Mental Health Disorders/Addictions and Treatment

A nursing team holds a conference to develop goals for the care of a withdrawn, shy male client with low self-esteem who is afraid to talk to members of the opposite sex.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

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

While watching television in the dayroom, a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse? 1 Walking to the end of the hallway where the client is standing 2 Accepting the action as the impulsive behavior of a sick person 3 Asking another client in the dayroom why the client acted in this way 4 Documenting the incident in the client's record while the memory is fresh

1 - Walking to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client. - Accepting the action as the impulsive behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person. - Another client's perception of the incident may or may not be valid. - Although it is important to document the incident in the client's record, this does not take precedence over letting the client know the nurse is available if needed.

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

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

A staff member tells a nurse that an older client becomes irritable when asked to assist with activities of daily living. On what general information about older adults should the nurse base a response? 1 Decreased ability to cope 2 Loss of ability to cooperate 3 Ambivalence toward authority 4 Difficulty performing step procedures

1 Fears and anxieties about themselves and their possessions are common in older adults because of a decreased self-concept and an altered body image; these changes result in a decreased ability to cope. - Aging need not necessarily bring about a loss of one's ability to cooperate. - The attitude of older adults concerning authority or others in their environment is set; indecision about life situations may be a result of insecurity. - Difficulty performing step procedures is noted in the middle stage of Alzheimer disease; usually it is not observed in older adults.

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

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

A nurse is caring for a client with an antisocial personality disorder. What consistent approach should the nurse use with this client? 1. Warm and firm without being punitive 2. Indifferent and detached but nonjudgmental 3. Conditionally acquiescent to client demands 4. Clearly communicative of personal disapproval

1 The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. - Acting indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. - Being conditionally acquiescent to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. - Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

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

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

A client with alcoholism was admitted a few hours ago for pancreatitis. For which symptoms should the nurse carefully monitor this client? Correct 1 Irritability and tremors 2 Yawning and convulsions 3 Disorientation and paranoia 4 Fever and profuse diaphoresis

1 The nurse should carefully monitor a client with alcoholism and pancreatitis for irritability and tremors when it has been a few hours since admission. Alcohol is a central nervous system depressant, and irritability and tremors are the body's neurologic adaptation during withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last alcoholic drink has been consumed. Although it has only been a few hours since admission, it is unknown how long it has been since the client last had an alcoholic drink or how much time was spent during transportation to the hospital, waiting to be seen, or in observation in the emergency department before admission. - Yawning occurs with heroin withdrawal. Convulsions (delirium tremens, or DTs) are a later sign of severe withdrawal that occurs with alcohol withdrawal delirium. Delirium (paranoia and disorientation) is not an early sign of alcohol withdrawal and occurs 48 to 72 hours after abstinence. Fever and diaphoresis may occur during prolonged periods of delirium and are due to autonomic hyperactivity.

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

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

A college student is brought to the mental health clinic by parents with a diagnosis of borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply. 1. Impulsiveness 2. Lability of mood 3. Ritualistic behavior 4. Psychomotor retardation 5. Self-destructive behavior

1, 2, 5 - Clients with borderline personality disorder often lead complex, chaotic lives because of their inability to control or limit impulses. - Extremes of emotions, ranging from apathy and boredom to anger, may be displayed within short periods. - Impulsive self-destructive acts such as reckless driving, spending money, and engaging in unsafe sex often result in negative consequences. - Ritualistic behavior is associated with obsessive-compulsive disorders. - Psychomotor retardation is associated with mood disorders such as depression. ch 24?

A nurse is preparing a teaching plan to educate a relative of a client with schizophrenia about the early signs of relapse. What signs should the nurse plan to include? Select all that apply. 1. Appearing disheveled 2. Socializing with peers 3. Staying alone in the house 4. Joining a local church singing group 5. Exhibiting indifference to family activities

1, 3, 5 - Appearing disheveled, a negative sign, may indicate schizophrenic relapse, because the individual does not have the interest or energy to complete the activities of daily living. - Staying at home alone can be a sign of mental illness relapse, because the individual is becoming isolated and not socializing. - Indifference to family activities may indicate mental illness relapse, because it may reflect feelings of apathy or a lack of emotional energy to become involved with others. - Socializing with peers is a sign of mental health, because the individual is interacting with others; humans are highly social beings. - Joining a church singing group indicates mental health, because the individual is interacting with others and is interested in an activity.

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

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

A nurse is interviewing a client with a phobia. Which treatment should the nurse inform the client has the highest success rate? 1. Insight therapy to determine the origin of the fear 2. Systematic desensitization involving relaxation techniques 3. Psychotherapy aimed at rearranging psychotic thought processes 4. Psychoanalytic exploration of repressed conflicts of an earlier developmental phase

2 - The most successful therapy for clients with phobias involves behavior modification techniques involving DESENSITIZATION. - Insight into the origin of the phobia is usually not successful in helping clients overcome phobias. - Psychotherapy aimed at rearranging psychotic thought processes may increase UNDERSTANDING of the phobia but may not help the client cope with the fear; there is no psychotic thought process associated with phobias. - Psychoanalysis may increase UNDERSTANDING of the phobia but may not help the client cope successfully with the overwhelming fear.

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

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

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

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

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

2 Delusion - a fixed false belief. Illusion - a false sense interpretation of an external stimulus. Confabulation - the client's attempt to fill gaps in memory with imaginary events. Hallucination - a false sensory perception with no external stimulus.

A depressed, withdrawn client exhibits sadness through nonverbal behavior. What should the nurse plan to help the client to do? 1 Increase structured physical activity. 2 Cope with painful feelings by sharing them. 3 Decide which unit activities the client can perform. 4 Improve the ability to communicate with significant others.

2 Sharing painful feelings reduces the isolation and sense of uniqueness that these feelings can cause; sharing of these feelings usually decreases depression. Increasing structured physical activity will do little to decrease the client's sadness and does not consider the client's low level of energy. Improving the client's ability to communicate with significant others may be important for the future, if a problem exists, but the sharing of painful feelings is more important than improving communication.

An adolescent is brought to the emergency department by her parents because she says her heart is racing and she cannot catch her breath. The primary healthcare provider rules out heart and lung problems. What should the nurse do after interviewing the client and obtaining vital signs? 1. Transfer the client to the adolescent psychiatric unit for observation. 2. Remain with the client until the symptoms subside to provide support. 3. Arrange for the client to be admitted to a two-bed medical unit for further diagnostic testing. 4. Arrange for the client to be monitored continuously by a nursing assistant to prevent suicide.

2 The adolescent is probably experiencing a panic attack. The nurse should stay with the client to provide support and to continue to assess whether the client's anxiety is progressing or lessening. - The decision to transfer is made by the primary healthcare provider in conjunction with the parents. - Panic attacks, unless severe or chronic, can usually be treated on an outpatient basis. The primary healthcare provider has ruled out a physical problem. - If the client is to be admitted, a private room is preferable as a means of limiting environmental stimuli. No data indicate that the adolescent is suicidal.

A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history? 1 Evaluating the client's adjustment to the unit 2 Providing the client with a sense of security and safety 3 Exploring the client's memory loss and fear of going out 4 Assessing the client's perception of reasons for the hospitalization

2 The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. Unless the client is provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.

During a group therapy session one of the clients asks a client with the diagnosis of antisocial personality disorder why the client is in the hospital. What response might the nurse expect from a client with this disorder? 1 "I need a lot of help with my troubles." 2 "Society makes people follow rules that don't apply to me." 3 "This might help me straighten out my life." 4 "I decided that it's time that I own up to my problems."

2 The client is incapable of accepting responsibility for self-created problems and blames society for the behavior. - An admission that the client needs a lot of help, that the therapy may help the client straighten out, or that it's time for the client to own up to problems demonstrates insight, and these individuals rarely develop insight into their problems. ch 34?

While a nurse is talking with a client, another client comes up and shouts, "I hate you! You're talking about me again!" and throws a glass of juice at the nurse. What is the best response by the nurse to this outburst? 1. Repeating the client's words and asking for clarification 2. Removing the client from the room because limits must be placed on such behavior 3. Ignoring both the behavior and the client, cleaning up the juice, and talking with the client later 4. Verbalizing feelings of annoyance as an example to the client that it is more acceptable to verbalize feelings than to act them out

2 The client's behavior is escalating and unsafe. The client should be removed from the room and taken to a place where there is less environmental stimulation and less chance to act out against others. Repeating the client's words and asking for clarification accepts the physical abuse, which should never be done. The behavior and the client should never be ignored; the client needs limits set on the behavior immediately. When a client is acting out, the nurse must intervene to stop the behavior. Discussing the client's feelings can come later, when the client is exhibiting more control.

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

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

A nurse who has been working with a client with the diagnosis of borderline personality disorder is leaving for vacation in 2 weeks and tells the client. What client response indicates to the nurse that the client's ability to maintain a more mature relationship has progressed? 1. States, "I need to get well enough by then so I can leave, too." 2. Wishes the nurse a safe trip and offers thanks for the help received 3. Responds, "I guess you leaving is just another loss I'll have to adjust to." 4. Informs the nurse that there is no sense in waiting and that the relationship can be ended today

2 Wishing the nurse a safe trip and offering thanks for the help received demonstrates the client's acceptance of the professional role of the nurse, as well as the ability to end dependent relationships. - The response "I need to get well enough by then so I can leave, too" shows an inability to relate to other staff members involved with the client's care. - The response "I guess you leaving is just another loss I'll have to adjust to" still shows the existence of manipulation on the client's part. - Informing the nurse that there is no sense in waiting and that the relationship can be ended today shows a childish need to punish the nurse for leaving.

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

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

A 2.5-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? Select all that apply. 1. "Kids have to learn to be careful on the stairs." 2. "Every time I turn around the kid is falling over something." 3. "This child tends to be adventurous and doesn't understand about getting hurt on the stairs." 4. "I can't understand it. This child didn't have a problem using the stairs without my help before this." 5. "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid."

2, 4 - Abusive parents often have a poor understanding of the expected growth and development of children and tend to blame the child. - Toddlers generally need supervision and some assistance when climbing stairs, but abusive parents have little understanding of toddlers' abilities. - Although "Kids have to learn to be careful on the stairs" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. - "This child tends to be adventurous and doesn't understand about getting hurt on the stairs" is an unlikely response from an abusive parent because these people do not have an understanding of children's needs in relation to growth and development. -Although "I try to keep an eye on my child, but little kids are always on the go and I just can't keep running after the kid" is a true statement about toddlers, it is an unlikely response from an abusive parent because these people usually do not have an understanding of children's needs in relation to growth and development.

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

3 ch 11

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

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

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? 1 Seclusion room 2 Four-point restraints 3 Constant one-on-one supervision 4 Removal of unsafe objects from the environment

3 A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. - Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. -Seclusion and four-point restraints are overly restrictive.

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

3 A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. - A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. - Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. - A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death. ch 25

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

3 Children who have experienced attachment difficulties with primary caregivers are not able to trust others and therefore relate superficially. - Physical abuse is a possibility but not a necessity for this diagnosis. - The child probably will not cling or react when separated from the mother. - Attachment will not occur with either parent. p. 302

The nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care? 1. Engages in many rituals 2. Independence of others 3. Exhibits lack of empathy for others 4. Possesses limited communication skills

3 Self-motivation and self-satisfaction are of paramount concern to people with antisocial personality disorder, and they have little or no concern for others. - Clients with obsessive-compulsive disorder, not antisocial personality disorder, engage in rituals. - Individuals with antisocial personality disorder are extremely dependent on others; they count on others to extricate them from their problems. - They are usually charming on the surface and can easily con people into doing what they want.

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

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

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory? 1 Subtract serial sevens from 100. 2 Copy one simple geometric figure. 3 State three random words mentioned earlier in the exam. 4 Name two common objects when the nurse points to them.

3 Stating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. - Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. - Copying one simple geometric figure is a test of visual comprehension. - Naming two common objects when the nurse points to them is a test of verbal skills to identify aphasia. ch 7

On the day after admission a suicidal client asks a nurse, "Why am I being watched around the clock, and why can't I walk around the whole unit?" Which reply is most appropriate? 1 "Why do you think we're observing you?" 2 "What makes you think we're observing you?" 3 "We're concerned that you might try to harm yourself." 4 "We're following your primary healthcare provider's instructions, so there must be a reason."

3 The statement "We're concerned that you might try to harm yourself" is honest and helps establish trust. Also, it may help the client realize that the staff members care. "Why do you think we're observing you?" will put the client on the defensive. "What makes you think we're observing you?" is an inappropriate response when the answer is so obvious. The response "We're following your primary healthcare provider's instructions, so there must be a reason" is evasive.

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

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

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

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

A psychiatric nurse has been working with a client who is experiencing a relapse of psychotic symptoms. Command hallucinations are ruled out, and the content of the auditory messages has been determined. What should the nurse's next planned intervention be? 1. Teaching the client how to prevent relapses 2. Instructing the client to eliminate dietary stimulants 3. Helping the client learn strategies for disregarding the voices 4. Assisting the client in recognizing hallucinations when they occur

4 After issues related to the safety of the client and others have been addressed, it is important to determine the frequency of the hallucinations; this is the first step toward enabling the client to gain insight, which is an essential step in outcome thought control. Although the client will eventually be taught how to prevent relapses, it is not the priority at this time. Instructing the client to eliminate dietary stimulants is appropriate for clients who are agitated; no data indicate that this client is agitated. The client should be taught strategies for disregarding the voices after the frequency has been determined and acknowledged by the client.

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

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

The nurse is caring for a client with Alzheimer disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, what instructions will the nurse give the staff to monitor the client? 1. At meals to help prevent choking 2. For the presence of mouth ulcers 3. To prevent injury caused by hot foods 4. For attempts at eating inedible objects

4 Hyperorality - the compulsive need to taste and chew inedible objects. Hyperorality is not related to choking, a tendency to mouth ulcers, or the inability to perceive temperature properly.

A client with schizophrenia is speaking made-up words that have no meaning to other people. What term should the nurse use to document these verbalizations? 1 Avolition 2 Echolalia 3 Anhedonia 4 Neologisms

4 Neologisms - unique words with personal meanings only to the client. Avolition - the lack of motivation associated with a reduced emotional expression (flat affect). Echolalia - parrotlike echoing of spoken words or sounds. Anhedonia - the loss of enjoyment of things that were formerly enjoyed.

An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing? 1. Mild 2. Panic 3. Severe 4. Moderate

4 The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety. - Mild anxiety - the level at which the individual is cognizant of all aspects of reality but has a "jumpy feeling" and "butterflies in the stomach." - Panic - the level at which the individual is no longer in contact with reality, is unable to make decisions, has impaired judgment, and is dysfunctional. - Severe anxiety - the level at which individuals lose touch with reality and have a feeling of impending doom, which tends to immobilize them.

Depersonalization

a feeling of unreality and alienation from one's self.

Hypocondriasis

a severe, morbid preoccupation with an unrealistic interpretation of real or imagined physical symptoms.