a. A client with a comorbid diagnosis of cirrhosis. Kava should be used with caution in clients with liver disease because of its potentially hepatotoxic effects. The other health problems do not pose immediate dangers.

An elderly adult presents with symptoms of delirium. The family reports, "Everything was fine until yesterday." What is the most important assessment information for the nurse to gather? a. A list of all medications the person currently takes b. Whether the person has experienced any recent losses c. Whether the person has ingested aged or fermented foods d. The person's recent personality characteristics and changes

a. A list of all medications the person currently takes Delirium is often the result of medication interactions or toxicity. The distracters relate to MAOI (monoamine oxidase inhibitor) therapy and depression.

A client diagnosed with major depressive disorder tells the nurse, "I want to try supplementing my selective serotonin reuptake inhibitor (SSRI) with St. John's wort." Which action should the nurse take first? a. Advise the client of the danger of serotonin syndrome. b. Suggest that aromatherapy may produce better results. c. Assess the client for depression and risk for suicide. d. Suggest the client decrease the antidepressant dose.

a. Advise the client of the danger of serotonin syndrome. Research has suggested that St. John's wort is a mild inhibitor of serotonin reuptake and could lead to serotonin syndrome; this risk is increased if the client is taking other medications that increase serotonin activity. Assessing the depression would be a secondary intervention. Aromatherapy has not been shown to be an effective adjunct or treatment for depression. Although a dosage reduction in her SSRI medication might reduce the risk of serotonin syndrome, this intervention is not in the nurse's scope of practice.

A client with a new diagnosis of cancer says, "My father died of pancreatic cancer. I took care of him during his illness, so I know what is ahead for me." Which nursing diagnosis applies? a. Anticipatory grieving b. Ineffective coping c. Ineffective denial d. Spiritual distress

a. Anticipatory grieving The patient's experience demonstrates anticipatory grieving. The other diagnoses may apply but are not supported by the comment.

An older adult client in the intensive care unit is experiencing visual illusions. Which intervention will be most helpful? a. Apply the client's glasses. b. Place personally meaningful objects in view. c. Position large clocks and calendars on the wall. d. Assure that the room is brightly lit but very quiet at all times.

a. Apply the client's glasses. Illusions are sensory misperceptions. Glasses and hearing aids help clarify sensory perceptions. Without glasses, clocks, calendars, and personal objects are meaningless. Round-the-clock lighting promotes sensory overload and sensory perceptual alterations.

Which statement provides the best rationale for closely monitoring a severely depressed client during antidepressant medication therapy? a. As depression lifts, physical energy becomes available to carry out suicide. b. Clients who previously had suicidal thoughts need to discuss their feelings. c. For most clients, antidepressant medication results in increased suicidal thinking. d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.

a. As depression lifts, physical energy becomes available to carry out suicide. Antidepressant medication has the objective of relieving depression. Risk for suicide is greater as the depression lifts, primarily because the client has more physical energy at a time when he or she may still have suicidal ideation. The other options have little to do with nursing interventions relating to antidepressant medication therapy.

A client has progressive memory deficits associated with dementia. Which nursing intervention would best help the individual function in the environment? a. Assist the client to perform simple tasks by giving step-by-step directions. b. Reduce frustration by performing activities of daily living for the client. c. Stimulate intellectual function by discussing new topics with the client. d. Read one story from the newspaper to the client every day.

a. Assist the client to perform simple tasks by giving step-by-step directions. Clients with cognitive impairment should perform all tasks of which they are capable. When simple directions are given in a systematic fashion, the client is better able to process information and perform simple tasks. Stimulating intellectual functioning by discussing new topics is likely to prove frustrating for the client. Clients with cognitive deficits may enjoy the attention of someone reading to them, but this activity does not promote their function in the environment.

The parents of a 15-year-old seek to have this teen declared a delinquent because of excessive drinking, habitually running away, and prostitution. The nurse interviewing the client should recognize these behaviors often occur in adolescents who are having or had what experience? a. Been abused. b. Attention seeking. c. An eating disorders. d. Are developmentally delayed.

a. Been abused. Self-mutilation, alcohol and drug abuse, bulimia, and unstable and unsatisfactory relationships are frequently seen in teens who are abused. These behaviors are not as closely aligned with any of the other options.

Which important points should the nurse teach a client about using herbal preparations? (Select all that apply.) a. Check active and inactive ingredients. b. Discontinue use if side or adverse effects occur. c. Avoid herbals during pregnancy and breast-feeding. d. Buying from online sources is preferable and cheaper. e. Inform your health care provider about the use of herbals.

a. Check active and inactive ingredients. b. Discontinue use if side or adverse effects occur. c. Avoid herbals during pregnancy and breast-feeding. e. Inform your health care provider about the use of herbals.

An 11-year-old says, "My parents don't like me. They call me stupid and say they wish I were never born. It doesn't matter what they think because I already know I'm dumb." Which nursing diagnosis applies to this child? a. Chronic low self-esteem related to negative feedback from parents b. Deficient knowledge related to interpersonal skills with parents c. Disturbed personal identity related to negative self-evaluation d. Complicated grieving related to poor academic performance

a. Chronic low self-esteem related to negative feedback from parents The child has indicated a belief in being too dumb to learn. The child receives negative and demeaning feedback from the parents. The child has internalized these messages, resulting in a low self-esteem. Deficient knowledge refers to knowledge of health care measures. Disturbed personal identity refers to an alteration in the ability to distinguish between self and non-self. Grieving may apply, but a specific loss is not evident in the scenario. Low self-esteem is more relevant to the child's statements.

A client diagnosed with serious mental illness (SMI) was living successfully in a group home but wanted an apartment. The prospective landlord said, "People like you have trouble getting along and paying their rent." The client and nurse meet for a problem-solving session. Which options should the nurse endorse? (Select all that apply.) a. Coach the client in ways to control symptoms effectively. b. Seek out landlords less affected by the stigma associated with mental illness. c. Threaten the landlord with legal action because of the discriminatory actions. d. Encourage the client to remain in the group home until the illness is less obvious. e. Suggest that the client list a false current address in the rental application. f. Have the case manager meet with the landlord to provide education about mental illness.

a. Coach the client in ways to control symptoms effectively. b. Seek out landlords less affected by the stigma associated with mental illness. f. Have the case manager meet with the landlord to provide education about mental illness. Managing symptoms so that they are less obvious or socially disruptive can reduce negative reactions and reduce rejection due to stigma. Seeking a more receptive landlord might be the most expeditious route to housing for this client. Educating the landlord to reduce stigma might make him more receptive and give the case manager an opportunity to address some of his concerns (e.g., the case manager could arrange a payee to assure that the rent is paid each month). However, threatening a lawsuit would increase the landlord's defensiveness and would likely be a long and expensive undertaking. Delaying the client's efforts to become more independent is not clinically necessary according to the data noted here; the problem is the landlord's bias and response, not the client's illness. It would be unethical to encourage falsification and poor role modeling to do so; further, if falsification is discovered, it could permit the landlord to refuse or cancel her lease. See related audience response question.

A nurse driving home after work comes upon a serious automobile accident. The driver gets out of the car with no apparent physical injuries. Which assessment findings would the nurse expect from the driver immediately after this event? (Select all that apply.) a. Difficulty using a cell phone b. Long-term memory losses c. Fecal incontinence d. Rapid speech e. Trembling

a. Difficulty using a cell phone d. Rapid speech e. Trembling Immediate responses to crisis commonly include shock, numbness, denial, confusion, disorganization, difficulty with decision making, and physical symptoms such as nausea, vomiting, tremors, profuse sweating, and dizziness associated with anxiety. Incontinence and long-term memory losses would not be expected.

An older adult is prescribed digoxin and hydrochlorothiazide daily as well as lorazepam as needed for anxiety. Over 2 days, the client developed confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation. What is the most likely reason for the client's change in mental status? a. Drug actions and interactions b. Benzodiazepine withdrawal c. Hypotensive episodes d. Renal failure

a. Drug actions and interactions Drug actions and interactions are common among elderly persons and predispose this population to delirium. Delirium is characterized by an abrupt onset of fluctuating levels of awareness, clouded consciousness, perceptual disturbances, and disturbed memory and orientation. The client takes lorazepam on a prn basis, so withdrawal is unlikely. Hypotensive episodes or problems with renal function may occur associated with the client's drug regime, but interactions are more likely the problem.

A consumer at a rehabilitative psychosocial program says to the nurse, "People are not cleaning up behind themselves in the bathrooms. The building is dirty and cluttered." How should the nurse respond? a. Encourage the consumer to discuss it at a meeting with everyone. b. Hire a professional cleaning service to clean the restrooms. c. Address the complaint at the next staff meeting. d. Tell the consumer, "That's not my problem."

a. Encourage the consumer to discuss it at a meeting with everyone. Consumer-run programs range from informal "clubhouses," which offer socialization and recreation, to competitive businesses, such as snack bars or janitorial services, which provide needed services and consumer employment while encouraging independence and building vocational skills. Consumers engage in problem solving under the leadership of staff. See related audience response question.

A nurse plans health education for a client who will be receiving warfarin for several weeks after knee-replacement surgery. Which substance should the nurse caution the client to avoid? a. Fish oil b. Black cohosh c. Lavender d. Mandarin

a. Fish oil Fish oil may increase bleeding time and therefore has a potentially hazardous interaction with the anticoagulant warfarin. Black cohosh is an herbal treatment for hot flashes. Mandarin and lavender may have calming effects, which may be helpful, but would not cause increased risk of bleeding.

Which actions by a nurse are most appropriate when caring for a hospice patient? (Select all that apply.) a. Giving choices b. Fostering personal control c. Explaining curative options d. Supporting the patient's spirituality e. Offering interventions that convey respect f. Providing answers to the patient's questions about spirituality

a. Giving choices b. Fostering personal control d. Supporting the patient's spirituality e. Offering interventions that convey respect The correct answers support the rights and choices of the dying individual. Acting on false information robs a client of the opportunity for honest dialogue and places barriers to achieving end-of-life developmental opportunities. The nurse supports the patient's spirituality but does not have the answers to all questions.

A client tells the nurse, "My husband lost his job. He's abusive only when he drinks too much. His family was like that when he was growing up. He always apologizes and regrets hurting me." What risk factor was most predictive for the husband to become abusive? a. History of family violence b. Loss of employment c. Abuse of alcohol d. Poverty

a. History of family violence An abuse-prone individual is an individual who has experienced family violence and was often abused as a child. This phenomenon is part of the cycle of violence. The other options may be present but are not as predictive.

Which assessment findings would the nurse expect in a client experiencing delirium? (Select all that apply.) a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention d. Apathy e. Agnosia

a. Impaired level of consciousness b. Disorientation to place, time c. Wandering attention Disorientation to place and time is an expected finding. Orientation to person (self) usually remains intact. Attention span is short, and difficulty focusing or shifting attention as directed is often noted. Clients with delirium commonly experience illusions and hallucinations. Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is associated with depression

Emergency response workers arrive in a community after a large-scale natural disaster. What is the workers' first action? a. Report to the incident command system (ICS) center. b. Determine whether the community is safe. c. Establish teams of workers with varied skills. d. Evaluate actions completed by local law enforcement.

a. Report to the incident command system (ICS) center. An ICS provides a common organizational structure facilitating an immediate response. It establishes a clear chain of command that supports the coordination of personnel and equipment at an event site. The incorrect responses describe actions that may or may not be taken by the ICS.

A client who recently emigrated from India is hospitalized. The client and family use ayurvedic medicine. The nurse wants to adjust this client's care so that it is more comfortable and familiar. What changes from usual Western practice should be considered? (Select all that apply.) a. In preparation for discharge, include a significant focus on preventive practices. b. Spend time exploring the client's life overall, focusing on broader issues than health. c. Involve the client's entire family and treatment team in decisions about treatment options. d. Anticipate that the client will prefer and value interventions with high technology features. e. Provide relevant health-related information and then encourage the client to determine which course of action to pursue.

a. In preparation for discharge, include a significant focus on preventive practices. b. Spend time exploring the client's life overall, focusing on broader issues than health. e. Provide relevant health-related information and then encourage the client to determine which course of action to pursue. Ayurvedic medicine, an ancient practice that originated in India, stresses individual responsibility for health, is holistic, promotes prevention, recognizes the uniqueness of the individual, and offers natural methods of treatment. Ayurvedic medicine does not require spiritual cleansing or the involvement of family and the treatment team in all decisions.

A client diagnosed with a serious mental illness (SMI) lives independently and attends a psychosocial rehabilitation program. The client presents at the emergency department seeking hospitalization. The client has no acute symptoms but says, "I have no money to pay my rent or refill my prescription." What is the nurse's best action? a. Involve the client's case manager to provide crisis intervention. b. Send the client to a homeless shelter until housing can be arranged. c. Arrange for a short in-client admission and begin discharge planning. d. Explain that one must have active psychiatric symptoms to be admitted.

a. Involve the client's case manager to provide crisis intervention. Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This client has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is the client homeless (although she may fear she is). Telling the client that she is not symptomatic enough to be admitted may prompt malingering.

A nurse assists a victim of intimate partner abuse to create a plan for escape if it becomes necessary. Which components should the plan include? (Select all that apply.) a. Keep a cell phone fully charged. b. Hide money with which to buy new clothes. c. Have the phone number for the nearest shelter. d. Take enough toys to amuse the children for 2 days. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave

a. Keep a cell phone fully charged. c. Have the phone number for the nearest shelter. e. Secure a supply of current medications for self and children. f. Assemble birth certificates, Social Security cards, and licenses. g. Determine a code word to signal children when it is time to leave The victim must prepare for a quick exit and so should assemble necessary items. Keeping a cell phone fully charged will help with access to support persons or agencies. Taking a large supply of toys would be cumbersome and might compromise the plan. People are advised to take one favorite small toy or security object for each child, but most shelters have toys to further engage the children. Accumulating enough money to purchase clothing may be difficult.

An older adult with moderately severe dementia forgets where the bathroom is and has episodes of incontinence. Which intervention should the nurse suggest to the client's family? a. Label the bathroom door clearly. b. Take the older adult to the bathroom hourly. c. Place the older adult in disposable adult briefs. d. Limit the intake of oral fluids to 1000 mL/day.

a. Label the bathroom door clearly. The client with moderately severe dementia has memory loss that begins to interfere with activities. This client may be able to use environmental cues such as labels on doors to compensate for memory loss. Regular toileting may be helpful, but a 2-hour schedule is often more reasonable. Placing the client in disposable briefs is more appropriate at a later stage. Severely limiting oral fluid intake would predispose the client to a urinary tract infection.

Which nursing interventions will be implemented for a client who is actively suicidal? (Select all that apply.) a. Maintain arm's length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. d. Remove the client's eyeglasses to prevent self-injury. e. Interact with the client every 15 minutes.

a. Maintain arm's length, one-on-one direct observation at all times. b. Check all items brought by visitors and remove risk items. c. Use plastic eating utensils; count utensils upon collection. One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the client to eat without silverware; "no silver or glassware" orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some clients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the client from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

An adult client tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Where should the nurse refer the client? (Select all that apply.) a. Psychoeducational classes b. Vocational rehabilitation c. Social skills training d. A homeless shelter e. Crisis intervention

a. Psychoeducational classes b. Vocational rehabilitation c. Social skills training The client does not understand the illness and need for adherence to the medication regimen. Psychoeducation for the client (and family) can address this lack of knowledge. The client, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many clients with SMI have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking the skill down into smaller verbal and nonverbal components. Work gives meaning and purpose to life, so vocational rehabilitation can assist with this aspect of care. The nurse case manager will function in the role of crisis stabilizer, so no related referral is needed. The client presently has a home and does not require a homeless shelter.

The nurse manager of a mental health center wants to improve medication adherence among the seriously mentally ill persons treated there. Which interventions are likely to help achieve this goal? (Select all that apply.) a. Maintain stable and consistent staff. b. Increase the length of medication education groups. c. Stress that without treatment, illnesses will worsen. d. Prescribe drugs in smaller but more frequent dosages. e. Make it easier to access prescribers and pay for drugs. f. Require adherence in order to participate in programming.

a. Maintain stable and consistent staff e. Make it easier to access prescribers and pay for drugs. Trust in one's providers is a key factor in treatment adherence, and mentally ill persons can sometimes take a very long time to develop such trust; therefore, interventions which stabilize staffing allow clients to have more time with staff to develop these bonds. Ready access to prescribers allows medicine-related concerns to be addressed quickly, reducing obstacles to adherence such as side effects or ineffective dosages. Medication costs can be obstacles to adherence as well. Many SMI clients have anosognosia and do not adhere to treatment because they believe they are not ill, so telling them nonadherence will worsen an illness they do not believe they have is unlikely to be helpful. Increasing medication education is helpful only when the cause of nonadherence is a knowledge deficit. Other issues that reduce adherence, particularly anosognosia and side effects, are seldom helped by longer medication education. Requiring medication adherence to participate in other programs is coercive and unethical. Smaller, more frequent doses do not reduce side effects and make the regimen more difficult for the client to remember

A client reports frequent sleep disturbances. Which interventions could be considered to help improve the client's sleep pattern? (Select all that apply.) a. Melatonin b. Chamomile c. Vitamin C d. Valerian e. SAM-e

a. Melatonin b. Chamomile d. Valerian Melatonin, chamomile, and valerian have relaxant effects that help sleep. SAM-e may help with mild depression. Vitamin C has no effect on sleep.

For which clients diagnosed with personality disorders would a family history of similar problems be most likely? (Select all that apply.) a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal e. Narcissistic

a. Obsessive-compulsive b. Antisocial c. Borderline d. Schizotypal Some personality disorders have evidence of genetic links, so the family history would show other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline, and obsessive-compulsive personality disorder.

A 10-year-old cares for siblings while the parents work because the family cannot afford a babysitter. This child says, "My father doesn't like me. He calls me stupid all the time." The mother says the father is easily frustrated and has trouble disciplining the children. The community health nurse should consider which resources as priorities to stabilize the home situation? (Select all that apply.) a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support d. A safety plan for the wife and children e. Placing the children in foster care

a. Parental sessions to teach childrearing practices b. Anger management counseling for the father c. Continuing home visits to give support Anger management counseling for the father is appropriate. Support for this family will be an important component of treatment. By the wife's admission, the family has deficient knowledge of parenting practices. Whenever possible, the goal of intervention should be to keep the family together; thus, removing the children from the home should be considered a last resort. Physical abuse is not suspected, so a safety plan would not be a priority at this time.

A client diagnosed with delirium is experiencing perceptual alterations. Which environmental adjustment should the nurse make for this client? a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. b. Maintain soft lighting day and night. Keep a radio on low volume continuously. c. Light the room brightly day and night. Awaken the client hourly to assess mental status. d. Keep the client by the nurse's desk while awake. Provide rest periods in a room with a television on.

a. Provide a well-lit room without glare or shadows. Limit noise and stimulation. A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a client with cognitive impairment associated with delirium. The other options have the potential to produce increased perceptual alterations.

A client diagnosed with moderate stage Alzheimer's disease has a self-care deficit of dressing and grooming. Designate appropriate interventions to include in the client's plan of care. (Select all that apply.) a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the client's name and name of the item. c. Administer antianxiety medication before bathing and dressing. d. Provide necessary items and direct the client to proceed independently. e. If the client resists dressing, use distraction and try again after a short interval.

a. Provide clothing with elastic and hook-and-loop closures. b. Label clothing with the client's name and name of the item. e. If the client resists dressing, use distraction and try again after a short interval. Providing clothing with elastic and hook-and-loop closures facilitates client independence. Labeling clothing with the client's name and the name of the item maintains client identity and dignity (provides information if the client has agnosia). When a client resists, it is appropriate to use distraction and try again after a short interval because client's moods are often labile. The client may be willing to cooperate given a later opportunity. Providing the necessary items for grooming and directing the client to proceed independently are inappropriate. Be prepared to coach by giving step-by-step directions for each task as it occurs. Administering anxiolytic medication before bathing and dressing is inappropriate. This measure would result in unnecessary overmedication.

Which intervention is appropriate for an individual diagnosed with an antisocial personality disorder who frequently manipulates others? a. Refer requests and questions related to care to the case manager. b. Encourage the client to discuss feelings of fear and inferiority. c. Provide negative reinforcement for acting-out behavior. d. Ignore, rather than confront, inappropriate behavior.

a. Refer requests and questions related to care to the case manager Manipulative people frequently make requests of many different staff, hoping one will give in. Having one decision maker provides consistency and avoids the potential for playing one staff member against another. Positive reinforcement of appropriate behaviors is more effective than negative reinforcement. The behavior should not be ignored; judicious use of confrontation is necessary. Clients with antisocial personality disorders rarely have feelings of fear and inferiority.

An adult has cared for a debilitated parent for 10 years. The health care provider recently recommended transfer of the parent to a skilled nursing facility. The adult says, "I've always been able to care for my parents. Nursing home placement goes against everything I believe." Successful resolution of this adult's crisis will most closely relate to what issue? a. Resolving the feelings associated with the threat to the person's self-concept. b. The ability of the person to identify situational supports in the community. c. The reliance on assistance from role models within the person's culture. d. Mobilization of automatic relief behaviors by the person.

a. Resolving the feelings associated with the threat to the person's self-concept The adult's crisis clearly relates to a loss of (or threatened change in) self-concept. Her capacity to care for her parents, regardless of the parent's condition, has been challenged. Crisis resolution will involve coming to terms with the feelings associated with this loss. Identifying situational supports is relevant, but less so than coming to terms with the threat to self-concept. Reliance on lessons from role models can be helpful but not the primary factor associated with resolution in this case. Automatic relief behaviors include withdrawal or flight and will not be helpful. Automatic relief behaviors are part of the third phase of crisis.

What is the priority intervention for a nurse beginning to work with a client diagnosed with a schizotypal personality disorder? a. Respect the client's need for periods of social isolation. b. Prevent the client from violating the nurse's rights. c. Teach the client how to select clothing for outings. d. Engage the client in community activities.

a. Respect the client's need for periods of social isolation Clients with schizotypal personality disorder are eccentric and often display perceptual and cognitive distortions. They are suspicious of others and have considerable difficulty trusting. They become highly anxious and frightened in social situations, thus the need to respect their desire for social isolation. Teaching the client to match clothing is not the priority intervention. Clients with schizotypal personality disorder rarely engage in behaviors that violate the nurse's rights or exploit the nurse

What is the priority nursing diagnosis for a client with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations? a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment b. Bathing/hygiene self-care deficit related to cerebral dysfunction, as evidenced by confusion and inability to perform personal hygiene tasks c. Disturbed thought processes related to medication intoxication, as evidenced by confusion, disorientation, and hallucinations d. Fear related to sensory perceptual alterations as evidenced by visual and tactile hallucinations

a. Risk for injury related to altered cerebral function, fluctuating levels of consciousness, disturbed orientation, and misperception of the environment The physical safety of the client is of highest priority among the diagnoses given. Many opportunities for injury exist when a client misperceives the environment as distorted, threatening, or harmful or when the client exercises poor judgment or when the client's sensorium is clouded. The other diagnoses may be concerns but are lower priorities.

After treatment for a detached retina, a survivor of intimate partner abuse says, "My partner only abuses me when I make mistakes. I've considered leaving, but I was brought up to believe you stay together, no matter what happens." Which diagnosis should be the focus of the nurse's initial actions? a. Risk for injury related to physical abuse from partner b. Social isolation related to lack of a community support system c. Ineffective coping related to uneven distribution of power within a relationship d. Deficient knowledge related to resources for escape from an abusive relationship

a. Risk for injury related to physical abuse from partner Risk for injury is the priority diagnosis because the partner has already inflicted physical injury during violent episodes. The other diagnoses are applicable, but the nurse must first address the client's safety.

An older adult with Lewy body dementia lives with family. After observing multiple bruises, the home health nurse talked with the daughter, who became defensive and said, "My mother often wanders at night. Last night she fell down the stairs." Which nursing diagnosis has priority? a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision b. Wandering related to confusion and disorientation as evidenced by sleepwalking and falls c. Chronic confusion related to degenerative changes in brain tissue as evidenced by nighttime wandering d. Insomnia related to sleep disruptions associated with cognitive impairment as evidenced by wandering at night

a. Risk for injury related to poor judgment, cognitive impairments, and inadequate supervision The client is at high risk for injury because of her confusion. The risk increases when caregivers are unable to give constant supervision. Insomnia, chronic confusion, and wandering apply to this client; however, the risk for injury is a higher priority.

What is the priority nursing diagnosis for a client diagnosed with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects? a. Risk for other-directed violence b. Risk for self-directed violence c. Impaired social interaction d. Ineffective denial

a. Risk for other-directed violence Violence against property, along with threats to harm staff, makes this diagnosis the priority. Clients with antisocial personality disorders have impaired social interactions, but the risk for harming others is a higher priority. They direct violence toward others; not self. When clients with antisocial personality disorders use denial, they use it effectively.

A wife received news that her husband died of heart failure and called her family to come to the hospital. She angrily tells the nurse who cared for him, "He would still be alive if you had given him your undivided attention." What is the nurse's most therapeutic action? a. Say, "I understand you are feeling upset. I will stay with you until your family comes." b. Say, "Your husband's heart was so severely damaged that it could no longer pump." c. Say, "I will call my supervisor to discuss this matter with you." d. Hold the spouse's hand in silence until the family arrives.

a. Say, "I understand you are feeling upset. I will stay with you until your family comes." When bereaved family behaves in a disturbed manner, the nurse should show patience and tact while offering sympathy and warmth. The distracters are defensive, evasive, or placating. Touch (holding hands) is culturally defined; it may or may not be appropriate in this situation.

A client diagnosed with borderline personality disorder was hospitalized several times after multiple episodes of head banging and carving on both wrists. The client remains impulsive. Which nursing diagnosis is the initial focus of this client's care? a. Self-mutilation b. Impaired skin integrity c. Risk for injury d. Powerlessness

a. Self-mutilation The scenario describes self-mutilation. Self-mutilation is a nursing diagnosis relating to client safety needs and is therefore of high priority. Impaired skin integrity and powerlessness may be appropriate foci for care but are not the priority related to this therapy. Risk for injury implies accidental injury, which is not the case for the client with borderline personality disorder.

A college student is extremely upset after failing two examinations. The student said, "No one understands how this will hurt my chances of getting into medical school." The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? (Select all that apply.) a. Shame b. Panic attack c. Humiliation d. Self-imposed isolation e. Recent stressful life event

a. Shame c. Humiliation d. Self-imposed isolation e. Recent stressful life event Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, "No one can understand," can be seen as recent lack of social support. Terminating access to one's social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

t has been 5 days since a suicidal client was hospitalized and prescribed an antidepressant medication. The client is now more talkative and shows increased energy. What is the highest priority nursing intervention? a. Supervise the client 24 hours a day. b. Begin discharge planning for the client. c. Refer the client to art and music therapists. d. Consider discontinuation of suicide precautions

a. Supervise the client 24 hours a day The client now has more energy and may have decided on suicide, especially given the prior suicide attempt history. The client must be supervised 24 hours per day. The client is still a suicide risk. The other options do not address the client's safety.

An adult has a history of physical violence against family when frustrated, followed by periods of remorse after each outburst. Which finding indicates a successful plan of care? a. The adult expresses frustration verbally instead of physically. b. The adult explains the rationale for behaviors to the victim. c. The adult identifies three personal strengths. d. The adult agrees to seek counseling.

a. The adult expresses frustration verbally instead of physically. The client will have developed a healthier way of coping with frustration if it is expressed verbally instead of physically. The incorrect options do not confirm achievement of outcomes.

What principle is most useful to a nurse planning crisis intervention for any client? a. The client is experiencing a state of disequilibrium. b. The client is experiencing a type of mental illness. c. The client poses a threat of violence to others. d. The client has high potential for self-injury.

a. The client is experiencing a state of disequilibrium. Disequilibrium is the only answer universally true for all clients in crisis. A crisis represents a struggle for equilibrium when problems seem unsolvable. Crisis does not reflect mental illness. Potential for self-violence or other-directed violence may or may not be a factor in crisis.

A client in good health and without any major health needs says, "I want to try some techniques to improve my mental and physical well-being, but I'm overwhelmed by all the suggestions on the Internet." Which techniques would be appropriate for the nurse to suggest? (Select all that apply.) a. Yoga b. Exercise c. Meditation d. Aromatherapy e. Acupuncture f. Spinal manipulation

a. Yoga b. Exercise c. Meditation d. Aromatherapy Yoga, exercise, meditation, and aromatherapy are self-help techniques that may have a positive effect on the client's physical and mental well-being. These techniques are unlikely to cause harm. The client is in good health; therefore, acupuncture and spinal manipulation are not indicated.

A client asks, "What is the major difference between conventional health care and complementary and alternative medicine (CAM)?" The nurse's best reply is that conventional health care a. focuses on what is done to the client, whereas CAM focuses on body-mind interaction with an actively involved client. b. has been tested by research so less regulation is needed, but CAM is religiously based and highly regulated. c. is controlled by the health care industry, but CAM is the people's medicine and not motivated by profit. d. is holistic and focused on health promotion, whereas CAM treats illnesses and is symptom specific.

a. focuses on what is done to the client, whereas CAM focuses on body-mind interaction with an actively involved client. Conventional health care focuses primarily on curative actions implemented on a mostly passive client, whereas CAM focuses more on the mind-body aspects of health, along with the active involvement of the client. Conventional health care is largely grounded in scientific research, and its various components are heavily regulated; the opposite tends to be true of CAM. Some forms of CAM have their roots in religious or cultural practices, but this is not characteristic of CAM as a whole. Both conventional health care and CAM can focus on health promotion and treatment of illness. Although critics express concern about the role of profit in conventional health care, the profit motive can also apply in CAM.

A college student who attempted suicide by overdose was hospitalized. When the parents were contacted, they responded, "We should have seen this coming. We did not do enough." What does the parents' reaction reflect? a. guilt. b. denial. c. shame. d. rescue feelings.

a. guilt. The parents' statements indicate guilt. Guilt is evident from the parents' self-chastisement. The feelings suggested in the distracters are not clearly described in the scenario.

Which feeling experienced by a client that should be assessed by the nurse as most predictive of elevated suicide risk? a. hopelessness. b. sadness. c. elation. d. anger.

a. hopelessness. Of the feelings listed, hopelessness is most closely associated with increased suicide risk. Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for suicide.

During an assessment interview, a client diagnosed with inflammatory bowel disease accompanied by frequent episodes of diarrhea says, "I've been using probiotics in small doses for about a week." When the nurse assesses mental status, what findings would be expected? a. intact cognitive function. b. slow verbal responses. c. paranoid thinking. d. slurred speech.

a. intact cognitive function. Probiotics may reduce inflammation and heal the gut. No effect on cognitive function would be associated with use of microbiomes, including probiotics. The client has taken small doses, so response times would be normal. It does not usually produce the effects cited in the distracters.

A hospitalized client diagnosed with delirium misinterprets reality. A client diagnosed with dementia wanders about the home. Which outcome is the priority in both scenarios? The clients will a. remain safe in the environment. b. participate actively in self-care. c. communicate verbally. d. acknowledge reality.

a. remain safe in the environment. Risk for injury is the nurse's priority concern. Safety maintenance is the desired outcome. The other outcomes are lower priorities and may not be realistic.

What should the goals of care for an older adult client diagnosed with delirium caused by fever and dehydration focus on? a. returning to premorbid levels of function. b. identifying stressors negatively affecting self. c. demonstrating motor responses to noxious stimuli. d. exerting control over responses to perceptual distortions.

a. returning to premorbid levels of function. The desired overall goal is that the delirious client will return to the level of functioning held before the development of delirium. Demonstrating motor response to noxious stimuli is an indicator appropriate for a client whose arousal is compromised. Identifying stressors that negatively affect the self is too nonspecific to be useful for a client with delirium. Exerting control over responses to perceptual distortions is an unrealistic indicator for a client with sensorium problems related to delirium.

While conducting the initial interview with a client in crisis, the nurse should implement what intervention? a. speak in short, concise sentences. b. convey a sense of urgency to the client. c. be forthright about time limits of the interview. d. let the client know the nurse controls the interview.

a. speak in short, concise sentences. Severe anxiety narrows perceptions and concentration. By speaking in short concise sentences, the nurse enables the client to grasp what is being said. Conveying urgency will increase the client's anxiety. Letting the client know who controls the interview or stating that time is limited is nontherapeutic.

A victim of intimate partner violence comes to the crisis center seeking help. Which crisis intervention strategies should the nurse focus on? a. supporting emotional security and reestablishing equilibrium. b. long-term resolution of issues precipitating the crisis. c. promoting growth of the individual. d. providing legal assistance.

a. supporting emotional security and reestablishing equilibrium. Strategies of crisis intervention address the immediate cause of the crisis and restoration of emotional security and equilibrium. The goal is to return the individual to the pre-crisis level of function. Crisis intervention is, by definition, short term. The correct response is the most global answer. Promoting growth is a focus of long-term therapy. Providing legal assistance might or might not be applicable.

What is the most critical question for the nurse to ask an adolescent who has threatened to take an overdose of pills? a. "Why do you want to kill yourself?" b. "Do you have access to medications?" c. "Have you been taking drugs and alcohol?" d. "Did something happen with your parents?"

b. "Do you have access to medications?" The nurse must assess the client's access to means to carry out the plan and, if there is access, alert the parents to remove from the home and take additional actions to assure the client's safety. The information in the other questions may be important to ask but are not the most critical. "Why" question should be avoid since they tend to imply blame.

The sibling of a client who was diagnosed with a serious mental illness (SMI) asks why a case manager has been assigned. Which nurse's reply best cites the major advantage of the use of case management? a. "The case manager can modify traditional psychotherapy for homeless clients so that it is more flexible." b. "Case managers coordinate services and help with accessing them, making sure the client's needs are met." c. "The case manager can focus on social skills training and esteem building in the real world where the client lives." d. "Having a case manager has been shown to reduce hospitalizations, which prevents disruption and saves money."

b. "Case managers coordinate services and help with accessing them, making sure the client's needs are met." The case manager helps the client gain entrance into the system of care, can coordinate multiple referrals that so often confuse the seriously mentally ill person and his family, and can help overcome obstacles to access and treatment participation. Case managers do not usually possess the credentials needed to provide psychotherapy or function as therapists. Case management promotes efficient use of services in general, but only ACT programming has been shown to reduce hospitalization (which the sibling might see as a disadvantage). Case managers operate in the community, but this is not the primary advantage of their services.

After the death of his wife, a man says, "I can't live without her ... she was my whole life." What is the nurse's most therapeutic reply? a. "Each day will get a little better." b. "Her death is a terrible loss for you." c. "It's important to recognize that she is no longer suffering." d. "Your friends will help you cope with this change in your life."

b. "Her death is a terrible loss for you." A statement that validates the bereaved person's loss is more helpful than commonplace clichés. It signifies understanding. The other options are clichés

A homeless client diagnosed with a serious mental illness (SMI) became suspicious and delusional. Depot antipsychotic medication is prescribed and housing is obtained in a local shelter. One month later, which statement by the client indicates significant improvement? a. "They will not let me drink. They have many rules in the shelter." b. "I feel comfortable here. Nobody bothers me." c. "Those shots make my arm very sore." d. "Those people watch me a lot."

b. "I feel comfortable here. Nobody bothers me." Evaluation of a client's progress is made based on client satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional client to admit to feeling comfortable and free of being "bothered" by others denotes improvement in the client's condition. The other options suggest that the client is in danger of relapse.

Which statement by a depressed client will alert the nurse to the client's need for immediate, active intervention? a. "I am mixed up, but I know I need help." b. "I have no one to turn to for help or support." c. "It is worse when you are a person of color." d. "I tried to get attention before I cut myself last time."

b. "I have no one to turn to for help or support." Hopelessness is evident. Lack of social support and social isolation increases the suicide risk. Willingness to seek help lowers risk. Being a person of color does not suggest higher risk because more whites commit suicide than do individuals of other racial groups. Attention seeking is not correlated with higher suicide risk.

A client comes to the crisis clinic after an unexpected job termination. The client paces, sobs, cringes when approached, and responds to questions with only shrugs or monosyllables. What is the nurse's best initial comment to this client? a. "Everything is going to be all right. You are here at the clinic and the staff will keep you safe." b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." c. "You need to try to stop crying and pacing so we can talk about your problems." d. "Let's set some guidelines and goals for your visit here."

b. "I see you are feeling upset. I'm going to stay and talk with you to help you feel better." A crisis exists for this client. The two primary thrusts of crisis intervention are to provide for the safety of the individual and use anxiety-reduction techniques to facilitate use of inner resources. The nurse offers therapeutic presence, which provides caring, ongoing observation relative to the client's safety, and interpersonal reassurance. None of the other options address these thrusts.

A client says, "The other nurses won't give me my medication early, but you know what it's like to be in pain and don't let your clients suffer. Could you get me my pill now? I won't tell anyone." Which response by the nurse would be most therapeutic? a. "I'm not comfortable doing that," and then ignore subsequent requests for early medication. b. "I understand that you have pain but giving medicine too soon would not be safe." c. "I'll have to check with your doctor about that; I will get back to you after I do." d. "It would be unsafe to give the medicine early; none of us will do that."

b. "I understand that you have pain but giving medicine too soon would not be safe." The client is attempting to manipulate the nurse. Empathetic mirroring reflects back to the client the nurse's understanding of the client's distress or situation in a neutral manner that does not judge it and helps elicit a more positive response to the limit that is being set. The other options would not be nontherapeutic; they lack the empathetic mirroring component that tends to elicit a more positive response from the client.

One month ago, an adult died from cancer. Family members now gather at the adult's home to dispose of the deceased's belongings. Which comments demonstrate the family member is coping with the loss in an effective way? (Select all that apply.) a. "Her possessions still have her scent. We should dispose of them." b. "Let's take turns selecting items of hers we would each like to have." c. "When I die, I hope someone who loved me goes through my things." d. "This was her favorite jacket. If we donate it to charity, someone else can enjoy it too." e. "We're violating her privacy by looking through her things. Let's call a charity to come pick up everything."

b. "Let's take turns selecting items of hers we would each like to have." c. "When I die, I hope someone who loved me goes through my things." d. "This was her favorite jacket. If we donate it to charity, someone else can enjoy it too."

A client diagnosed with a serious mental illness (SMI) died suddenly at age 52. The client lived in the community for 5 years without relapse and held supported employment the past 6 months. The distressed family asks, "How could this happen?" Which response by the nurse accurately reflects research and addresses the family's question? a. "A certain number of people die young from undetected diseases, and it's just one of those sad things that sometimes happen." b. "Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight." c. "We will have to wait for the autopsy to know what happened. There were some medical problems, but we were not expecting death." d. "We are all surprised. The client had been doing so well and saw the nurse every other week."

b. "Mentally ill people tend to die much younger than others, perhaps because they do not take as good care of their health, smoke more, or are overweight." The family is in distress. Because they do not understand his death, they are less able to accept it and seek specific information to help them understand what happened. Persons with SMI die an average of 25 years prematurely. Contributing factors include failing to provide for their own health needs (e.g., forgetting to take medicine), inability to access or pay for care, higher rates of smoking, poor diet, criminal victimization, and stigma. The most accurate answer indicates that seriously mentally ill people are at much higher risk of premature death for a variety of reasons. Staff would not have been surprised that the client died prematurely, and they would not attribute his death to random, undetected medical problems. Although the cause of death will not be reliably established until the autopsy, this response fails to address the family's need for information.

A staff nurse asks a hospice nurse, "Who should be referred for hospice care?" What is the hospice nurse's best response? a. "Hospice is for terminally ill patients diagnosed with cancer." b. "Patients in the end stage of any disease are eligible for hospice." c. "Hospice is designed to care for patients experiencing end-stage renal disease." d. "Patients diagnosed with degenerative neurological diseases are eligible for hospice after paralysis occurs."

b. "Patients in the end stage of any disease are eligible for hospice." A hospice service cares for terminally ill patients regardless of diagnosis.

Many persons brought before a criminal court have mental illness, have committed minor offenses, and are non-medication adherent. The judge consults the nurse at the local community mental health center for guidance about how to respond when handling such cases. Which advice from the nurse would be most appropriate? a. "Sometimes a little time in jail makes a person rethink what they've been doing and puts them back on the right track." b. "Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses." c. "Arresting these people helps them in the long run. Sometimes we cannot hospitalize them, but in jail they will get their medication." d. "Research suggests that special mental health courts do not make much difference so far, but outpatient commitment does seem to help."

b. "Sentencing such persons to participate in treatment instead of incarcerating them has been shown to reduce repeat offenses." Research supports the use of special mental health courts that can sentence mentally ill persons to treatment instead of jail. Jail exposes vulnerable mentally ill persons to criminals, victimization, and high levels of stimulation and stress. Incarceration can also interrupt eligibility for benefits or lead to the loss of housing and often provides lower-quality mental health treatment in other settings. Recidivism rates for both mentally ill and non-mentally ill offenders are relatively high, so it does not appear that incarceration necessarily leads people to behave more appropriately. In addition, a criminal record can leave them more desperate and with fewer options after release. Research indicates that outpatient commitment is less effective at improving the mental health of mentally ill persons than was expected.

A client has tried a variety of complementary and alternative medicine (CAM) approaches to manage health concerns. The nurse asks, "How is going to CAM practitioners different from seeing your medical doctors?" What is he client most likely response? a. "The CAM practitioners usually prescribe a course of invasive and sometimes painful treatments." b. "The CAM practitioners spend more time talking with me and not just about my symptoms." c. "The CAM practitioners say I need to become much more spiritual to be well." d. "The CAM practitioners order many tests to determine my diagnoses."

b. "The CAM practitioners spend more time talking with me and not just about my symptoms." CAM practitioners often spend considerable time assessing the person in a holistic way. Visits typically involve lengthy discussions, in contrast to traditional physician visits, where contact is often brief. CAM remedies can sometimes be invasive or slightly painful, but usually they are noninvasive and well-tolerated. Some CAM practices are very spiritually focused, but most do not have overt religious elements. Conventional health care involves more diagnostic testing than CAM.

A client tells the nurse, "I've been having problems getting a good night's sleep. I read some information on the Internet and started taking kava." What is the nurse's priority response? a. "The Internet does not have reliable health information for consumers." b. "The Food and Drug Administration warned against using it due to the link to severe liver damage." c. "Melatonin has been shown to have better effects for treating sleep disturbances." d. "Your sleep disturbances are related to your problems with anxiety. Herbs will not help."

b. "The Food and Drug Administration warned against using it due to the link to severe liver damage." The Food and Drug Administration (FDA) warned against using kava due to the link to severe liver damage. The nurse has responsibilities to educate clients regarding safe use of complementary therapies. Melatonin may be useful for sleep disturbances, but the client's safety is a higher priority. The other distracters are misleading.

. An elderly client is admitted with delirium secondary to a urinary tract infection. The family asks whether the client will ever recover. What is the nurse's best response? a. "The health care provider is the best person to answer your question." b. "The confusion will probably get better as we treat the infection." c. "Unfortunately, delirium is a progressively disabling disorder." d. "I will be glad to contact the chaplain to talk with you."

b. "The confusion will probably get better as we treat the infection." Usually, as the underlying cause of the delirium is treated, the symptoms of delirium clear. The distracters mislead the family.

A nurse assesses a client in crisis. What is the most appropriate question for the nurse to ask to assess this client's situational support? a. "Has anything upsetting occurred in the past few days?" b. "Who can be helpful to you during this time?" c. "How does this problem affect your life?" d. "What led you to seek help at this time?"

b. "Who can be helpful to you during this time?" Only the answer focuses on situational support. The incorrect options focus on the client's perception of the precipitating event.

A client diagnosed with pancreatic cancer says, "I know I am dying, but I am still alive. I want to be in control as long as I can." Which reply by the nurse shows active listening? a. "Our staff will do their best to manage your pain." b. "Your mind and spirit are healthy, although your body is frail." c. "It's important for you to let others help you to ease their own pain." d. "Are you saying you want people to stop focusing on your diagnosis?"

b. "Your mind and spirit are healthy, although your body is frail." The client has strengths and capabilities and is asking for acknowledgment that he/she is not incapacitated, even though the diagnosis is likely terminal. The correct answer provides that acknowledgment. The other responses are tangential.

Which finding indicates successful completion of an individual's grief and mourning? a. For 2 years after her husband's death, a widow has kept her husband's belongings in their usual places. b. After 15 months, a widower realistically remembers both the pleasures and disappointments of his relationship with his wife. c. Three years after her husband's death, the widow talks about her husband as if he is alive and weeps when others mention his name. d. Eighteen months after a spouse's death, an adult says, "I have never cried or had feelings of loss, even though we were very close."

b. After 15 months, a widower realistically remembers both the pleasures and disappointments of his relationship with his wife The goals of mourning have evolved from doing the grief work, getting over it, and moving on with life. The work of grieving is over when the bereaved person can remember the individual realistically and acknowledge both the pleasure and disappointments associated with the loved one. The individual is then free to enter into new relationships and activities. The incorrect options suggest maladaptive grief.

An older adult diagnosed with Alzheimer's disease lives with family in a rural area. During the week, this adult attends a day care center while the family is at work. In the evenings, members of the family provide care. Which factor makes this adult most vulnerable to abuse? a. Multiple caregivers b. Alzheimer's disease c. Living in a rural area d. Being part of a busy family

b. Alzheimer's disease Older adults are at high risk for violence, particularly when there is significant dependency such as would be expected with dementia or other cognitive impairments. The incorrect responses are not identified as placing an individual at high risk.

Consider these phenomena: accumulation of b-amyloid outside the neurons, neurofibrillary tangles, and neuronal degeneration in the hippocampus. Which health problem corresponds to these events? a. Huntington's disease b. Alzheimer's disease c. Parkinson's disease d. Vascular dementia

b. Alzheimer's disease The pathophysiological phenomena described apply to Alzheimer's disease. Parkinson's disease is associated with dopamine dysregulation. Huntington's disease is genetic. Vascular dementia is the consequence of circulatory changes

Which event is most likely to precipitate grief across a community? a. A local bank is robbed twice in a single month b. An adolescent shoots the principal of a local high school c. The elderly pastor of the town's largest church dies of heart failure d. Concrete pilings crumble in a bridge important to movement of local traffic

b. An adolescent shoots the principal of a local high school The correct response identifies an event likely to be perceived as a public tragedy. The distracters are occurrences that are more commonplace. They may precipitate concern but not grief.

A woman just received notification that her husband died. She approaches the nurse who cared for him during his last hours and says angrily, "If you had given him your undivided attention, he would still be alive." Which analysis applies? a. The comment warns of a malpractice suit. b. Anger is a phenomenon experienced during grief. c. The wife had conflicted feelings about her husband. d. In some cultures, grief is expressed solely through anger.

b. Anger is a phenomenon experienced during grief. Anger may be manifested toward the health care system, God, or even the deceased. Anger may protect the bereaved from facing the devastating reality of loss. Anger expressed during mourning is not directed toward the nurse personally, even though accusations and blame may make him/her feel as though it is.

A client comes to the crisis center saying, "I'm in a terrible situation. I don't know what to do." The triage nurse can initially assume that the client is experiencing what response? a. Suicidal ideations. b. Anxiety and fear. c. Misperceived reality. d. Potential homicidal thoughts.

b. Anxiety and fear. individuals in crisis are universally anxious. They are often frightened and may be mildly confused. Perceptions are often narrowed with anxiety. There is no assessment data to support the other options.

A client says, "I have taken mega doses of vitamins for 3 months to improve my circulation, but I think I feel worse." Which action should the nurse take first? a. Explain to the client that vitamin mega doses may be harmful and advise caution. b. Assess the client for symptoms and signs of toxicity from excess vitamin exposure. c. Assess for signs of circulatory integrity to determine whether improvement has occurred. d. Educate the client that research has not shown that megavitamin therapy produces benefits.

b. Assess the client for symptoms and signs of toxicity from excess vitamin exposure. Mega doses of many vitamins, especially when taken over long periods, may produce dangerous side effects or toxicity. The priority for the nurse is to assess for signs of any dangerous consequences of the client's use of such a regimen. Secondary interventions would include client education about research findings related to the practice, along with any benefits and undesired effects associated with the practice. A health care provider should also assess the client for cardiovascular concerns.

A nurse plans care for an individual diagnosed with antisocial personality disorder. Which characteristic behaviors will the nurse expect? (Select all that apply.) a. Reclusive behavior b. Callous attitude c. Perfectionism d. Aggression e. Clinginess f. Anxiety

b. Callous attitude d. Aggression Individuals with antisocial personality disorders characteristically demonstrate manipulative, exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders are more likely to be impulsive than to be perfectionists.

What is the priority intervention for a client diagnosed with delirium who has fluctuating levels of consciousness, disturbed orientation, and perceptual alterations? a. Distraction using sensory stimulation b. Careful observation and supervision c. Avoidance of physical contact d. Activation of the bed alarm

b. Careful observation and supervision Careful observation and supervision are of ultimate importance because an appropriate outcome would be that the client will remain safe and free from injury. Physical contact during care cannot be avoided. Activating a bed alarm is only one aspect of providing for the client's safety.

During morning care, a nurse asks a client diagnosed with dementia, "How was your night?" The client replies, "It was lovely. I went out to dinner and a movie with my friend." Which term applies to the client's response? a. Sundown syndrome b. Confabulation c. Perseveration d. Delirium

b. Confabulation Confabulation refers to making up of stories or answers to questions by a person who does not remember. It is a defensive tactic to protect self-esteem and prevent others from noticing memory loss. The client's response was not sundown syndrome. Perseveration refers to repeating a word or phrase over and over. Delirium is not present in this scenario.

An adult comes to the crisis clinic after termination from a job of 15 years. The client says, "I don't know what to do. How can I get another job? Who will pay the bills? How will I feed my family?" Which nursing diagnosis applies? a. Hopelessness b. Powerlessness c. Chronic low self-esteem d. Interrupted family processes

b. Powerlessness The client describes feelings of lack of control over life events. No direct mention is made of hopelessness or chronic low self-esteem. The client's family processes are not interrupted at this point.

A client had a venous thrombosis 3 weeks ago and is now taking warfarin. When visiting the laboratory to have a prothrombin time drawn, the client reports drinking ginseng tea to stimulate the immune system. Which nursing diagnosis applies? a. Impaired memory related to neurological changes b. Deficient knowledge related to potentially harmful drug interactions c. Ineffective denial related to consequences of mismanagement of therapeutic regime d. Effective management of the therapeutic regime related to augmentation of anticoagulant therapy

b. Deficient knowledge related to potentially harmful drug interactions Ginseng tea is amongst the top 10 herbal products used in the United States and believed to have multiple beneficial properties. Because it antagonizes platelet-activating factor, it should not be taken by clients who are receiving anticoagulants or who have other potential bleeding problems. Thus, deficient knowledge is an appropriate nursing diagnosis.

Consider these cerebral pathophysiologies: Lewy body development, frontotemporal degeneration, and accumulation of protein b-amyloid. Which diagnosis applies? a. Cyclothymia b. Dementia c. Delirium d. Amnesia

b. Dementia The listed cerebral pathophysiologies are all associated with development of dementia.

A person diagnosed with a serious mental illness (SMI) enters a shelter for the homeless. Which intervention should be the nurse's initial priority? a. Find supported employment. b. Develop a trusting relationship. c. Administer prescribed medication. d. Teach appropriate health care practices.

b. Develop a trusting relationship. Basic psychosocial needs do not change because a person is homeless. The first step in caring for health care needs is establishing rapport. Once a trusting relationship is established, the nurse pursues other interventions.

A person diagnosed with serious mental illness (SMI) has frequent relapses, usually precipitated by situational stressors such as running out of money or the absence of key staff at the mental health center. Which interventions would the nurse suggest to reduce the risk of stressors to cause relapse? (Select all that apply.) a. Discourage potentially stressful activities such as groups or volunteer work. b. Develop written plans that will help the client remember what to do in a crisis. c. Help the client identify and anticipate events that are likely to be overwhelming. d. Encourage health-promoting activities such as exercise and getting adequate rest. e. Accompany the client to a National Alliance on Mental Illness (NAMI) support group.

b. Develop written plans that will help the client remember what to do in a crisis. c. Help the client identify and anticipate events that are likely to be overwhelming. d. Encourage health-promoting activities such as exercise and getting adequate rest. e. Accompany the client to a National Alliance on Mental Illness (NAMI) support group. Basic interventions for coping with crises involve anticipating crises where possible and then developing a plan with specific actions to take when faced with an overwhelming stressor. Written plans are helpful; it can be difficult for anyone, especially a person with cognitive or memory impairments, to develop or remember steps to take when under overwhelming stress. Health-promoting activities enhance a person's ability to cope with stress. As the name suggests, support groups help a person develop a support system, and they provide practical guidance from peers who learned from experience how to deal with issues the client may be facing. Groups and volunteer work may involve a measure of stress but also provide benefits that help persons cope and should not be discouraged unless they are being done to excess.

An adult outpatient client diagnosed with major depressive disorder has a history of several suicide attempts by overdose. Given this client's history and diagnosis, which antidepressant medication would the nurse expect to be prescribed? a. Amitriptyline b. Fluoxetine c. Desipramine d. Tranylcypromine sulfate

b. Fluoxetine Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations, which is not true of the other medications listed. Given this client's history of overdosing, it is important that the medication be as safe as possible in the event of another overdose of prescribed medication.

A client diagnosed with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. Which alternative could the nurse suggest to the family members? a. Wear large name tags. b. Focus interaction on familiar topics. c. Frequently repeat the reorientation strategies. d. Place large clocks and calendars strategically.

b. Focus interaction on familiar topics Reorientation may seem like arguing to a client with cognitive deficit and increases the client's anxiety. Validating, talking with the client about familiar, meaningful things, and reminiscing give meaning to existence both for the client and family members. The option that suggests using validating techniques when communicating is the only option that addresses an interactional strategy. Wearing large name tags and placing large clocks and calendars strategically are reorientation strategies. Frequently repeating the reorientation strategies is inadvisable because clients with dementia sometimes become more agitated with reorientation.

Which communication technique will the nurse use more in crisis intervention than traditional counseling? a. Role modeling b. Giving direction c. Information giving d. Empathic listening

b. Giving direction The nurse working in crisis intervention must be creative and flexible in looking at the client's situation and suggesting possible solutions to the client. Giving direction is part of the active role a crisis intervention therapist takes. The other options are used equally in crisis intervention and traditional counseling roles.

What feelings are most commonly experienced by nurses working with abusive families? a. Outrage toward the victim and discouragement regarding the abuser b. Helplessness regarding the victim and anger toward the abuser c. Unconcern for the victim and dislike for the abuser d. Vulnerability for self and empathy with the abuser

b. Helplessness regarding the victim and anger toward the abuser Intense protective feelings, helplessness, and sympathy for the victim are common emotions of a nurse working with an abusive family. Anger and outrage toward the abuser are common emotions of a nurse working with an abusive family.

A client previously hospitalized for 2 weeks committed suicide the day after discharge. Which initial nursing measure will be most important regarding this event? a. Request the information technology manager to verify the client's medical record is secure in the hospital information system. b. Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments. c. Consult the hospital's legal department regarding potential consequences of the event. d. Document a report of a sentinel event in the client's medical record.

b. Hold a meeting for staff to provide support, express feelings, and identify overlooked clues or faulty judgments. Support and an opportunity for staff to safely express feelings about the event should occur first. Interventions should help the staff come to terms with the loss and grow because of the incident. Identifying overlooked clues or faulty judgments will provide the groundwork for identifying changes needed in policies and procedures for future clients. Consulting the legal department is not an initial measure. A sentinel event report is not part of the medical record and can be prepared later. The other incorrect options will not control information or would result in unsafe care.

Which complementary and alternative medicine (CAM) method is associated with using allergy injections of small amounts of an allergen in solution? a. Naturopathy b. Homeopathy c. Chiropractic d. Shiatsu

b. Homeopathy Homeopathy uses small doses of a substance to stimulate the body's defenses and healing mechanisms to treat illness. Naturopathy emphasizes health restoration rather than disease. Chiropractic uses manipulation of the body to restore health. Shiatsu is a type of massage.

A client diagnosed as mild stage Alzheimer's disease tires easily and prefers to stay home rather than attend social activities. The spouse does the grocery shopping because the client cannot remember what to buy. Which nursing diagnosis applies at this time? a. Self-care deficit b. Impaired memory c. Caregiver role strain d. Adult failure to thrive

b. Impaired memory Memory impairment begins at the mild stage and progresses in the subsequent stages. This client is able to perform most self-care activities. Caregiver role strain and adult failure to thrive occur later.

What is the most challenging nursing intervention with clients diagnosed with personality disorders who use manipulation? a. Supporting behavioral change b. Maintaining consistent limits c. Monitoring suicide attempts d. Using aversive therapy

b. Maintaining consistent limits Maintaining consistent limits is by far the most difficult intervention because of the client's superior skills at manipulation. Supporting behavioral change and monitoring client safety are less difficult tasks. Aversive therapy would probably not be part of the care plan because positive reinforcement strategies for acceptable behavior seem to be more effective than aversive techniques.

An older male client has been treated for episodic pruritus and skin eruptions for over 2 years. This client tells the nurse, "When my skin gets better for a few days, I start worrying that it's going to start itching again soon. I think my worry may actually trigger the problems to start all over again." Which self-help technique should the nurse consider suggesting for this client? a. Melatonin b. Meditation c. Purification d. Acupuncture

b. Meditation The client's comment suggests an element of anxiety accompanies the skin problem. Meditation is a popular self-help method recommended to reduce physical and emotional stress and to promote wellness. Purification, associated with ayurvedic practices, may or may not appeal to this client. Acupuncture is performed by a professional practitioner, so it is not a self-help technique. The scenario does not indicate the client is experiencing insomnia, so melatonin is not indicated.

A team of nurses report to the community after a category 5 hurricane devastates many homes and businesses. The nurses provide emergency supplies of insulin to persons with diabetes and help transfer clients in skilled nursing facilities to sites that have electrical power. Which aspects of disaster management have these nurses fulfilled? (Select all that apply.) a. Preparedness b. Mitigation c. Response d. Recovery e. Evaluation

b. Mitigation c. Response This community has experienced a catastrophic event. There are five phases of the disaster management continuum. The nurses' activities applied to mitigation (attempts to limit a disaster's impact on human health and community function) and response (actual implementation of a disaster plan). Preparedness occurs before an event. Recovery actions focus on stabilizing the community and returning it to its previous status. Evaluation of the response efforts apply to the future.

A client diagnosed with borderline personality disorder has a history of self-mutilation and suicide attempts. The client reveals feelings of depression and anger with life. Which type of medication would the nurse expect to be prescribed? a. Benzodiazepine b. Mood stabilizing medication c. Monoamine oxidase inhibitor (MAOI) d. Cholinesterase inhibitor

b. Mood stabilizing medication Mood stabilizing medications have been effective for many clients with borderline personality disorder. Cholinesterase inhibitors are prescribed for persons diagnosed with neurocognitive disorders. Use of anxiolytic medications is not supported by data given in the scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used for clients who are impulsive.

A nurse counsels the family of a client diagnosed with Alzheimer's disease who lives at home and wanders at night. Which action is most important for the nurse to recommend for enhancing safety? a. Apply a medical alert bracelet to the client. b. Place locks at the tops of doors. c. Discourage daytime napping. d. Obtain a bed with side rails.

b. Place locks at the tops of doors. Placing door locks at the top of the door makes it more difficult for the client with dementia to unlock the door because the ability to look up and reach upward is diminished. The client will try to climb over side rails, increasing the risk for injury and falls. Avoiding daytime naps may improve the client's sleep pattern but does not assure safety. A medical alert bracelet will be helpful if the client leaves the home, but it does not prevent wandering or assure the client's safety.

An older woman diagnosed with Alzheimer's disease lives with family and attends day care. After observing poor hygiene, the nurse talked with the caregiver. This caregiver became defensive and said, "It takes all my energy to care for my mother. She's awake all night. I never get any sleep." Which nursing intervention has priority? a. Teach the caregiver about the effects of sundowner's syndrome. b. Secure additional resources for the mother's evening and night care. c. Support the caregiver to grieve the loss of the mother's cognitive abilities. d. Teach the family how to give physical care more effectively and efficiently.

b. Secure additional resources for the mother's evening and night care. The client's caregivers were coping with care until the client began to stay awake at night. The family needs assistance with evening and night care to resume their pre-crisis state of functioning. Secondary prevention calls for the nurse to mobilize community resources to relieve overwhelming stress. The other interventions may then be accomplished.

Which change in the brain's biochemical function is most associated with suicidal behavior? a. Dopamine excess b. Serotonin deficiency c. Acetylcholine excess d. g-aminobutyric acid deficiency

b. Serotonin deficiency Research suggests that low levels of serotonin may play a role in the decision to commit suicide. The other neurotransmitter alterations have not been implicated in suicidality

A client tells the nurse, "I get sick so much, so I started taking ginseng to boost my immune system." The client's only other medication is warfarin daily. Which potential complication should be included in the nursing assessment? a. Gastrointestinal distress b. Spontaneous bleeding c. Thromboembolism d. Drowsiness

b. Spontaneous bleeding Ginseng may interact with anticoagulants and cause spontaneous bleeding. Warfarin is such an agent and can predispose the client to spontaneous bleeding. It would not increase the risk of thromboembolism. Drowsiness and gastrointestinal complaints are common side effects.

A client living independently had command hallucinations to shout warnings to neighbors. After a short hospitalization, the client was prohibited from returning to the apartment. The landlord said, "You cause too much trouble." What problem is the client experiencing? a. Grief b. Stigma c. Homelessness d. Nonadherence

b. Stigma The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a client problem. Data do not suggest that the client is actually homeless. See relationship to audience response question.

Which rationale best explains why a nurse should be aware of personal feelings while working with a family experiencing family violence? a. Self-awareness enhances the nurse's advocacy role. b. Strong negative feelings interfere with assessment and judgment. c. Strong positive feelings lead to healthy transference with the victim. d. Positive feelings promote the development of sympathy for clients.

b. Strong negative feelings interfere with assessment and judgment. Strong negative feelings cloud the nurse's judgment and interfere with assessment and intervention, no matter how well the nurse tries to cover or deny feelings. Strong positive feelings lead to overinvolvement with victims rather than healthy transference.

As death approaches, a client diagnosed with AIDS says, "I do not have enough energy for many visitors anymore and I am embarrassed about how I look. I only want to see my parents and sister." Which actions should the nurse take? (Select all that apply.) a. Encourage the client to reconsider this decision so that interested and caring friends can provide support. b. Support the client to share the request with the parents and sister. c. Assist family to inform the patient's friends of the request. d. Suggest that the client discuss these wishes with clergy. e. Place a "No Visitors" sign on the patient's door.

b. Support the client to share the request with the parents and sister. c. Assist family to inform the patient's friends of the request. The correct responses empower the client to maintain dignity, control, personal space, and confidentiality. As some patients approach death, they begin to withdraw. In the stage of acceptance, many patients are exhausted and tired, and interactions of a social nature are a burden. Many prefer to have someone present at the bedside who will sit without talking constantly.

Which situation demonstrates use of primary intervention related to crisis? a. Implementation of suicide precautions for a depressed client b. Teaching stress-reduction techniques to a first-year college student c. Assessing coping strategies used by a client who attempted suicide d. Referring a client diagnosed with schizophrenia to a partial hospitalization program

b. Teaching stress-reduction techniques to a first-year college student Primary care-related crisis intervention promotes mental health and reduces mental illness. The incorrect options are examples of secondary or tertiary interventions.

Which assessment finding would be likely for a client experiencing a hallucination? a. The client looks at shadows on a wall and says, "I see scary faces." b. The client states, "I feel bugs crawling on my legs and biting me." c. The client reports telepathic messages from the television. d. The client speaks in rhymes.

b. The client states, "I feel bugs crawling on my legs and biting me." A hallucination is a false sensory perception occurring without a corresponding sensory stimulus. Feeling bugs on the body when none are present is a tactile hallucination. Misinterpreting shadows as faces is an illusion. An illusion is a misinterpreted sensory perception. The other incorrect options apply to thought insertion and clang associations.

A survivor of physical spousal abuse was treated in the emergency department for a broken wrist. This client said, "I've considered leaving, but I made a vow and I must keep it no matter what happens." Which outcome should be met before discharge? a. The client will facilitate counseling for the abuser. b. The client will name two community resources for help. c. The client will demonstrate insight into the abusive relationship. d. The client will reexamine cultural beliefs about marital commitment.

b. The client will name two community resources for help. The only outcome indicator clearly attainable within this time is for staff to provide the victim with information about community resources that can be contacted. Development of insight into the abusive relationship and reexamining cultural beliefs will require time. Securing a restraining order can be accomplished quickly but not while the client is in the emergency department. Facilitating the abuser's counseling may require weeks or months.

What is the desired outcome for a client who uses valerian? a. The client will report stress level is lower. b. The client will report undisturbed sleep throughout the night. c. The client will report increased interest in recreational activities. d. The client will report early morning waking without an alarm clock.

b. The client will report undisturbed sleep throughout the night. Valerian decreases sleep latency, nocturnal waking, and leads to a subjective sense of good sleep. Sleeping through the night is the best indicator the herb was effective. Although the client's stress level may be lowered by use of valerian, the problem is insomnia; outcomes should relate to the problem. Early morning waking is indicative of depression or anxiety.

For clients diagnosed with serious mental illness (SMI), what is the major advantage of case management? a. The case manager can modify traditional psychotherapy. b. With one coordinator of services, resources can be more efficiently used. c. The case manager can focus on social skills training and esteem building. d. Case managers bring groups of clients together to discuss common problems.

b. With one coordinator of services, resources can be more efficiently used. The case manager coordinates the care and multiple referrals that so often confuse the seriously mentally ill client and the client's family. Case management promotes efficient use of services. The other options are lesser advantages or are irrelevant.

How is serious mental illness (SMI) characterized? a. any mental illness of more than 2 weeks' duration. b. a major long-term mental illness marked by significant functional impairments. c. a mental illness accompanied by physical impairment and severe social problems. d. a major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities.

b. a major long-term mental illness marked by significant functional impairments. "Serious mental illness" has replaced the term "chronic mental illness." Global impairments in function are evident, particularly social. Physical impairments may be present. SMI can be treated, but remissions and exacerbations are part of the course of the illness.

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman says tearfully, "What else can happen?" If the woman's immediate family is unable to provide sufficient support, the nurse should take what initial action? a. suggest hospitalization for a short period. b. ask what other relatives or friends are available for support. c. tell the client, "You are a strong person. You can get through this crisis." d. foster insight by relating the present situation to earlier situations involving loss.

b. ask what other relatives or friends are available for support. The assessment of situational supports should continue. Even though the client's nuclear family may not be supportive, other situational supports may be available. If they are adequate, admission to an inpatient unit will be unnecessary. Psychotherapy is not appropriate for crisis intervention. Advice is usually nontherapeutic.

After 5 years in a state hospital, an adult diagnosed with schizophrenia was discharged to the community. This client now requires continual direction to accomplish activities of daily living and expects others to provide meals and do laundry. The nurse assesses this behavior as the probable result of what factor? a. side effects of antipsychotic medications. b. dependency caused by institutionalization. c. cognitive deterioration from schizophrenia. d. stress associated with acclimation to the community.

b. dependency caused by institutionalization. Institutions tend to impede independent functioning; for example, daily activities are planned and directed by staff; others provide meals and only at set times. Over time, clients become dependent on the institution to meet their needs and adapt to being cared for rather than caring for themselves. When these clients return to the community, many continue to demonstrate passive behaviors despite efforts to promote. Cognitive dysfunction and antipsychotic side effects can make planning and carrying out activities more difficult, but the question is more suggestive of adjustment to institutional care and difficulty readjusting to independence instead.

Which nursing diagnosis is appropriate to consider for a client diagnosed with any of the personality disorders? a. nonadherence. b. impaired social interaction. c. disturbed personal identity. d. diversional activity deficit.

b. impaired social interaction. Without exception, individuals with personality disorders have problems with social interaction with others; hence, the diagnosis of "impaired social interaction." For example, some individuals are suspicious and lack trust, others are avoidant, and still others are manipulative. None of the other diagnoses are universally applicable to clients with personality disorders; each might apply to selected clinical diagnoses, but not to others.

A client report, "Last night I had several mixed drinks at a party. When I got home, I had difficulty falling sleep. I made two cups of herbal tea with lavender. This morning, I feel very groggy and have a headache." What explanation should the nurse provide the client? a. lavender should be delayed at least 1 hour after using alcohol to avoid side effects. b. lavender may increase sedation from other central nervous system depressants. c. herbal teas often cause nervous system side effects such as headaches. d. these feelings are actually a hangover from excessive alcohol intake.

b. lavender may increase sedation from other central nervous system depressants. Lavender has sedative properties that are potentiated when used in combination with other central nervous system depressants. Headaches are another possible side effect of this herbal medicine. The nurse should advise caution in ingesting alcohol and lavender for these reasons. Taking lavender an hour after alcohol will not prevent these interactions, and it is likely that the lavender played a role in her feeling perhaps worse than usual after this episode of drinking. Herbal teas cause headaches in some cases, but it is not characteristic of this group of herbal remedies

What personality traits are most likely to be documented by a client demonstrating characteristics of an obsessive-compulsive personality disorder (OCPD)? a. affable, generous. b. perfectionist, inflexible. c. suspicious, holds grudges. d. dramatic speech, impulsive.

b. perfectionist, inflexible. The individual with obsessive-compulsive personality disorder is perfectionist, rigid, preoccupied with rules and procedures, and afraid of making mistakes. The other options refer to behaviors or traits not usually associated with OCPD.

A client diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The health care provider prescribes daily dressing changes. The nurse performing this care should understand the need to deliver the care in what manner? a. maintaining a stern and authoritarian affect. b. providing care in a matter-of-fact manner. c. encouraging the client to express anger. d. being very rigid but not challenging.

b. providing care in a matter-of-fact manner A matter-of-fact approach does not provide the client with positive reinforcement for selfmutilation. The goal of providing emotional consistency is supported by this approach. The distracters provide positive reinforcement of the behavior or fail to show compassion.

A nurse set limits while interacting with a client demonstrating behaviors associated with borderline personality disorder. The client tells the nurse, "You used to care about me. I thought you were wonderful. Now I can see I was wrong. You're evil." This outburst can be documented using what term? a. denial. b. splitting. c. defensive. d. reaction formation.

b. splitting. Splitting involves loving a person, then hating the person because the client is unable to recognize that an individual can have both positive and negative qualities. Denial is unconsciously motivated refusal to believe something. Reaction formation involves unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate defensiveness.

A nurse interacts with an outclient client who has a history of multiple suicide attempts. What is the most helpful response for a nurse to make when the client states, "I am considering committing suicide."? a. "I'm glad you shared this. Please do not worry. We will handle it together." b. "I think you should admit yourself to the hospital to keep you safe." c. "Bringing up these feelings is a very positive action on your part." d. "We need to talk about the good things you have to live for."

c. "Bringing up these feelings is a very positive action on your part." The correct response gives the client reinforcement, recognition, and validation for making a positive response rather than acting out the suicidal impulse. It gives neither advice nor false reassurance, and it does not imply stereotypes such as "You have a lot to live for." It uses the client's ambivalence and sets the stage for more realistic problem solving.

A nurse and client are discussing the client's need to agree not to harm themselves. What is the preferable wording from the client? a. "I will not try to harm myself during the next 24 hours." b. "I will not make a suicide attempt while I am hospitalized." c. "For the next 24 hours, I will not in any way attempt to harm or kill myself." d. "I will not kill myself until I call my primary nurse or a member of the staff."

c. "For the next 24 hours, I will not in any way attempt to harm or kill myself." The correct answer leaves no loopholes. The wording about not harming oneself and not making an attempt leaves loopholes or can be ignored by the client who thinks "I am not going to harm myself, I am going to kill myself" or "I am not going to attempt suicide, I am going to commit suicide." A client may call a therapist and leave the telephone to carry out the suicidal plan

Which statement made by a client diagnosed with borderline personality disorder indicates the treatment plan is effective? a. "I think you are the best nurse on the unit." b. "I'm never going to get high on drugs again." c. "I felt empty and wanted to hurt myself, so I called you." d. "I hate my mother. I called her today, and she wasn't home."

c. "I felt empty and wanted to hurt myself, so I called you." Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.

A nurse assesses a client who reports a 3-week history of depression and periods of uncontrolled crying. The client says, "My business is bankrupt, and I was served with divorce papers." Which subsequent statement by the client alerts the nurse to a concealed suicidal message? a. "I wish I were dead." b. "Life is not worth living." c. "I have a plan that will fix everything." d. "My family will be better off without me."

c. "I have a plan that will fix everything." Verbal clues to suicide may be overt or covert. The incorrect options are overt references to suicide. The correct option is more veiled. It alludes to the client's suicide as being a way to "fix everything" but does not say it outright.

A client shows a nurse to respond to this advertisement: "Our product is a scientific breakthrough helpful for depression, anxiety, and sleeplessness. Made from an ancient formula, it stimulates circulation and excretes toxins. Satisfaction guaranteed or your money back." What is the nurse's best response? a. "Over-the-counter products for sleep problems are ineffective." b. "Do not take anything unless it's prescribed by your doctor." c. "Let's do some additional investigation of that product." d. "It sounds like you are trying to self-medicate."

c. "Let's do some additional investigation of that product." Helping consumers actively evaluate the quality of information available to them is important. It is important for the nurse to work with the client and include the client's preferences regarding management of health. Advertisements indicating scientific breakthroughs or promising miracles for multiple ailments are usually for products that are useless and being fraudulently marketed. Some may even be harmful. Some over-the-counter products can be useful, and clients do not need a prescription for these products. The broader issue is safety and efficacy, rather than whether the client is trying to self-medicate.

A client tells the nurse, "I prefer to treat my physical problems with herbs and vitamins. They are natural substances, and natural products are safe." Which response by the nurse would be most appropriate? a. "Natural substances tend to be safer than conventional medical remedies." b. "Natural remedies give you the idea that you are controlling your treatment." c. "The word natural can be a marketing term used to imply a product is healthy, but that's not always true." d. "You should not treat your own physical problems. You should see your health care provider for these problems."

c. "The word natural can be a marketing term used to imply a product is healthy, but that's not always true." CAM remedies are usually natural substances, but it is a fallacy that products labeled natural are safer than conventional medicines. Some natural products contain powerful ingredients that can cause illness and damage to the body if taken inappropriately and, for some persons, can be dangerous even when used as directed. This is the most important message for the nurse to convey to the client. So-called natural substances can have a number of significant side effects. Natural substances may give one the belief that he is controlling his own treatment, but that is not the message that most needs to be communicated here. Many clients can safely self-manage minor physical problems.

A nurse talks with a woman who recently learned that her husband died while jogging. What is the appropriate statement for the nurse to provide in response? a. "At least your husband did not suffer." b. "It's better to go quickly as your husband did." c. "Your husband's loss must be very painful for you." d. "You will begin to feel better after you get over the shock."

c. "Your husband's loss must be very painful for you." The most helpful responses by others validate the bereaved person's experience of loss. Avoid clichés, because they are ineffective

A client who is visiting the crisis clinic for the first time asks, "How long will I be coming here?" The nurse's reply should consider that the usual duration of crisis intervention is what time frame? a. 1 to 2 weeks. b. 3 to 4 weeks. c. 4 to 6 weeks. d. 8 to 12 weeks.

c. 4 to 6 weeks. The disorganization associated with crisis is so distressing that it usually cannot be tolerated for more than 4 to 6 weeks. If it is not resolved by that time, the individual usually adopts dysfunctional behaviors that reduce anxiety without solving the problem. Crisis intervention can shorten the duration.

Which client would most likely benefit from taking St. John's wort? a. A client with mood swings. b. A client with hypomanic symptoms. c. A client with mild depressive symptoms. d. A client with panic disorder with agoraphobia.

c. A client with mild depressive symptoms. St. John's wort may be effective in treating mild to moderate depression. St John's wort has not been found to be effective in treatment of cyclothymic, bipolar, or anxiety disorders.

Which referral will be most helpful for a woman who was severely beaten by intimate partner, has no relatives or friends in the community, is afraid to return home, and has limited financial resources? a. A support group b. A mental health center c. A women's shelter d. Vocational counseling

c. A women's shelter Because the woman has no safe place to go, referral to a shelter is necessary. The shelter will provide other referrals as necessary.

Which characteristic of personality disorders makes it most necessary for staff to schedule frequent team meetings in order to address the client's needs and maintain a therapeutic milieu? a. Ability to achieve true intimacy b. Flexibility and adaptability to stress c. Ability to provoke interpersonal conflict d. Inability to develop trusting relationships

c. Ability to provoke interpersonal conflict Frequent team meetings are held to counteract the effects of the client's attempts to split staff and set them against one another, causing interpersonal conflict. Clients with personality disorders are inflexible and demonstrate maladaptive responses to stress. They are usually unable to develop true intimacy with others and are unable to develop trusting relationships. Although problems with trust may exist, it is not the characteristic that requires frequent staff meetings.

The history shows that a newly admitted client is impulsive. The nurse would expect the client to demonstrate what characteristic behavior? a. Adherence to a strict moral code. b. Manipulative, controlling strategies. c. Acting without thought on urges or desires. d. Postponing gratification to an appropriate time.

c. Acting without thought on urges or desires. The impulsive individual acts in haste without taking time to consider the consequences of the action. None of the other options describes impulsivity

An older adult was stopped by police for driving through a red light. When asked for a driver's license, the adult hands the police officer a pair of sunglasses. What sign of dementia is evident? a. Aphasia b. Apraxia c. Agnosia d. Anhedonia

c. Agnosia Agnosia refers to the loss of sensory ability to recognize objects. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movement. Anhedonia refers to a loss of joy in life.

Which service would be expected to provide resources 24 hours a day, 7 days a week if needed for persons with serious mental illness (SMI)? a. Clubhouse model b. Cognitive-behavioral therapy (CBT) c. Assertive community treatment (ACT) d. Cognitive enhancement therapy (CET)

c. Assertive community treatment (ACT) ACT involves consumers working with a multidisciplinary team that provides a comprehensive array of services. At least one member of the team is available 24 hours a day for crisis needs, and the emphasis is on treating the client within his own environment.

One month ago, a client diagnosed with borderline personality disorder and a history of selfmutilation began dialectical behavior therapy. Today the client telephones to say, "I feel empty and want to hurt myself." The nurse should immediately take what action? a. Arrange for emergency inpatient hospitalization. b. Send the client to the crisis intervention unit for 8 to 12 hours. c. Assist the client to choose coping strategies for triggering situations. d. Advise the client to take an antianxiety medication to decrease the anxiety level.

c. Assist the client to choose coping strategies for triggering situations. The client has responded appropriately to the urge for self-harm by calling a helping individual. A component of dialectical behavior therapy is telephone access to the therapist for "coaching" during crises. The nurse can assist the client to choose an alternative to self-mutilation. The need for a protective environment may not be necessary if the client is able to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate. Taking a sedative and going to sleep should not be the first-line intervention because sedation may reduce the client's ability to weigh alternatives to mutilating behavior.

Which intervention will the nurse recommend for the distressed family and friends of someone who has committed suicide? a. Participating in reminiscence therapy b. Psychological postmortem assessment c. Attending a self-help group for survivors d. Contracting for at least two sessions of group therapy

c. Attending a self-help group for survivors Survivors need outlets for their feelings about the loss and the deceased person. Self-help groups provide peer support while survivors work through feelings of loss, anger, and guilt. Psychological postmortem assessment would not provide the support necessary to work through feelings of loss associated with the suicide. Reminiscence therapy is not geared to loss resolution. Contracting for two sessions of group therapy would not provide sufficient time to work through the issues associated with a death by suicide.

When assessing a client's plan for suicide, what aspect has priority? a. Client's financial and educational status b. Client's insight into suicidal motivation c. Availability of means and lethality of method d. Quality and availability of client's social support

c. Availability of means and lethality of method If a person has plans that include choosing a method of suicide readily available and if the method is one that is lethal (i.e., will cause the person to die with little probability for intervention), the suicide risk is high. These areas provide a better indication of risk than the areas mentioned in the other options. See relationship to audience response question.

Others describe a worker as very shy and lacking in self-confidence. This worker stays in an office cubicle all day, never coming out for breaks or lunch. Which term best describes this behavior? a. Narcissistic b. Histrionic c. Avoidant d. Paranoid

c. Avoidant Clients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and avoid situations in which they might fail. They believe themselves to be inferior and unappealing. Individuals with histrionic personality disorder are seductive, flamboyant, shallow, and attention-seeking. Paranoia and narcissism are not evident.

Which nursing diagnosis is likely to apply to an individual diagnosed with a serious mental illness (SMI) who is homeless? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

c. Chronic low self-esteem Many individuals with SMI do not live with their families and become homeless. Life on the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis one that should be considered. Substance abuse is not an approved North American Nursing Diagnosis Association (NANDA)-International diagnosis. Insomnia may be noted in some clients but is not a universal problem. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not seen in a majority of the homeless.

A nurse gives anticipatory guidance to the family of a client diagnosed with mild early stage Alzheimer's disease. Which problem common to that stage should the nurse address? a. Violent outbursts b. Emotional disinhibition c. Communication deficits d. Inability to feed or bathe self

c. Communication deficits Families should be made aware that the client will have difficulty concentrating and following or carrying on in-depth or lengthy conversations. The other symptoms and problems are usually seen at later stages of the disease.

The nurse wants to enroll a client with poor social skills in a training program for clients diagnosed with schizophrenia. Which description accurately describes social skills training? a. Clients learn to improve their attention and concentration. b. Group leaders provide support without challenging clients to change. c. Complex interpersonal skills are taught by breaking them into simpler behaviors. d. Clients learn social skills by practicing them in a supported employment setting.

c. Complex interpersonal skills are taught by breaking them into simpler behaviors. In social skills training, complex interpersonal skills are taught by breaking them down into component behaviors that are covered in a stepwise fashion. Social skills training is not based in employment settings, although such skills can be addressed as part of supported employment services. The other distracters are less relevant to social skills training.

A client diagnosed with depression confidently tells the nurse, "I've been supplementing my prescribed antidepressant with St. John's wort. It has helped a great deal." What is the nurse's priority action? a. Assess changes in the client's level of depression. b. Remind the client to use a secondary form of birth control. c. Educate the client about the risks of selective serotonin syndrome. d. Suggest adding valerian to the treatment regimen to further improve results.

c. Educate the client about the risks of selective serotonin syndrome St. John's wort inhibits serotonin reuptake by elevating extracellular sodium; thus, it may interact with medication, particularly selective serotonin reuptake inhibitors, to produce serotonin syndrome. Discussing the client's birth control method is a secondary priority.

An 11-year-old reluctantly tells the nurse, "My parents don't like me. They said they wish I was never born." Which type of abuse is likely? a. Sexual b. Physical c. Emotional d. Economic

c. Emotional Examples of emotional abuse include having an adult demean a child's worth, frequently criticize, or belittle the child. No data support physical battering or endangerment, sexual abuse, or economic abuse.

When a client diagnosed with a personality disorder uses manipulation to get needs met, the staff applies limit-setting interventions. What is the correct rationale for this action? a. It provides an outlet for feelings of anger and frustration. b. It respects the client's wishes, so assertiveness will develop. c. External controls are necessary due to failure of internal control. d. Anxiety is reduced when staff assumes responsibility for the client's behavior.

c. External controls are necessary due to failure of internal control A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning, and flattering. To protect the rights of others, external controls must be consistently maintained until the client is able to behave appropriately.

A college student who failed two tests cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate and asked to be left alone for a few hours. Which behavior provides the strongest clue of an impending suicide attempt? a. Calling parents b. Excessive crying c. Giving away sweaters d. Staying alone in dorm room

c. Giving away sweaters Giving away prized possessions may signal that the individual thinks he or she will have no further need for the item, such as when a suicide plan has been formulated. Calling parents, remaining in a dorm, and crying do not provide direct clues to suicide.

An adult tells the nurse, "My partner abuses me when I make mistakes, but I always get an apology and a gift afterward. I've considered leaving but haven't been able to bring myself to actually do it." Which phase in the cycle of violence prevents this adult from leaving? a. Tension-building b. Acute battering c. Honeymoon d. Stabilization

c. Honeymoon The honeymoon stage is characterized by kind, loving behaviors toward the abused spouse when the perpetrator feels remorseful. The victim believes the promises and drops plans to leave or seek legal help. The tension-building stage is characterized by minor violence in the form of abusive verbalization or pushing. The acute battering stage involves the abuser beating the victim. The violence cycle does not include a stabilization stage.

A person diagnosed with a serious mental illness (SMI) living in the community was punched, pushed to the ground, and robbed of $7 during the day on a public street. Which statements about violence and SMI in general are accurate? (Select all that apply.) a. Persons with SMI are more likely to be violent. b. SMI persons are more likely to commit crimes than to be the victims of crime. c. Impaired judgment and social skills can provoke hostile or assaultive behavior. d. Lower incomes force SMI persons to live in high-crime areas, increasing risk. e. SMI persons experience higher rates of sexual assault and victimization than others. f. Criminals may believe SMI persons are less likely to resist or testify against them

c. Impaired judgment and social skills can provoke hostile or assaultive behavior. d. Lower incomes force SMI persons to live in high-crime areas, increasing risk. e. SMI persons experience higher rates of sexual assault and victimization than others. f. Criminals may believe SMI persons are less likely to resist or testify against them. Mentally ill persons are more likely to be victims of crime than perpetrators of criminal acts. They are often victims of criminal behavior, including sexual crimes, at a higher rate than others. When a mentally ill person commits a crime, it is usually nonviolent. Mental illnesses interfere with employment and are associated with poverty, limiting SMI persons to living in inexpensive areas that also tend to be higher-crime areas. SMI persons may inadvertently provoke others because of poor judgment or socially inappropriate behavior, or they may be victimized because they are perceived as passive, less likely to resist, and less likely to be believed as witnesses. See related audience response question.

A client who was widowed 18 months ago says, "I can remember good times we had without getting upset. Sometimes I even think about the disappointments. I am still trying to become accustomed to sleeping in the bed all alone." How should the work of mourning be described? a. It is beginning. b. It has not begun. c. It is at or near completion. d. It is progressing abnormally.

c. It is at or near completion. The work of mourning has been successfully completed when the bereaved can acknowledge both positive and negative memories about the deceased and when the task of restructuring the relationship with the deceased is completed.

After celebrating the fortieth birthday, an individual becomes concerned with the loss of youthful appearance. What type of crisis has occurred? a. Reactive b. Situational c. Maturational d. Body image

c. Maturational Maturational crises occur when a person arrives at a new stage of development and finds that old coping styles are ineffective but has not yet developed new strategies. Situational crises arise from sources external to the individual. "Reactive" and "body image" are not types of crisis.

Which complementary and alternative therapy may be safely combined with traditional Western medicine in the treatment of anxiety disorder? a. Electroconvulsive therapy b. Mega doses of vitamins c. Meditative practices d. Herbal therapy

c. Meditative practices Yoga, meditation, and prayer are considered to be beneficial adjuncts to treatment for anxiety disorder. Research supports this with findings of lower catecholamine levels following meditation. Client self-reports suggest client satisfaction, with increased ability to relax. Meditation and spiritual practices have no associated untoward side effects. Herbal therapy and megadoses of vitamins have potential associated side effects and interactions. Electroconvulsive therapy is not CAM.

Which medication prescribed to clients diagnosed with Alzheimer's disease antagonizes Nmethyl-D-aspartate (NMDA) channels rather than cholinesterase? a. Donepezil b. Rivastigmine c. Memantine d. Galantamine

c. Memantine Memantine blocks the NMDA channels and is used in moderate-to-late stages of the disease. Donepezil, rivastigmine, and galantamine are all cholinesterace inhibitors. These drugs increase the availability of acetylcholine and are most often used to treat mild-to-moderate Alzheimer's disease.

An older adult drove to a nearby store but was unable to remember how to get home or state an address. When police intervened, they found that this adult was wearing a heavy coat and hat, even though it was July. Which stage of Alzheimer's disease is evident? a. Sundowning b. Early c. Middle d. Late

c. Middle In the middle stage, deterioration is evident. Memory loss may include the inability to remember addresses or the date. Activities such as driving may become hazardous, and frustration by the increasing difficulty of performing ordinary tasks may be experienced. The individual has difficulty with clothing selection. Mild cognitive decline (early-stage) Alzheimer's can be diagnosed in some, but not all, individuals. Symptoms include misplacing items and misuse of words. In the late stage there is severe cognitive decline along with agraphia, hyperorality, blunting of emotions, visual agnosia, and hypermetamorphosis. Sundowning is not a stage of Alzheimer's disease.

Which agency provides coordination in the event of a terrorist attack? a. Food and Drug Administration (FDA) b. Environmental Protection Agency (EPA) c. National Incident Management System (NIMS) d. Federal Emergency Management Agency (FEMA)

c. National Incident Management System (NIMS) The NIMS provides a systematic approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector during disaster situations.

An older adult with Lewy body dementia lives with family and attends a day care center. A nurse at the day care center noticed the adult had a disheveled appearance, strong odor of urine, and bruises on the limbs and back. What type of abuse might be occurring? a. Psychological b. Financial c. Physical d. Sexual

c. Physical Lewy body dementia results in cognitive impairment. The assessment of physical abuse would be supported by the nurse's observation of bruises. Physical abuse includes evidence of improper care as well as physical endangerment behaviors, such as reckless behavior toward a vulnerable person that could lead to serious injury. No data substantiate the other options.

What is a nurse's legal responsibility if child abuse or neglect is suspected? a. Discuss the findings with the child's parent and health care provider. b. Document the observation and suspicion in the medical record. c. Report the suspicion according to state regulations. d. Continue the assessment.

c. Report the suspicion according to state regulations. Each state has specific regulations for reporting child abuse that must be observed. The nurse is a mandated reporter. The reporter does not need to be sure that abuse or neglect occurred, only that it is suspected. Speculation should not be documented, only the facts.

A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest priority? a. Powerlessness b. Social isolation c. Risk for suicide d. Compromised family coping

c. Risk for suicide This diagnosis is the only one with life-or-death ramifications and is therefore of higher priority than the other options.

As a nurse prepares to administer medication to a client diagnosed with a borderline personality disorder, the client says, "Just leave it on the table. I'll take it when I finish combing my hair." What is the nurse's best response? a. Reinforce this assertive action by the client. Leave the medication on the table as requested. b. Respond to the client, "I'm worried that you might not take it. I'll come back later." c. Say to the client, "I must watch you take the medication. Please take it now." d. Ask the client, "Why don't you want to take your medication now?"

c. Say to the client, "I must watch you take the medication. Please take it now." The individual with a borderline personality disorder characteristically demonstrates manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital not only for the client's safety, but also to prevent splitting other staff. "Why" questions are not therapeutic.

Two clients in a residential care facility are diagnosed with dementia. One shouts to the other, "Move along, you're blocking the road." The other client turns, shakes a fist, and shouts, "You're trying to steal my car." What is the nurse's best action? a. Administer one dose of an antipsychotic medication to both clients. b. Reinforce reality. Say to the clients, "Walk along in the hall. This is not a traffic intersection." c. Separate and distract the clients. Take one to the day room and the other to an activities area. d. Step between the two clients and say, "Please quiet down. We do not allow violence here."

c. Separate and distract the clients. Take one to the day room and the other to an activities area. Separating and distracting prevents escalation from verbal to physical acting out. Neither client loses self-esteem during this intervention. Medication probably is not necessary. Stepping between two angry, threatening clients is an unsafe action and trying to reinforce reality during an angry outburst will probably not be successful when the clients are cognitively impaired.

An adolescent comes to the crisis clinic and reports sexual abuse by an uncle. The adolescent told both parents about the uncle's behavior, but the parents did not believe the adolescent. What type of crisis exists? a. Maturational b. Tertiary c. Situational d. Organic

c. Situational A situational crisis arises from events that are extraordinary, external rather than internal, and often unanticipated. Sexual molestation falls within this classification. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. "Organic" and "Tertiary" are not types of crisis.

Six months ago, a woman had a prophylactic double mastectomy because of a family history of breast cancer. One week ago, this woman learned her husband was involved in an extramarital affair. The woman tearfully says to the nurse, "What else can happen?" What type of crisis is this person experiencing? a. Maturational b. Mitigation c. Situational d. Recurring

c. Situational Severe physical or mental illness is a potential cause of a situational crisis. The potential loss of a loved one also serves as a potential cause of a situational crisis. Maturational crisis occurs as an individual arrives at a new stage of development, when old coping styles may be ineffective. No classification of recurring crisis exists. Mitigation refers to attempts to limit a disaster's impact on human health and community function.

What is an appropriate initial outcome for a client diagnosed with a personality disorder who frequently manipulates others? a. The client will identify when feeling angry. b. The client will use manipulation only to get legitimate needs met. c. The client will acknowledge manipulative behavior when it is called to his or her attention. d. The client will accept fulfillment of his or her requests within an hour rather than immediately.

c. The client will acknowledge manipulative behavior when it is called to his or her attention. This is an early outcome that paves the way for later taking greater responsibility for controlling manipulative behavior. Identifying anger relates to anger and aggression control. Using manipulation to get legitimate needs is an inappropriate outcome. The client would ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests within an hour rather than immediately relates to impulsivity control.

At the last contracted visit in the crisis intervention clinic, an adult says, "I've emerged from this a stronger person. You helped me get my life back in balance." The nurse responds, "I think we should have two more sessions to explore why your reactions were so intense." Which analysis applies? a. The client is experiencing transference. b. The client demonstrates need for continuing support. c. The nurse is having difficulty terminating the relationship. d. The nurse is empathizing with the client's feelings of dependency.

c. The nurse is having difficulty terminating the relationship. Termination is indicated; however, the nurse's remark is clearly an invitation to work on other problems and prolong contact with the client. The focus of crisis intervention is the problem that precipitated the crisis, not other issues. The scenario does not describe transference. The client shows no need for continuing support. The scenario does not describe dependency needs.

Which nursing diagnoses are most applicable for a client diagnosed with severe late stage Alzheimer's disease? (Select all that apply.) a. Acute confusion b. Anticipatory grieving c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain

c. Urinary incontinence d. Disturbed sleep pattern e. Risk for caregiver role strain The correct answers are consistent with problems frequently identified for clients with late-stage Alzheimer's disease. Confusion is chronic, not acute. The client's cognition is too impaired to grieve.

Which behavior demonstrated by that a client diagnosed with an antisocial personality disorder most clearly warrants limit setting? a. Flattering the nurse b. Lying to other clients c. Verbal abuse of another client d. Detached superficiality during counseling

c. Verbal abuse of another client Limits must be set in areas in which the client's behavior affects the rights of others. Limiting verbal abuse of another client is a priority intervention and particularly relevant when interacting with a client diagnosed with an antisocial personality disorder. The other concerns should be addressed during therapeutic encounters.

A new psychiatric technician says, "Schizophrenia ... schizotypal! What's the difference?" The nurse's response should include which information? a. A client diagnosed with schizophrenia is not usually overtly psychotic. b. In schizotypal personality disorder, the client remains psychotic much longer. c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. d. Schizotypal personality disorder causes more frequent and more prolonged hospitalizations than schizophrenia.

c. With schizotypal personality disorder, the person can be made aware of misinterpretations of reality. The client with schizotypal personality disorder might have problems thinking, perceiving, and communicating and might have an odd, eccentric appearance; however, they can be made aware of misinterpretations and overtly psychotic symptoms are usually absent. The individual with schizophrenia is more likely to display psychotic symptoms, remain ill for longer periods, and have more frequent and prolonged hospitalizations.

An adult diagnosed with a serious mental illness (SMI) says, "I do not need help with money management. I have excellent ideas about investments." This client usually does not have money to buy groceries by the middle of the month. The nurse assesses the client as demonstrating what defense mechanism? a. rationalization. b. identification. c. anosognosia. d. projection.

c. anosognosia. The client scenario describes anosognosia, the inability to recognize one's deficits due to one's illness. The client is not projecting an undesirable thought or emotion from himself onto others. He is not justifying his behavior via rationalization and is not identifying with another.

Several children are seen in the emergency department for treatment of various illnesses and injuries. Which assessment finding would create the most suspicion for child abuse? a. complaints of abdominal pain. b. repeated middle ear infections. c. bruises on extremities. d. diarrhea.

c. bruises on extremities. Injuries such as immersion or cigarette burns, facial fractures, whiplash, bite marks, traumatic injuries, bruises, and fractures in various stages of healing suggest the possibility of abuse. In older children, vague complaints such as back pain may also be suspicious. Ear infections, diarrhea, and abdominal pain are problems that were unlikely to have resulted from violence.

A tearful, anxious client at the outpatient clinic reports, "I should be dead." What is the initial task the nurse conducting the assessment interview should implement? a. assess lethality of suicide plan. b. encourage expression of anger. c. establish trust with the client. d. determine risk factors for suicide.

c. establish trust with the client. This scenario presents a potential crisis. Establishing trust facilitates a therapeutic alliance that will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan, lethality of plan, and presence of risk factors for suicide.

Acupuncture is a traditional Chinese medical treatment based on what belief? a. insertion of needles in key locations will drain toxic energies. b. pressure on meridian points will correct problems in energy flow. c. insertion of needles modulates the flow of energy along body meridians. d. taking small doses of noxious substances will alleviate specific symptoms.

c. insertion of needles modulates the flow of energy along body meridians. Acupuncture involves the insertion of needles to modulate the flow of body energy (qi) along specific body pathways called meridians. Acupressure uses pressure to affect energy flow. Homeopathy involves the use of micro-dosages of specific substances to effect health improvement. Traditional Chinese medicine (TCM) is more concerned with energy and life force balance, and acupuncture is not predicated on the removal of toxic energies.

Consider this comment to three different nurses by a client diagnosed with an antisocial personality disorder, "Another nurse said you don't do your job right." Collectively, these interactions can be documented using which term? a. seductive. b. detached. c. manipulative. d. guilt-producing.

c. manipulative. Clients manipulate and control staff in various ways. By keeping staff off balance or fighting among themselves, the person with an antisocial personality disorder is left to operate as he or she pleases. Seductive behavior has sexual connotations. The client is displaying the opposite of detached behavior. Guilt is not evident in the comments.

A widow repeatedly tells details of finding her elderly husband not breathing, performing cardiopulmonary resuscitation, and seeing him pronounced dead. Family members are concerned and ask, "What can we do?" What response should the nurse provide when counsel the family? a. they should express their feelings to the widow and ask her not to retell the story. b. the retelling should be limited to once daily to avoid unnecessary stimulation. c. repeating the story and her feelings is a helpful and necessary part of grieving. d. retelling of memories is expected as part of the aging process.

c. repeating the story and her feelings is a helpful and necessary part of grieving. Nurses are encouraged to tell bereaved patients that telling the personal story of loss as many times as needed is acceptable and healthy because repetition is a helpful and necessary part of grieving.

A nurse uses the SAD PERSONS scale to interview a client. This tool provides data relevant to be used for assessing what? a. current stress level. b. mood disturbance. c. suicide potential. d. level of anxiety.

c. suicide potential. The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age, depression, previous attempt, ethanol use, rational thinking loss, social supports lacking, organized plan, no spouse, and sickness. The tool does not have categories to provide information on the other options listed.

An adult seeks counseling after the spouse was murdered. The adult angrily says, "I hate the beast that did this. It has ruined my life. During the trial, I don't know what I'll do if the jury doesn't return a guilty verdict." What is the nurse's highest priority response? a. "Would you like to talk to a psychiatrist about some medication to help you cope during the trial?" b. "What resources do you need to help you cope with this situation?" c. "Do you have enough support from your family and friends?" d. "Are you having thoughts of hurting yourself or others?"

d. "Are you having thoughts of hurting yourself or others?" The highest nursing priority is safety. The nurse should assess suicidal and homicidal potential. The distracters are options, but the highest priority is safety.

A client with fluctuating levels of consciousness, disturbed orientation, and perceptual alteration begs, "Someone get these bugs off me." What is the nurse's best response? a. "No bugs are on your legs. You are having hallucinations." b. "I will have someone stay here and brush off the bugs for you." c. "Try to relax. The crawling sensation will go away sooner if you can relax." d. "I don't see any bugs, but I can tell you are frightened. I will stay with you."

d. "I don't see any bugs, but I can tell you are frightened. I will stay with you." When hallucinations are present, the nurse should acknowledge the client's feelings and state the nurse's perception of reality, but not argue. Staying with the client increases feelings of security, reduces anxiety, offers the opportunity for reinforcing reality, and provides a measure of physical safety. Denying the client's perception without offering help does not support the client emotionally. Telling the client to relax makes the client responsible for self-soothing. Telling the client that someone will brush the bugs away supports the perceptual distortions.

A client's spouse filed charges after repeatedly being battered. Which statement by this person supports an antisocial personality disorder? a. "I have a quick temper, but I can usually keep it under control." b. "I've done some stupid things in my life, but I've learned a lesson." c. "I'm feeling terrible about the way my behavior has hurt my family." d. "I hit because I am tired of being nagged. My spouse deserves the beating."

d. "I hit because I am tired of being nagged. My spouse deserves the beating." The person with an antisocial personality disorder often impulsively acts out feelings of anger and feels no guilt or remorse. Persons with antisocial personality disorders rarely seem to learn from experience or feel true remorse. Problems with anger management and impulse control are commonly observed with other psychiatric conditions.

An outpatient diagnosed with schizophrenia attends programming at a community mental health center. The client says, "I threw away the pills because they keep me from hearing God." Which response by the nurse would most likely to benefit this client? a. "You need your medicine. Your schizophrenia will get worse without it." b. "Do you want to be hospitalized again? You must take your medication." c. "I would like you to come to the medication education group every Thursday." d. "I noticed that when you take the medicine, you are able to keep the job you wanted."

d. "I noticed that when you take the medicine, you are able to keep the job you wanted." The client appears not to understand that he has an illness. He has stopped his medication because it interferes with a symptom that he finds desirable (auditory hallucinations—the voice of God). Connecting medication adherence to one of the client's goals (the job) can serve to motivate the client to take the medication and override concerns about losing the hallucinations. Exhorting a client to take medication because it is needed to control his illness is unlikely to be successful; he does not believe he has an illness. Medication psychoeducation would be appropriate if the cause of nonadherence was a knowledge deficit.

An immigrant from China needs a colonic resection but is anxious and reluctant about surgery. This client usually follows traditional Chinese health practices. Which comment by the nurse would most likely reduce the client's anxiety and reluctance? a. "Surgery will help rebalance the yin and yang forces and return you to harmony." b. "The surgery we are recommending will help you achieve final transformation." c. "I know this is new to you, but you can trust us to take very good care of you." d. "If you would like, we could investigate using acupuncture to help control pain."

d. "If you would like, we could investigate using acupuncture to help control pain." It would be helpful to incorporate elements of TCM as appropriate; such as acupuncture for pain control. TCM has the goal of healing in harmony with one's environment and all of creation in mind, body, and spirit, as well as balance of yin and yang energies and a state of transition. However, it would not be helpful to suggest that surgery will balance the yin and the yang, since this is not how balance is achieved in TCM. Transformation is recognized as a stage of healing occurring when mutual, creative, active participation occurs between healers and the client toward changes in the mind, body, and spirit; but "final transformation" could imply the end of corporeal life and might be perceived as hastening his demise. Appealing to him to trust persons whose practices are foreign to him conflicts with the client's values and would not likely be effective.

An older client diagnosed with severe, late-stage dementia no longer recognizes family members. The family asks how long it will be before this client recognizes them when they visit. What is the nurse's best reply? a. "Your family member will never again be able to identify you." b. "I think that is a question the health care provider should answer." c. "One never knows. Consciousness fluctuates in persons with dementia." d. "It is disappointing when someone you love no longer recognizes you."

d. "It is disappointing when someone you love no longer recognizes you." Therapeutic communication techniques can assist the family to come to terms with the losses and irreversibility dementia imposes on both the loved one and themselves. Two incorrect responses close communication. The nurse should take the opportunity to foster communication. Consciousness does not fluctuate in clients with dementia.

A nurse counsels a client with recent suicidal ideation. Which is the nurse's most therapeutic comment? a. "Let's make a list of all your problems and think of solutions for each one." b. "I'm happy you're taking control of your problems and trying to find solutions." c. "When you have bad feelings, try to focus on positive experiences from your life." d. "Let's consider which problems are very important and which are less important."

d. "Let's consider which problems are very important and which are less important." The nurse helps the client develop effective coping skills. Assist the client to reduce the overwhelming effects of problems by prioritizing them. The incorrect options continue to present overwhelming approaches to problem solving.

The parent of a seriously mentally ill adult asks the nurse, "Why are you making a referral to a vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse's best reply? a. "We make this referral to continue eligibility for federal funding." b. "Are you concerned that we're trying to make your child too independent?" c. "If you think the program would be detrimental, we can postpone it for a time." d. "Most clients are capable of employment at some level, competitive or supported."

d. "Most clients are capable of employment at some level, competitive or supported." Studies have shown that most clients who complete vocational rehabilitation programs are capable of some level of employment. They also demonstrate significant improvement in assertiveness and work behaviors as well as decreased depression.

A bystander was killed during a robbery 2 weeks ago. His widow, who is diagnosed with schizoaffective disorder, cries spontaneously when talking about his death. What is the nurse's most therapeutic response? a. "Are you hearing voices at night?" b. "I am worried about how much you are crying. Your grief over your husband's death has gone on too long." c. "This loss is harder to accept because of your mental illness. I will refer you to a partial hospitalization program." d. "The unexpected death of your husband must be very painful. I am glad you are able to talk to me about your feelings."

d. "The unexpected death of your husband must be very painful. I am glad you are able to talk to me about your feelings." The client is expressing feelings related to the loss, and this is an expected and healthy behavior. This client is at risk for dysfunctional grieving because of the history of a serious mental illness, but the nurse's priority intervention is to form a therapeutic alliance and support the patient's expression of feelings. The crying 2 weeks after his death is expected and normal.

A client is seen in the clinic for superficial cuts on both wrists. Initially the client paces and sobs but after a few minutes, the client is calmer. The nurse attempts to determine the client's perception of the precipitating event by asking which question? a. "Tell me why you were crying." b. "How did your wrists get injured?" c. "How can I help you feel more comfortable?" d. "What was happening when you started feeling this way?"

d. "What was happening when you started feeling this way?" A clear definition of the immediate problem provides the best opportunity to find a solution. Asking about recent upsetting events facilitates assessment of the precipitating event. The client is unlikely to be able to articulate what interventions will increase feelings of comfort. "Why" questions are nontherapeutic.

Which individual in the emergency department should be considered at highest risk for completing suicide? a. An adolescent Asian American girl with superior athletic and academic skills who has asthma b. A 38-year-old single, African American female church member with fibrocystic breast disease c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate

d. A 79-year-old single, white male diagnosed recently with terminal cancer of the prostate High-risk factors include being an older adult, single, male, and having a co-occurring medical illness. Cancer is one of the somatic conditions associated with increased suicide risk. Protective factors for African American women and Hispanic individuals include strong religious and family ties. Asian Americans have a suicide rate that increases with age.

Which scenario is an example of a situational crisis? a. The death of a child from sudden infant death syndrome b. Development of a heroin addiction c. Retirement of a 55-year-old person d. A riot at a rock concert

d. A riot at a rock concert The rock concert riot is unplanned, accidental, violent, and not a part of everyday life. The incorrect options are examples of maturational crises.

A widower tells friends, "I am taking my neighbor out for dinner. It's time for me to be more sociable again." Considering the stages of grief described by Kübler-Ross, which stage is evident? a. Anger b. Denial c. Depression d. Acceptance

d. Acceptance As an individual accepts loss, the person renews interest in people and activities. The person is seeking to move into new relationships. The patient's comment demonstrates an attempt to regain control. Bargaining is evidenced by people reviewing what could have been done differently. While the person may also experience occasional anger or sadness, the comment speaks directly to acceptance.

A client diagnosed with Alzheimer's disease calls the fire department saying, "My smoke detectors are going off." Firefighters investigate and discover that the client misinterpreted the telephone ringing. Which problem is this client experiencing? a. Hyperorality b. Aphasia c. Apraxia d. Agnosia

d. Agnosia Agnosia is the inability to recognize familiar objects, parts of one's body, or one's own reflection in a mirror. Hyperorality refers to placing objects in the mouth. Aphasia refers to the loss of language ability. Apraxia refers to the loss of purposeful movements, such as being unable to dress.

An adult says to the nurse, "The cancer in my neck spread in only 2 months. I've been cursed my whole life. Maybe if I had been more generous with others ..." Considering the stages of grief described by Kübler-Ross, which stage is evident? a. Anger b. Denial c. Depression d. Bargaining

d. Bargaining The patient's comment demonstrates an attempt to regain control. Bargaining is evidenced by people reviewing what could have been done differently. While the person may also be experiencing anger and depression, the comment speaks directly to bargaining. The person shows acceptance of the disease.

A woman said, "I can't take anymore! Last year my husband had an affair and now we don't communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college." What is the nurse's priority assessment? a. Identify measures useful to help improve the couple's communication. b. The client's feelings about the possibility of having a mastectomy c. Whether the husband is still engaged in an extramarital affair d. Clarify what the client means by "I can't take anymore."

d. Clarify what the client means by "I can't take anymore." During crisis intervention, the priority concern is client safety. This question helps assess personal coping skills. The other options are incorrect because the focus of crisis intervention is on the event that occurred immediately before the client sought help.

A woman says, "I can't take anymore. Last year my husband had an affair and now we do not communicate. Three months ago, I found a lump in my breast. Yesterday my daughter said she's quitting college and moving in with her boyfriend." Which issue should the nurse focus on during crisis intervention? a. The possible mastectomy b. The disordered family communication c. The effects of the husband's extramarital affair d. Coping with the reaction to the daughter's events

d. Coping with the reaction to the daughter's events The focus of crisis intervention is on the most recent problem: "the straw that broke the camel's back." The client had coped with the breast lesion, the husband's infidelity, and the disordered communication. Disequilibrium occurred only with the introduction of the daughter leaving college and moving.

A troubled adolescent pulled out a gun in a school cafeteria, fatally shot three people and injured many others. Hundreds of parents come to the school after hearing news reports. After police arrest the shooter, which action should occur next? a. Ask police to encircle the school campus with yellow tape to prevent parents from entering. b. Announce over the loudspeakers, "The campus is now secure. Please return to your classrooms." c. Require parents to pass through metal detectors and then allow them to look for their children in the school. d. Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents.

d. Designate zones according to the alphabet and direct students to the zones based on their surnames to facilitate reuniting them with their parents. Chaos is likely among students and desperate parents. A directive approach is best. Once the scene is secure, creative solutions are needed. Creating zones by letters of the alphabet will assist anxious parents and their children to unite. Preventing parents from uniting with their children will further incite the situation.

A family discusses the impact of a seriously mental ill member. Insurance partially covers treatment expenses, but the family spends much of their savings for care. The client's sibling says, "My parents have no time for me." The parents are concerned that when they are older, there will be no one to care for the client. Which response by the nurse would be most helpful? a. Acknowledge their concerns and consult with the treatment team about ways to bring the client's symptoms under better control. b. Give them names of financial advisors that could help them save or borrow sufficient funds to leave a trust fund to care for their loved one. c. Refer them to crisis intervention services to learn ways to manage caregiver stress and provide titles of some helpful books for families. d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the client become more independent.

d. Discuss benefits of participating in National Alliance on Mental Illness (NAMI) programs and ways to help the client become more independent. The family has raised a number of concerns, but the major issues appear to be the effects caregiving has had on the family and their concerns about the client's future. NAMI offers support, education, resources, and access to other families who have experience with the issues now facing this family. NAMI can help address caregiver burden and planning for the future needs of SMI persons. Improving the client's symptom control and general functioning can help reduce caregiver burden but would likely be a slow process, whereas NAMI involvement could benefit them on a number of fronts, possibly in a shorter time period. The family will need more than financial planning; their issues go beyond financial. The family is distressed but not in crisis. Crisis intervention is not an appropriate resource for the longer-term issues and needs affecting this family.

A young adult has recently had multiple absences from work. After each absence, this adult returned to work wearing dark glasses and long-sleeved shirts. During an interview with the occupational health nurse, this adult says, "My partner beat me, but it was because I did not do the laundry." What is the nurse's next action? a. Call the police. b. Arrange for hospitalization. c. Call the adult protective agency. d. Document injuries with a body map.

d. Document injuries with a body map. Documentation of injuries provides a basis for possible legal intervention. In most states, the abused adult would need to make the decision to involve the police. Because the worker is not an older adult and is competent, the adult protective agency is unable to assist. Admission to the hospital is not necessary.

A client diagnosed with borderline personality disorder (BPD) self-inflicted wrist lacerations after gaining new privileges on the unit. In this case, the self-mutilation may have been due to which trigger? a. An inherited disorder that manifests itself as an incapacity to tolerate stress. b. Use of projective identification and splitting to bring anxiety to manageable levels. c. A constitutional inability to regulate affect, predisposing to psychic disorganization. d. Fear of abandonment associated with progress toward autonomy and independence.

d. Fear of abandonment associated with progress toward autonomy and independence. Fear of abandonment is a central theme for most clients with borderline personality disorder. This fear is often exacerbated when clients with borderline personality disorder experience success or growth. None of the other options is generally a trigger for those diagnosed with BPD)

Which measure would be considered a form of primary prevention for suicide? a. Psychiatric hospitalization of a suicidal client b. Referral of a formerly suicidal client to a support group c. Suicide precautions for 24 hours for newly admitted clients d. Helping school children learn to manage stress and be resilient

d. Helping school children learn to manage stress and be resilient This measure promotes effective coping and reduces the likelihood that such children will become suicidal later in life. Admissions and suicide precautions are secondary prevention measures. Support group referral is a tertiary prevention measure.

A student accused a college professor of sexual intimidation. The professor tells the nurse, "I cannot teach nor do any research. My mind is totally preoccupied with these false accusations." What is the priority nursing diagnosis? a. Ineffective denial related to threats to professional identity b. Deficient knowledge related to sexual harassment protocols c. Impaired social interaction related to loss of teaching abilities d. Ineffective coping related to distress from false accusations

d. Ineffective coping related to distress from false accusations Ineffective coping may be evidenced by inability to meet basic needs, inability to meet role expectations. This nursing diagnosis is the priority because it reflects the consequences of the precipitating event associated with the professor's crisis. There is no evidence of denial. Deficient knowledge may apply, but it is not the priority. Data are not present to diagnose impaired social interaction.

A homeless individual diagnosed with serious mental illness (SMI) and a history of persistent treatment nonadherence plans to begin attending the day program at a community mental health center. Which intervention should be the team's initial focus? a. Teach appropriate health maintenance and prevention practices. b. Educate the client about the importance of treatment adherence. c. Help the client obtain employment in a local sheltered workshop. d. Interact regularly and supportively without trying to change the client.

d. Interact regularly and supportively without trying to change the client. Given the history of treatment nonadherence and the difficulty achieving other goals until psychiatrically stable and adherent, getting the client to accept and adhere to treatment is the fundamental goal to address. The intervention most likely to help meet that goal at this stage is developing a trusting relationship with the client. Interacting regularly, supportively, and without demands is likely to build the necessary trust and relationships that will be the foundation for all other interventions later on. No data here suggest the client is in crisis, so it is possible to proceed slowly and build this foundation of trust.

A hospitalized client diagnosed with schizophrenia has a history of multiple relapses. The client usually responds quickly to antipsychotic medication but soon discontinues the medication. Discharge plans include follow-up at the mental health center, group home placement, and a psychosocial day program. Which strategy should apply first as the client transitions from hospital to community? a. Administer a second-generation antipsychotic to help negative symptoms. b. Use a quick-dissolving medication formulation to reduce "cheeking." c. Prescribe a long-acting intramuscular antipsychotic medication. d. Involve the client in decisions about which medication is best.

d. Involve the client in decisions about which medication is best. Persons with schizophrenia are at high risk for treatment nonadherence, so the strategy needs primarily to address that risk. Of the options here, involving the client in the decision is best because it will build trust and help establish a therapeutic alliance with care providers, an essential foundation to adherence. Intramuscular depot medications can be helpful for promoting adherence if other alternatives have been unsuccessful, but IM medications are painful and may jeopardize the client's acceptance. All of the other strategies also apply but are secondary to trust and bonding with providers.

Four individuals have given information about their suicide plans. Which plan evidences the highest suicide risk? a. Turning on the oven and letting gas escape into the apartment during the night b. Cutting the wrists in the bathroom while the spouse reads in the next room c. Overdosing on aspirin with codeine while the spouse is out with friends d. Jumping from a railroad bridge located in a deserted area late at night

d. Jumping from a railroad bridge located in a deserted area late at night This is a highly lethal method with little opportunity for rescue. The other options are lower lethality methods with higher rescue potential. See relationship to audience response question.

What is the priority need for a client diagnosed with severe, late-stage dementia? a. Promotion of self-care activities b. Meaningful verbal communication c. Preventing the client from wandering d. Maintenance of nutrition and hydration

d. Maintenance of nutrition and hydration In severe (late-stage) dementia, the client often seems to have forgotten how to eat, chew, and swallow. Nutrition and hydration needs must be met if the client is to live. The client is incapable of self-care, ambulation, or verbal communication.

A client wants to learn more about integrative therapies. Which resource should the nurse suggest for the most reliable information? a. Internet b. American Nurses Association (ANA) c. Food and Drug Administration (FDA) d. National Center for Complementary and Integrative Health (NCCIH)

d. National Center for Complementary and Integrative Health (NCCIH) The NCCIH provides reliable, objective, and scientific information to help in making decisions about use of these practices. NCCIH supports not only research, but also the development and sharing of this kind of information. The FDA has information, but it is not as extensive as NCCIH. The Internet has many resources, but some are unreliable. The ANA does not provide extensive information about this topic.

An adult has recently been absent from work for 3-day periods on several occasions. Each time, the individual returned wearing dark glasses. Facial and body bruises were apparent. What is occupational health nurse's priority assessment? a. Interpersonal relationships b. Work responsibilities c. Socialization skills d. Physical injuries

d. Physical injuries The individual should be assessed for possible battering. Physical injuries are abuse indicators and are the primary focus for assessment. No data support the other options

A client with a history of asthma says, "I've been very nervous lately. I think aromatherapy will help. I am ordering $250 worth of oils from an Internet site that promised swift results." What is the nurse's best action? a. Support the client's efforts to become informed and to find health solutions. b. Suggest the client check with friends who have tried aromatherapy for treatment of anxiety. c. Remind the client, "If you spend that much on oils, you may not be able to buy your prescribed medication." d. Tell the client, "Aromatherapy can complicate respiratory problems such as asthma. Let's consider some other options."

d. Tell the client, "Aromatherapy can complicate respiratory problems such as asthma. Let's consider some other options." Safety is paramount, and aromatherapy may cause complications for a client with asthma. The nurse should view alternative treatments with an open mind and try to recognize the importance of the treatment to the client while trying to give the client accurate, reliable information about the treatment. Although efforts to become health literate should be supported, educating the client about the pitfalls of relying on the Internet is essential. The opinions of others, whether they are positive or negative, lack a scientific basis and are subject to confounding variables such as the placebo effect and individual factors such as age and health history. Admonishing the client may jeopardize the relationship.

For which client behavior would limit setting be most essential? a. The client who clings to the nurse and asks for advice about inconsequential matters. b. The client who is flirtatious and provocative with staff members of the opposite sex. c. The client who is hypervigilant and refuses to attend unit activities. d. The client who urges a suspicious client to hit anyone who stares.

d. The client who urges a suspicious client to hit anyone who stares. This is a manipulative behavior. Because manipulation violates the rights of others, limit setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the safety of at least two other clients is at risk. Limit setting may occasionally be used with dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff members), but other therapeutic techniques are also useful. Limit setting is not needed for a client who is hypervigilant and refuses to attend unit activities; rather, the need to develop trust is central to client compliance.

A nurse determines desired outcomes for a client diagnosed with schizotypal personality disorder. What is the best outcome? a. The client will adhere willingly to unit norms. b. The client will report decreased incidence of self-mutilative thoughts. c. The client will demonstrate fewer attempts at splitting or manipulating staff. d. The client will demonstrate ability to introduce self to a stranger in a social situation.

d. The client will demonstrate ability to introduce self to a stranger in a social situation. Schizotypal individuals have poor social skills. Social situations are uncomfortable for them. It is desirable for the individual to develop the ability to meet and socialize with others. Individuals with schizotypal PD (Personality Disorder) usually have no issues with adherence to unit norms, nor are they self-mutilative or manipulative.

A child drowned while swimming in a local lake 2 years ago. Which behavior best indicates the child's parents are mourning in an effective way? a. They forbid their other children from going swimming. b. They keep a place set for the deceased child at the family dinner table. c. They sealed their child's room exactly as the child left it 2 years ago. d. They throw flowers on the lake at each anniversary date of the accident.

d. They throw flowers on the lake at each anniversary date of the accident. Loss of a child is among the highest risk situations for maladaptive grieving. Depending on many factors, this process can take many months to a number of years. The parents who throw flowers on the lake on each anniversary date of the accident are openly expressing their feelings. The incorrect options indicate the parents are isolating themselves and/or denying their feelings.

Four teenagers died in an automobile accident. Six months later, which behavior by the parents best demonstrates acceptance of the tragedy? a. isolating themselves at home. b. returning immediately to employment. c. forbidding other teens in the household to drive a car. d. creating a scholarship fund at their child's high school.

d. creating a scholarship fund at their child's high school. Loss of a child is among the highest risk situations for maladaptive grieving. The parents who create a scholarship fund are openly expressing their feelings and memorializing their child. The other parents in this question are isolating themselves and/or denying their feelings.

A person who attempted suicide by overdose was treated in the emergency department and then hospitalized. What is the initial outcome for this client? a. verbalizing a will to live by the end of the second hospital day. b. describing two new coping mechanisms by the end of the third hospital day. c. accurately delineating personal strengths by the end of first week of hospitalization. d. exercising suicide self-restraint by refraining from attempts to harm self for 24 hours.

d. exercising suicide self-restraint by refraining from attempts to harm self for 24 hours. Suicide self-restraint relates most directly to the priority problem of risk for self-directed violence. The other outcomes are related to hope, coping, and self-esteem.

When preparing to interview a client diagnosed with narcissistic personality disorder, a nurse can anticipate the assessment findings will include which characteristics? a. preoccupation with minute details; perfectionist. b. charm, drama, seductiveness; seeking admiration. c. difficulty being alone; indecisive, submissiveness. d. grandiosity, self-importance, and a sense of entitlement.

d. grandiosity, self-importance, and a sense of entitlement. The characteristics of grandiosity, self-importance, and entitlement are consistent with narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are seen in clients with histrionic personality disorder. Preoccupation with minute details and perfectionism are seen in individuals with obsessive-compulsive personality disorder. Clients with dependent personality disorder often express difficulty being alone and are indecisive and submissive.

After a spouse's death, an adult repeatedly says, "I should have recognized what was happening and been more helpful." What emotion is this adult experiencing? a. depression. b. sadness. c. anger. d. guilt.

d. guilt. Guilt is expressed by the bereaved person's self-reproach. Anger, depression, and sadness cannot be assessed from data given in the scenario.

A client diagnosed with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." How should the nurse identify the etiology of the client's ineffective management of the medication regime? a. inadequate discharge planning. b. poor therapeutic alliance with clinicians. c. dislike of antipsychotic medication side effects. d. impaired reasoning secondary to the schizophrenia.

d. impaired reasoning secondary to the schizophrenia. The client's ineffective management of the medication regime is most closely related to impaired reasoning associated with the thought disturbances of schizophrenia. The client believes in being an exalted personage who hears God's voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest any of the other factors often related to medication nonadherence.

A health care provider recently convicted of Medicare fraud says to a nurse, "Sure I overbilled. Everyone takes advantage of the government. There are too many rules to follow and I deserve the money." These statements support what client characteristic? a. shame. b. suspiciousness. c. superficial remorse. d. lack of guilt feelings.

d. lack of guilt feelings. Rationalization is being used to explain behavior and deny wrongdoing. The individual who does not believe he or she has done anything wrong will not manifest anxiety, remorse, or guilt about the act. The client's remarks cannot be assessed as shameful. Lack of trust and concern that others are determined to do harm is not shown.

The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder would expect assessment findings to include what characteristics? a. arrogant, grandiose, and a sense of self-importance. b. attention seeking, melodramatic, and flirtatious. c. impulsive, restless, socially aggressive behavior. d. socially anxious, rambling stories, peculiar ideas.

d. socially anxious, rambling stories, peculiar ideas. Individuals with schizotypal personality disorder do not want to be involved in relationships. They are shy and introverted, speak little, and prefer fantasy and daydreaming to being involved with real people. The other behaviors would characteristically be noted in narcissistic, histrionic, and antisocial personality disorder

A hospice client tells the nurse, "Life has been good. I am proud of being self-educated. I overcame adversity and always gave my best. I intend to die as I lived." The nurse planning care for this client would recognize the priority of supporting which client need? a. providing aggressive pain and symptom management. b. helping the client reassess and explore existing conflicts. c. assisting the client to focus on the meaning in life and death. d. supporting the patient's use of own resources to meet challenges.

d. supporting the patient's use of own resources to meet challenges. The client whose intrinsic strength and endurance have been a hallmark often wishes to approach dying by staying optimistic and in control. Helping such patients use their own resources to meet challenges would be appropriate.

An outpatient diagnosed with schizophrenia tells the nurse, "I am here to save the world. I threw away the pills because they make God go away." What does the nurse suspect is the client's reason for medication nonadherence? a. poor alliance with clinicians. b. inadequate discharge planning. c. dislike of medication side effects. d. thought disturbances associated with the illness

d. thought disturbances associated with the illness. The client's nonadherence is most closely related to thought disturbances associated with the illness. The client believes he is an exalted personage who hears God's voice rather than an individual with a serious mental disorder who needs medication to control his symptoms. While the distracters may play a part in the client's nonadherence, the correct response is most likely.