Mental Health EAQ

A client experiencing hallucinations tells a nurse, "The voices are telling me I'm no good." The client asks whether the nurse hears the voices. What is the most appropriate response by the nurse?

"I don't hear the voices, but I believe that you can hear them.

A client with the diagnosis of an antisocial personality disorder responds to limit-setting by a nurse by saying, "You sure do look messy today." What is the most appropriate response by the nurse?

"I get the feeling you're angry with me."

A nurse is counseling the caregiver of a client with a personality disorder about antipsychotic medication. Which statement made by the caregiver during evaluation indicates a need for further teaching?

"I should cut down on the salt content in her food."

A nurse is evaluating statements made by the nursing student about the care to be rendered to a client with a personality disorder. Which statement by the nursing student indicates a need for further teaching?

"I should use gestures when talking with the client."

A client with generalized anxiety disorder is prescribed chlordiazepoxide hydrochloride. The primary health care provider gives instructions regarding the medication regimen to the client. Which statement by the client indicates that further instruction is needed?

"I'll stop the medication as soon as I feel less anxious." Chlordiazepoxide hydrochloride is an antianxiety agent used in the treatment of generalized anxiety disorder. Such medications should not be stopped abruptly after long-term use, because withdrawal symptoms may occur. The client is right to avoid drinking alcohol with this medication, because drinking may further aggravate depression. Antianxiety agents may cause drowsiness, so the client is right to not drive immediately after taking the medication. Taking the medication with food in case of stomach upset will help ensure the client's comfort, so this statement demonstrates understanding as well.

A licensed practical nurse (LPN) is learning about delirium tremens (DTs), an alcoholism-associated disorder that occurs as a complication of alcohol withdrawal. Which statement made by the LPN indicates effective understanding?

"It is characterized by shaking, an increase in activity, disorientation, hallucinations, and increased temperature."

The nurse notes that a client has been experiencing a somatic delusion. Which statement led to this conclusion?

"My stomach has disintegrated."

A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy?

"Negative thoughts can precipitate anxiety."

A female client with acute schizophrenia tells the nurse, "Everyone hates me." What is the best response by the nurse?

"Tell me more about this."

A client with schizophrenia is going to occupational therapy for the first time. The client doesn't want to go and tells the nurse so. What is the most therapeutic initial response by the nurse?

"Tell me what concerns you about going to occupational therapy."

While communicating with a client, the nurse begins to suspect that the client is experiencing a persecution delusion. Which statement made by the client support's the nurse's suspicion?

"They've put a transmitter in my mouth to monitor my words."

A client with the diagnosis of schizophrenia, paranoid type, is admitted to the hospital. The client says to the nurse, "I know they're spying on me in here, too. I'm not safe anywhere!" What is the most therapeutic response by the nurse?

"You don't feel safe anywhere, not even in the hospital?"

A male client with the diagnosis of antisocial personality disorder takes a female nurse by the shoulders, kisses her, and shouts, "I like you." What is the most appropriate response by the nurse?

"Your behavior is inappropriate. Don't do that again."

The nurse is reviewing the medical data of four clients with depression. Which client is most likely to exhibit the clinical manifestation of irritability?

13-year-old

what is persecution delusion?

A delusion where the person thinks that they are being punished

Which client is most likely to exhibit increased forgetfulness, low self-esteem, and depression as a result of abuse?

A married 31-year-old woman

Which activity is the least therapeutic for a severely depressed client?

Activity selected by the client

Before a treatment requiring informed consent can be performed, what information must the client be given? Select all that apply.

Alternative treatment options The risks and benefits of the treatment The risks involved in refusing the treatment The nature of the problem requiring the treatment

What is ambivalence?

Ambivalence is the experience of feeling opposite emotions at the same time.

Which antidepressant works best when administered at bedtime due to its sedating effects?

Amitriptyline

A client with schizophrenia is unable to feel happiness and joy. What is the name of this condition?

Anhedonia

During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, "Welcome to the funny farm. I'm Jo-Jo, the head yo-yo." Which meaning can the nurse assign to the client's statement?

Anxious over the arrival of new staff members

What are the symptoms of major depression? Select all that apply

Apathy Guilt feelings Sleep disturbances

Which side effect may be experienced by a client taking an antianxiety agent?

Ataxia

As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of what?

Attitudes and beliefs

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention?

Avoiding focusing on the client's physical symptoms

How can a nurse minimize agitation in a disturbed client?

By limiting unnecessary interactions with the clien

A male college student who is smaller than average and unable to participate in sports becomes the life of the party and a stylish dresser. What defense mechanism does the nurse determine that the client is using?

COMPENSATION: By developing skills in one area, the individual compensates for a real or imagined deficiency in another, thereby maintaining a positive self-image.

What is the compensation effect?

COMPENSATION: By developing skills in one area, the individual compensates for a real or imagined deficiency in another, thereby maintaining a positive self-image.

When a person who is nonathletic and uncoordinated is successful in a musical career, it may be related to which defense mechanism?

COMPENSATION: is replacing a weak area or trait with a more desirable one.

A hospitalized 7-year-old boy wakes up crying because he has wet his bed. What is it most appropriate for the nurse to do?

Change the child's bed while he changes his pajamas

What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?

Channeling unacceptable impulses into socially approved behavior

A nurse is assessing the symptoms of four different clients in a psychiatric ward. Which client does the nurse expect to have the highest risk for obsessive-compulsive disorder (OCD)?

Client B: ODC has uncontrollable recurrent, intrusive, and senseless thoughts that produce anxiety, as described in Client B.

Which medication is used in the treatment of obsessive-compulsive disorder (OCD)?

Clomipramine

What are cognitive distortions?

Cognitive distortions are thought patterns that exaggerate reality or are irrational, such as black-and-white thinking or overgeneralization

What should a nurse conclude that a client is doing when he makes up stories to fill in blank spaces of memory?

Confabulating

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. What should the nurse keep in mind regarding confusion when planning care for this client?

Confusion occurs with a transfer to new surroundings.

A client is to receive donepezil for treatment of dementia of the Alzheimer type. The nurse sits down with the primary caregiver and the client and reviews the purpose of the drug, its dosage, and the usual side effects. What side effect identified by the caregiver leads the nurse to conclude that further teaching is needed?

Constipation

In which mood disorder are there repeated swings between hypomania and depression?

Cyclothymic disorder

An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." What defense mechanism does the nurse identify?

DENIAL: The client's statement is an example of the use of denial, a defense that blocks problems by unconsciously refusing to admit that they exist.

An older client reports fatigue, restlessness, insomnia, slowed speech, and anxiety lasting longer than two weeks. Which disease does the nurse suspect?

DEPRESSION: Symptoms such as fatigue, restlessness, enduring anxiety, insomnia, and slowed speech are manifestations of depression in older adults.

A male long-distance jumper improves his distance by 3 ½ inches (8 cm) and earns the praise of his coach, but on another day, when he does not reach his mark, he forcefully kicks the door of his locker. What defense mechanism does his outburst demonstrate?

DISPLACEMENT: is the discharging of pent-up feelings on a less threatening object, in this case the locker door.

A nurse is caring for a client exhibiting compulsive behaviors. The nurse concludes that the compulsive behavior usually incorporates the use of which defense mechanism?

DISPLACEMENT: is the unconscious redirection of an emotion from a threatening source to a nonthreatening source.

Which treatment strategy is beneficial for a client with panic disorder?

Debriefing technique

A 6-year-old child recently started school but has been refusing to go for the past 3 weeks. What does the nurse determine is an appropriate intervention for this child?

Develop a behavior modification program with the child

What is the displacement mechanism?

Displacement is a defense that is used to allow the shifting of feeling from an emotionally charged person or object to a safe substitute person or object

What is the dissociation defense mechanism?

Dissociation is a temporary alteration of consciousness or identity used to handle conflict; amnesia is an example

A healthcare provider prescribes divalproex for a client with the diagnosis of bipolar I disorder, manic episode. What side effects of this medication might the client report during a follow-up visit?

Dizziness, nausea, and vomiting

A client's parents ask about the treatment of their child who has a recent diagnosis of schizophrenia. Before responding, what should the nurse consider?

Drug therapy, although it does not eliminate the underlying problem, reduces the symptoms of acute schizophrenia.

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation?

Electroconvulsive therapy

The parents of a young adult client visit regularly. After one visit the client becomes very agitated. What should the nurse do to relieve the client's distress?

Explore the client's response to the parents' behavior

A frail, depressed client who frequently paces the halls becomes physically tired from the activity. What action should the nurse take to help reduce this activity?

Have the client perform simple, repetitive tasks

A disturbed client who has been out of touch with reality has been hospitalized for several weeks. One day the nurse notes that the client's hair is dirty and asks whether the client wants to wash it. The client answers, "Yes, and I'd like to shower and change my clothes, too." What can the nurse conclude about the client in relation to this response?

He has some feelings of self-worth

What is most important for the nurse to do to assist a couple to cope with their feelings about the husband's terminal illness?

Helping the couple express to each other their feelings about his terminal illness

A young adult client with schizophrenia is prescribed haloperidol. When the nurse administers the medication, the client asks, "What's this for?" The nurse responds that the medication has which effect?

Helps the client relax and think more clearly

A client with diabetes mellitus is able to discuss in detail the diabetic metabolic process while eating a piece of chocolate cake. What defense mechanism does the nurse identify when evaluating this behavior?

INTELLECTUALIZATION: is the avoidance of a painful emotion with the use of a rational explanation that removes the event from any personal significance.

A client who recently was diagnosed as having myelocytic leukemia discusses the diagnosis by referring to statistics, facts, and figures. The nurse determines that the client is using which defense mechanism?

INTELLECTUALIZATION: the use of reasoning and thought processes to avoid the emotional aspects of a situation; this is a defense against anxiety.

A client in the mental health clinic who has been seeing a therapist for more than 6 months begins to talk and act like a therapist who is analyzing coworkers. What defense mechanism does the nurse identify?

INTROJECTION: is treating something outside the self as if it is actually inside the self; it is unconsciously incorporating the wishes, values, and attitudes of another as if they were one's own.

Survivors of a major earthquake are being interviewed on admission to the hospital. The nurse notes that they exhibit a flattened affect, make minimal eye contact, and speak in a monotone. These behaviors are indicative of the defense mechanism known as what?

ISOLATION: is the separation of thought or memory from feeling. Splitting is the polarization of positive and negative feelings.

A client with schizophrenia sees a group of visitors sitting together talking. The client tells the nurse, "I know they're talking about me." Which altered thought process should the nurse identify?

Ideas of reference

Which is a symptom of generalized anxiety?

Imsomnia

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of what?

Integrity versus despair

What is the intellectualization defense mechanism?

Intellectualization is the use of abstract thinking to minimize painful feelings.

A client who has a history of psychiatric problems, including an antisocial personality disorder, is admitted to the hospital. What typical behavior does the nurse anticipate?

Interpersonal difficulties

What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client 30 years of age?

Intimacy versus isolation

What is the introjection defense mechanism?

Introjection is the integration of the beliefs and values of another into one's own ego

What is the introjection defense mechanism?

Introjection is the integration of the beliefs and values of another into one's own ego structure.

An adult is found to have schizotypal personality disorder. How should a nurse describe the client's behavior?

Introverted and emotionally withdrawn

What is the isolation defense mechanism?

Isolation is the separation of a thought from a feeling tone.

A client with psychosis is receiving olanzapine. What special information about this drug does the nurse recall?

It dissolves instantly after oral administration

A client with schizophrenia is prescribed antipsychotic medication. During the follow-up visit, the primary health-care provider (PHP) administers parenteral diphenhydramine to the client. Which symptom required the administration of parenteral diphenhydramine by the PHP?

Lip smacking and tongue protrusion

A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem?

Low self-esteem

A nurse administers prescribed anxiolytics to clients with severe emotional disorders. What is the goal of this treatment?

Makes the client more amenable to psychotherapy

A client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol (Haldol) tablets orally to reduce agitation and preoccupation with auditory hallucinations. There has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started. What should the nurse's priority intervention be?

Making certain that the client is swallowing the medication

When attempting to evaluate the behavior of an older adult with a diagnosis of vascular dementia, a nurse knows that the client is probably what?

Making exaggerated use of old, familiar mechanisms

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type?

Managing the client's unsafe behaviors

Which treatment strategies are beneficial to a client with generalized anxiety disorder? Select all that apply.

Massage Visual imagery Relaxation therapy

How should the nursing staff fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity?

Offering high-calorie snacks frequently that the client can hold

The primary healthcare provider notices that a client exhibits a period of mania followed by hypomania and depression and prescribes lithium carbonate. What is the mode of administration of the prescribed drug?

Oral route

When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? Select all that apply.

PROJECTION: Projection is the unconscious denial of unacceptable feelings and emotions in one's self while attributing them to others. This defense mechanism commonly is used by clients with alcoholism because it helps make reality more acceptable.

A young client who has become a mother for the first time is anxious about her new parenting role. With the nurse's encouragement, she joins the new mothers' support group at the local YMCA. What kind of prevention does this activity reflect?

Primary prevention

A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." What does the nurse conclude that the client is using?

Projection

What is a projection defense?

Projection is denying unacceptable traits and regarding them as belonging to another person.

Hospitalization or day-treatment centers are often indicated for the treatment of a client with obsessive-compulsive disorder because these settings do what?

Provide the neutral environment the client needs to work through conflicts

What is important when the nurse plans care for a client with paranoid ideation?

Providing the client with opportunities for nonthreatening social interaction

A client in the mental health clinic who has concerns about getting married says to the nurse, "I guess I'd better get married. All the plans are made and paid for, and the invitations have all been mailed." What defense mechanism is the client using?

RATIONALIZATION: seemingly logical reasons are used to justify behaviors or feelings that are unacceptable or painful. This is not introjection, because the client has not assumed the feelings of another.

Incidences of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation?

REPRESSION: is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress or anxiety, thoughts or feelings surface and come into one's conscious awareness. .

What is the rationalization defensive mechanism?

Rationalization is the attempt to mask unacceptable feelings or behaviors by providing excuses and explanations.

What is reaction formation?

Reaction formation is the expression of unacceptable desires by adopting opposite behaviors in an exaggerated way.

A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member?

Regression

What is the regression defense mechanism?

Regression is the use of an unconscious coping mechanism through which a person avoids anxiety by returning to an earlier more satisfying or comfortable time in life.

An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance?

Reinforcing routines and supporting her usual habits

Which subtypes of schizophrenia have a poor prognosis?

Residual and disorganized

A shy, withdrawn adolescent boy, newly admitted to the psychiatric unit, asks one of the female psychiatric nurses for a date. What is the best initial response by the nurse?

Restating the purpose of the nurse-client relationship

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care?

Routines provide stability for clients with dementia

A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense is the client using when identifying the other clients thusly?

SPLITTING: Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others.

What is "splitting"?

SPLITTING: Splitting is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others.

When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response?

Saying, "I'll be back in a few minutes so we can talk."

A client who has exhibited bizarre behavior and an inability to relate to other people reports to the nurse, "I hear my father calling me. He died 2 years ago." Which psychological condition does the nurse suspect on the basis of the client's statement?

Schizophrenia

What is the sublimination defense mechanism?

Sublimation is a defense in which socially acceptable behavior is substituted for unacceptable instincts

What is the sublimation defense mechanism?

Sublimation is a defense wherein the person redirects the energy of unacceptable impulses into socially acceptable behaviors or activities.

What is the supression defense mechanism?

Suppression is a process that is often considered to be as a defense mechanism, but it is actually a conscious, intentional exclusion of material from one's awareness.

A client is responding within an hour of receiving naloxone to combat respiratory depression from an overdose of heroin. Why should a nurse continue to closely monitor this client's status?

Symptoms of the heroin overdose may return after the naloxone is metabolized.

A nurse reminds a client that it is time for group therapy. The client responds by shouting, "You're always telling me what to do, just like my father!" What defense mechanism is the client using?

TRANSFERENCE: a client assigns to someone the feelings and attitudes originally associated with an important significant other.

What is transference defense mechanism?

TRANSFERENCE: a client assigns to someone the feelings and attitudes originally associated with an important significant other. In regression a client reverts to past levels of coping to reduce anxiety.

A nurse reminds a client that it is time for group therapy. The client responds by shouting, "You're always telling me what to do, just like my father!" What defense mechanism is the client using?

TRANSFERENCE: a client assigns to someone the feelings and attitudes originally associated with an important significant other. In regression a client reverts to past levels of coping to reduce anxiety. In reaction formation a client displays the exact opposite behavior, attitude, or feeling to that which is demonstrated in a given situation. .

A client with chronic undifferentiated schizophrenia is receiving an antipsychotic medication. For which potentially irreversible extrapyramidal side effect should a nurse monitor the client?

Tardive dyskinesia

A 22-year-old client with antisocial personality disorder is being discharged and is to continue psychotherapy on an outpatient basis. When evaluating the client's chance of improvement, what should the nurse anticipate?

That the client's ability to change will be limited unless there is a readiness to accept the uncertainty associated with change

A nurse who is talking to a client suspects the client has agoraphobia. Which of these responses by the client support the nurse's suspicion? Select all that apply.

The client is afraid to walk in parking lots The client is afraid to venture out of the house alone. The client refuses to use a public bus for transportation.

A nurse notes that a client with dementia tries to cope with anxiety by using confabulation. What does the nurse plan to teach the family about confabulating?

The client will make up what they cannot be remembered

Three days after a stressful incident a client can no longer remember why it was stressful. The nurse, in relating to this client, can be most therapeutic by identifying that the inability to recall the situation is an example of which defense mechanism?

The client's inability to recall is an example of repression, which is the unconscious and involuntary forgetting of painful events, ideas, and conflicts.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider what about clients with OCD?

They do not want to repeat the ritual but feel compelled to do so

A client with schizophrenia is prescribed antipsychotic medications and instructed to increase fluid intake. What is the rationale behind this instruction?

To provide relief from autonomic reactions

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit?

Toilet the client more frequently with supervision.

A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary?

UNDOING: Undoing is atonement for or an attempt to dissipate unacceptable acts or wishes. Denial is the refusal to accept or perceive unpleasantness as it actually exists.

A client's hands are raw and bloody from a ritual involving frequent hand washing. Which defense mechanism does the nurse identify?

UNDOING: is an act that partially negates a previous one; the client is using this primitive defense mechanism to reduce anxiety. Clients who wash their hands compulsively may be having thoughts that they consider "dirty."

A nurse administers an antipsychotic medication to a client. For which common manageable side effect should the nurse evaluate the client?

Unintentional tremor

what is a somatic delusion?

false, fixed belief about a body part

What is confabulation?

making up lies to fills gaps in memory loss. (saying you were somewhere you weren't)

The nurse cares for a client who has schizophrenia and is taking chlorpromazine. The nurse instructs the family members to inform the nurse if any adverse effects develop. Which side effects are considered late extrapyramidal side effects?

worm-like tongue movements

A client with a history of obsessive-compulsive behaviors has a marked decrease in symptoms and expresses a wish to obtain a part-time job. On the day of a job interview the client arrives at the mental health center with signs of anxiety. What is the most therapeutic response to the client's behavior by the nurse?

"Going for your interview triggered some feelings in you. Perhaps you could call a friend to drive you there."

With the client's permission, the nurse should inform the family about what is happening. What is the main reason for this action?

An informed family is better equipped to assist the client.

A nurse in a mental health facility is caring for a client with the diagnosis of borderline personality disorder. What should the nurse plan to do to maintain a therapeutic relationship?

Be firm, consistent, and understanding because there is a need for structure

A client has recently started taking a new neuroleptic drug, and the nurse notes extrapyramidal effects. Which drug does the nurse anticipate will be prescribed to limit these side effects?

Benztropine mesylate (Cogentin)

One afternoon the nurse on the unit overhears a young female client having an argument with her boyfriend. A while later the client complains to the nurse that dinner is always late and the meals are terrible. What does the nurse identify the defense mechanism that the client is using as?

DISPLACEMENT: reduces anxiety by transferring the emotions associated with an object or person to another emotionally safer object or person.

A client with type 1 diabetes is found to have a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination?

Decreased control of the diabetes

One afternoon a male client on the inpatient psychiatric service complains to the nurse that he has been waiting for more than an hour for someone to accompany him to activities. The nurse replies, "We're doing the best we can. There are many other people on the unit who need attention, too." This response demonstrates the nurse's use of what type of behavior?

Defensive behavior

A client who survived a train accident 8 months ago reports illusions and hallucinations of the incident and expresses guilt over being a survivor. Which psychological condition is likely present in this client?

Delayed post-traumatic stress disorder

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

Denial

Which personality disorder is characterized by anxious and fearful behavior?

Dependent Personality Disorder

A client with phobias about elevators and large crowds comes to the clinic for help because of feelings of depression related to these fears. What is an appropriate short-term goal for this client?

Describing the thoughts and feelings experienced in terrifying situations

What does the nurse determine is the therapy that has the highest success rate for people with phobias?

Desensitization involving relaxation techniques

A client with a diagnosis of schizophrenia, undifferentiated type, is being admitted to the psychiatric unit. What clinical manifestations does the nurse expect when assessing this client? Select all that apply.

Excited behaviors Loose associations Inappropriate affect

Which of these are symptoms of depression commonly observed in older adults? Select all that apply.

Fatigue Sadness Agitation

A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates that she is hearing voices. When a nurse begins to walk toward her, the client pulls out a large knife. What is the best approach by the nurse?

Firm

A client is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. The client's anxiety level is approaching a panic level, and the client's ritual is interfering with work and daily living. Which selective serotonin reuptake inhibitor (SSRI) does the nurse anticipate that the primary healthcare provider may prescribe?

Fluvoxamine

Which statement regarding anxiety is correct?

Generalized anxiety disorder is characterized by a high degree of anxiety or avoidance behavior. Panic is an acute, not chronic, form of anxiety. Anxiety trait is learned but is not in response to a specific event. Signal anxiety is a learned response to a specific event such as test-taking.

Which herb used in the treatment of Alzheimer's disease lowers the blood glucose level?

Ginseng

An older resident in a nursing home who has a diagnosis of dementia hoards leftover food from the meal tray and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them." What should the nurse plan to do?

Give the resident a small bag in which to place selected personal articles and food

what is the identification defense mechanism?

Identification is the reduction of anxiety by imitating someone respected or feared.

Which nursing intervention is beneficial for the client with mania?

Increasing intake of fresh vegetables and fruits

A female client in the mental health clinic has pressured speech and mumbles incoherently. What is the most appropriate nursing intervention?

Indicating to the client that she needs to slow down because what she says is important and cannot be understood

While caring for a client displaying inappropriate emotional responses, delusions, and bizarre behavior, the nurse finds that the client is unable to relate to other people because of an impairment in communication. Which other psychological findings may be present in this client? Select all that apply.

Ineffective coping Disturbed sleep pattern Disturbed personal identity

A client with catatonic schizophrenia who is in a vegetative state is admitted to the psychiatric hospital. The nurse identifies short- and long-term outcomes in the client's clinical pathway. What is the priority short-term outcome of care that the client should be able to attain?

Ingesting adequate fluid and food with assistance

Why is observation an especially important aspect of nursing care for a withdrawn client?

It helps the nurse understand the client's behavior.

A nurse is assigned to care for a group of clients who have been found to have depression. Which clinical manifestations does the nurse anticipate? Select all that apply.

Labiality of affect Neglect of personal hygiene "I don't know" answers to questions Apathetic response to the environment

The nurse understands that paranoid delusions may be related to which defense mechanism?

PROJECTION: is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.

A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior

Performing passive range-of-motion exercises three times a day for effective joint health

After an automobile collision involving a fatality and a subsequent arrest for speeding, a client has amnesia regarding the events surrounding the accident. Which defense mechanism is being used by the client?

REPRESSION: is coping with overwhelming emotions by blocking awareness or memory of the stressful event.

What is the repression defense mechanism?

REPRESSION: is coping with overwhelming emotions by blocking awareness or memory of the stressful event.

A client who had to be cut out of a car after a motor vehicle collision has no visible physical effects from the ordeal. The client responds to the emergency department nurse's questions factually in a soft voice with a composed manner. What may this behavior indicate about the client?

The client is controlling the expression of feelings.

A client is undergoing treatment for generalized anxiety disorder. Which outcome indicates that the nursing interventions are effective?

The client recognizes the signs of escalating anxiety

A client in the early dementia stage of Alzheimer disease is admitted to a long-term care facility. Which activities must the nurse initiate?

Weighing the client once a week Having specialized rehabilitation equipment available Establishing a schedule with periods of rest after activities