Mental Health EAQs

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

Answer: 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 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

Answer: 3 Alcoholic clients have loss of memory and adapt to this by unconsciously filling in with false information areas that cannot be remembered. Ideas of grandeur do not occur in this disease.

The nurse is caring for a client experiencing a crisis. What role is most important for the nurse to assume when providing therapeutic crisis intervention? 1.Passive listener 2. Friendly advisor 3. Active participant 4. Participant observer

Answer: 3 To intervene in a crisis, the nurse must assume a direct, active role because the client's ability to cope is lessened and help is needed to solve problems. Being a passive listener is insufficient to help the client. Being a friendly advisor can blur the boundaries between a professional and a social relationship. The role of the nurse should not include giving advice. Being a participant observer is insufficient to help the client.

In the care of a withdrawn, reclusive psychotic client, the priority goal is for the client to develop what? 1.Trust 2. Self-worth 3. A sense of identity 4. An ability to socialize

Answer: 1 Trust is basic to all therapies; without trust a therapeutic relationship cannot be established. The development of self-worth is a long-term goal; developing trust is the priority. There is nothing to indicate that the client does not have a sense of identity. Although helping the client relate to others is a part of the treatment, it is not a priority goal at this time.

A client experiencing nonspecific, excessive, unpleasant feelings of being worried concerning one's safety likely is experiencing which mental health disorder? 1. Phobia 2. Panic disorder 3. Generalized anxiety disorder (GAD) 4. Posttraumatic stress disorder (PTSD)

Answer: 3 Generalized anxiety disorder is the manifestation of both physical and cognitive symptoms of chronic or excessive anxiety/worry. A phobia is a fear of a specific type of stimuli. Panic is an extreme stage of anxiety. Posttraumatic stress disorder is a state of anxiety resulting from a traumatic experience.

A psychiatric nurse is hired to work in the psychiatric emergency department of a large teaching hospital. While reviewing the manuals, the nurse reads, "People with mental health emergencies shall be triaged within 5 minutes of entering the emergency department." What does the nurse consider this statement to represent? 1 Hospital policy 2 Standard of care 3 Hospital procedure 4 Mental Health Bill of Rights

1. Policies are statements that help define a course of action; what is to be done is stated in policies, and how a task or skill is to be performed is defined in a procedure manual. Standards of care are published by the American Nurses Association; they reflect current knowledge and represent levels of practice agreed on by experts within the specialty; in legal terms, the standard of care is that level of practice that a reasonably prudent nurse would provide. A hospital procedure defines how a task or skill is to be performed. The Mental Health Bill of Rights states that all clients have the right to respectful care, confidentiality, continuity of care, relevant information, and refusal of treatment, except in an emergency or by law.

A client is found to have a borderline personality disorder. What is a realistic initial intervention for this client? 1. Establishing clear boundaries 2. Exploring job possibilities with the nurse 3. Initiating a discussion of feelings of being victimized 4. Spending 1 hour twice a day discussing problems with the nurse

1. answer Individuals with borderline personality disorder are impulsive and have difficulty identifying and respecting boundaries in relation to others. Exploration of this topic in a meaningful manner can be done only after an ongoing relationship has been established. Feeling victimized is a frequent theme among clients with this disorder; however, they rarely have the insight to initiate discussion of these feelings and usually show resistance when the topic is broached. An individual with a borderline personality disorder may not be able to spend this length of time having a meaningful discussion with the nurse; usually they are too impulsive to engage in consistent work until a therapeutic relationship has been established.

The nurse manager is observing the performance of a nursing assistant. Which behavior by the nursing assistant toward a client reflects a boundary violation? 1. Offering advice to the client 2. Providing false reassurance 3. Accepting a gift from the client 4. Engaging in excessive probing

3. A boundary violation occurs when a provider of care goes beyond the established therapeutic relationship standard and enters into a personal or social relationship with a client, such as with accepting a gift from the client. Offering advice is inadequate communication skills; advice should not be given because it undermines the client's ability to solve problems and may precipitate dependency and helplessness. False reassurance is inadequate communication skills; false reassurance should not be given because it is not based in reality and may close off communication. Engaging in excessive probing is an inadequate communication skills; inappropriate probing is not therapeutic and may be done by the provider of care to prevent uncomfortable silences or obtain information because of curiosity.

The client repeatedly performs ritualistic behaviors throughout the day to limit anxious feelings. How does the nurse characterize these behaviors? 1. Obsessions 2. Compulsions 3. Under personal control 4. Related to rebelliousness

Answer: 2 A compulsion is an uncontrollable, persistent urge to perform an act repetitively to relieve anxiety. An obsession is a persistent idea, thought, or impulse that cannot be eliminated from consciousness with logical reasoning. The urge to perform a compulsive act is not under the client's control because avoiding the act increases anxiety. Clients are compelled to perform these ritualistic behaviors; they are not trying to rebel.

What should the nurse's approach be when when working with clients who use manipulative, socially acting-out behaviors? 1.Strict, punishing, and restrictive 2. Sincere, cautious, and consistent 3. Supportive, accepting, and friendly 4. Sympathetic, nurturing, and encouraging

Answer: 2 A sincere, cautious, and consistent attitude limits this type of individual's ability to manipulate both situations and staff members. A strict, punishing, and restrictive approach may create a power struggle and limit the development of a therapeutic nurse-client relationship. When accepting the person, the nurse should not support negative behavior; a friendly attitude may encourage further problem behavior. A sympathetic, nurturing, and encouraging approach may encourage the clients to continue in this lifestyle rather than learn appropriate ways to relate to others.

A client with emotional problems is being discharged from a psychiatric unit. What should the nurse encourage the client to do? 1. Go back to regular activities. 2. Enroll in an aftercare program. 3. Call the unit whenever she is upset. 4. Find a group that has similar problems.

Answer: 2 Close follow-up and continued monitoring of medication, behavior, and emotional state are necessary to enable the client to maintain a positive behavioral change. Returning to regular activities depends on what the client's regular activities were. Calling the unit whenever the client is upset encourages dependence. A self-help group may be part of aftercare planning, but follow-up regarding medications and individual psychotherapy should be considered first.

A nurse plans to give greater responsibility for self-control to clients with a long history of alcohol abuse who are about to enter a detoxification program. What should the nurse plan to do? 1. Tell them about the detoxification program. 2. Help them adopt more healthful coping patterns. 3. Confront them with their history of substance abuse. 4. Administer their medications in accordance with the prescribed schedule.

Answer: 2 The client must learn to develop and use more healthful coping mechanisms if drinking is to be stopped; the responsibility lies with the client because the client must do the changing. Telling the clients about the detoxification program will tell them what to expect but will not instill responsibility for change. Confronting them with their history of substance abuse will place clients on the defensive; it usually does not foster the development of a trusting relationship. Medications may decrease withdrawal symptoms, but they do not provide the motivation for change; this must come from within.

What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing? 1.Acting out in reverse something already done or thought 2. Returning to an earlier, less mature stage of development 3. Channeling unacceptable impulses into socially appropriate behavior 4. Excluding from consciousness thoughts that are psychologically disturbing

Answer: 3 The individual using sublimation attempts to fulfill desires by selecting a socially appropriate activity rather than one that is socially unacceptable. Acting out in reverse something already done or thought is reaction formation. Returning to an earlier, less mature stage of development is regression. Excluding from consciousness thoughts that are psychologically disturbing is repression.

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal which symptom? 1. Edema 2. Diarrhea 3. Amenorrhea 4. Hypertension

Answer: 3 Amenorrhea results from endocrine imbalances that occur when fat stores are depleted. The client is dehydrated; edema is not expected. Constipation, not diarrhea, may occur because of lack of fiber in the diet. Hypotension, not hypertension, may occur because of dehydration.

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type? 1. Restricting gross motor activity 2. Preventing further deterioration 3. Keeping the client oriented to time 4. Managing the client's unsafe behaviors

Answer: 4 Clients with Alzheimer disease require external controls to minimize the danger of injury caused by lack of judgment. The staff should not prevent all gross motor activity; the client needs to use the muscles, or atrophy will occur. Further deterioration usually cannot be prevented in this disorder with nursing interventions; donepezil may help delay deterioration in some clients. It may not be possible to keep the client continuously oriented.

A nurse on the psychiatric unit concludes that the staff's approach to setting limits for a demanding, angry client is effective. What behavior by the client leads the nurse to this conclusion? 1. No longer calls the nursing staff for assistance 2. Understands the reasons that frequent calls to the staff were made 3. Apologizes for disrupting the unit's routine when something is needed 4 Discusses concerns regarding the emotional condition that required hospitalization

Answer: 4 Discussing concerns regarding the emotional condition that required hospitalization demonstrates that the client feels comfortable enough to discuss the problems that motivated the behavior. No longer calling the nursing staff for assistance does not demonstrate a resolution of problems underlying the behavior. Without discussion of the problems underlying the behavior, little is accomplished. Apologizing for disrupting the unit's routine when something is needed does not demonstrate a resolution of problems underlying the behavior.

What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness? 1. The need to develop a close support system 2. The need to create a stress-free environment 3. The need to refrain from activities that cause anxiety 4. The need to follow the prescribed medication regimen

Answer: 4 Following the prescribed medication regimen is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse or recurrence of symptoms. Although a close support system is beneficial, it may not always be possible to achieve. It is impossible to create a stress-free environment; clients need to learn better ways to cope with stress. Refraining from any activity that may cause anxiety is too restrictive.

What is most important for a nurse to do when initially helping clients resolve a crisis situation? 1 Encourage socialization. 2 Meet dependency needs. 3 Support coping behaviors. 4 Involve them in a therapy group.

3. In a crisis situation, the individual frequently just needs support to regroup and re-establish the ability to cope. Socialization is part of recovery; this is not done during the initial stage of a crisis. Meeting dependency needs is not possible or realistic. Involving clients in a therapy group may have the effect of increasing anxiety, thereby making the crisis situation worse.

What does a psychiatric nurse identify as the primary purpose of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition(DSM-5)? 1. Facilitate communication between researchers and clinicians. 2. Aid in teaching psychopathology to mental health professionals. 3. Assist in collecting accurate public health statistics through the use of diagnostic codes. 4. Provide a classification of types of mental disorders and guidelines to aid in making a diagnosis.

4. answer The prime purpose of the DSM-5 is to serve the clinician as a guide in identifying a client's mental health or psychiatric diagnosis. Although the DSM-5 is useful in facilitating communication, the teaching of psychopathology, and the collection of accurate public health statistics, none of these are the primary purpose of this publication.

The parents of an adolescent who is experiencing posttraumatic stress disorder have decided to care for their child at home. What is the priority intervention that the home health nurse must include in the plan of care? 1. Encouraging the parents to keep their child in the home environment 2. Helping the parents identify the things that cause the child to be fearful 3. Helping the parents understand that their child may avoid emotional attachments 4. Discussing with the parents their feelings of ambivalence about what their child is enduring

Answer 3 The client will tend to avoid emotional attachment to significant others, because this is a common way to protect the self from the experience of potential future losses. The priority at this time is to have family members develop an understanding of what is happening to the client. Although it is important to keep the client safe and secure when in the home, the family should not restrict the client to the home environment. Although issues concerning the client's problems need to be resolved, this is not the priority. Although a discussion of the parents' feelings of ambivalence may be necessary, it is not the priority.

A client is admitted to the mental health unit with the diagnosis of major depressive disorder. Which statement alerts the nurse to the possibility of a suicide attempt? 1. "I don't feel too good today." 2. "I feel much better; today is a lovely day." 3. "I feel a little better, but it probably won't last." 4. "I'm really tired today, so I'll take things a little slower."

Answer: 2 A rapid mood upswing and psychomotor change may signal that the client has made a decision and has developed a plan for suicide. "I don't feel too good today"; "I feel a little better, but it probably won't last"; and "I'm really tired today, so I'll take things a little slower" are all typical of the depressed client; none of these statements signals a change in mood.

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. What does the nurse's behavior reflect? 1. Affiliation 2. Displacement 3. Compensation 4. Countertransference

4. answer With countertransference the professional provider of care exhibits an emotional reaction to a client based on a previous relationship or on unconscious needs or conflicts. Affiliation is turning to others for support and help when stressed or conflicted. Displacement is the discharge of pent-up feelings onto something or someone else that is less threatening than the original source of the feelings. Compensation is attempting to balance deficiencies in one area by excelling in another area.

A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client? 1. Outbursts of anger 2 Focused concentration 3 Preoccupation with delusions 4 Intense interpersonal relationships

Answer: 1 Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients who have schizophrenia rather than with clients experiencing depression and hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have the physical or emotional energy for intense interpersonal relationships.

The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. What is the best term to describe this situation? 1. Apraxia 2. Agnosia 3. Aphasia 4. Amnesia

Answer: 2 Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting on clothing properly.

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem? 1. A long history of inadequate nutrition 2. Disruptions in cerebral blood flow, resulting in thrombi or emboli 3. A delayed response to severe emotional trauma in early adulthood 4. Anatomical changes in the brain that produce acute, transient symptoms

Answer: 2 Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis can cause primary degenerative dementia. Severe emotional trauma may contribute to primary degenerative dementia but does not necessarily cause it. Neural degeneration leads to permanent, not transient, changes

The nurse is leading a relapse-prevention group for clients who experience bipolar disorder manic episodes. Which strategies should the nurse teach to help prevent or identify impending relapse? Select all that apply. 1. Watch for changes in libido. 2. Keep dietary changes to a minimum. 3. Maintain a regular sleeping schedule. 4. Plan multiple varied activities every day. 5. Monitor yourself for increased irritability or mood instability.

Answer: 1,2,3,5 Increased sex drive often indicates the beginning of a manic episode. Changes in the eating pattern can trigger a manic episode. Changes in the sleeping pattern may increase anxiety and trigger a manic episode. An elevated, expansive, or irritable mood often indicates the beginning of a manic episode. Too many activities may be too stimulating and precipitate a manic episode. Simple, repetitive routines should be followed to limit change or anxiety.

When being admitted to a mental health facility, a young male adult tells the nurse that the voices he hears frighten him. The nurse knows that clients tend to hallucinate more vividly at what point in their routine? 1. Before meals 2. After going to bed 3. During group activities 4. While watching television

Answer: 2 Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions. Before meals, during group activities, and during television watching are all times of relatively high, competing environmental stimuli.

During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care? 1. Client's orientation to time, place, and person 2. Ability to perform daily activities without assistance from others 3. Stressors that appear to precipitate the client's disruptive behavior 4. That cognitive impairments will increase until adjustment to the home is accomplished

Answer: 3 Additional information must be collected to determine what may be precipitating the disruptive behavior. Clients with cognitive impairment may have difficulty controlling behaviors and may need the environment to provide the structure needed to act appropriately. The client's disorientation is documented and will not change, although some day-to-day variations may occur. Disorientation alone usually does not lead to disruptive behavior. The client's ability to perform daily activities is important, but it is not necessarily related to disruptive behavior. The client may never achieve adjustment to the nursing home.

A delusional client is actively hallucinating and worried about being stalked by a terrorist group. What defense mechanism does the nurse identify as the most prominent in this situation? 1. Splitting 2. Undoing 3. Projection 4. Sublimation

Answer: 3 Projection is the common defense mechanism found in delusions. Projection is attributing to others one's own unacceptable feelings, impulses, or thoughts. Splitting is when the individual fails to integrate the positive and negative qualities of the self or others into cohesive images and compartmentalizes opposite affective states. Undoing is symbolically canceling out an experience. Sublimation is the channeling of unacceptable impulses into constructive activities.

To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors as the central factors that influence development? 1. Cognitive theory 2. Psychosocial theory 3. Interpersonal theory 4. Psychosexual theory

3. Answer The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachments and a longing to meet biologic and psychological needs are two dimensions associated with this theory. Cognitive theory is associated with Jean Piaget; cognitive theory explains how thought processes develop, are structured, and influence behavior. Psychosocial theory is associated with Erik Erikson; psychosocial theory identifies social interaction as the source that influences human development. Erikson identified eight stages of human life, with each stage built on the previous stages and influenced by past experiences. Psychosexual theory is associated with Sigmund Freud; psychosexual theory views child development as a biologically driven series of conflicts and gratifying internal needs.

A client who is to be discharged from an inpatient mental health facility is referred to a mental health daycare center in the community. What should the nurse identify as the primary reason for this referral? 1. Improving social skills 2. Getting out of the house for a few hours daily 3. Maintaining gains achieved during hospitalization 4. Avoiding direct confrontation with the community

3. answer The daycare center provides the client with a therapeutic setting for a few hours each day during the transitional stage between hospital and total discharge. The goal is to maintain and enhance progress made during inpatient treatment. Daycare treatment may improve social skills or allow the client to get out of the house for a few hours, but neither is its primary purpose. Avoiding direct confrontation with the community may help during the transition stage, but it is not the primary goal of daycare.

A nurse is preparing a teaching plan for a client who is to undergo electroconvulsive therapy. What instructions should the nurse include? 1. Void just before the procedure. 2. Wear cotton clothing during the procedure. 3. Sleep for several hours after the procedure. 4. Eat a light breakfast 1 hour before the procedure.

Answer: 1 During the expected seizure the client may become incontinent. The client will awaken 20 to 30 minutes after the procedure. Although the client will be groggy and confused, there is no requirement that the client sleep for several hours. The client should be supervised until oriented and capable of self-care. There are no restrictions concerning the type of fabrics that should be worn; however, the clothing should be comfortable and metal hair accessories should not be worn. Food or fluid should not be consumed for at least 4 hours before therapy as a means of preventing vomiting and aspiration.

A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. 1. Chronic stress 2. Severe anxiety 3. Generalized pain 4. Excessive caffeine 5. Chronic depression 6. Environmental noise/distractors

Answer: 1,4,6 Acute or primary insomnia [1] [2] is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia? 1 Increase in serotonin 2 Deficiency of thiamine 3 Reduction in iron intake 4 Malabsorption of riboflavin

Answer: 2 Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism.

When planning care for a client who has just completed withdrawal from multiple-drug abuse, what reality in relation to the client should the nurse take into consideration? 1. Unable to give up drugs 2. Unconcerned with reality 3. Unable to delay gratification 4. Unaware of the danger of drug addiction

Answer: 3 A person with an addictive personality is unable to delay gratification; drugs help blur reality and ease frustration. Giving up drugs is possible but not easy; it requires a change in attitude and a deconditioning process. Users of drugs are concerned with reality, and their drug use is an attempt to blur the pains of reality. Intellectually these people may be aware of the dangers of drug addiction, but emotionally they cannot buy into the reality that it can happen to them.

A nurse in a hospice program cares for clients and family members who are coping with imminent loss. What is the most important factor in predicting a person's potential reaction to grief? 1. Family interactions 2. Social support system 3 Emotional relationships 4 Earlier experiences with grief

4. How a person has handled grief in the past provides clues to how he or she will cope with grief in the present. Although family interactions, social support system, and emotional relationships are all important, none is the paramount predictor of a client's reaction to grief.

A nurse is assessing a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident? 1. 2 years 2. 6 years 3. 6 months 4. 1 to 3 months

Answer: 1 By 2 years of age the child should demonstrate an interest in others, communicate verbally, and possess the ability to learn from the environment. Before the age when these skills develop, autism is difficult to diagnose. Usually by 3 years the signs of autism become more profound. Autism can be diagnosed long before a child is 6 years old. Infantile autism may occur in an infant of 1 to 3 months, but at this age it is difficult to diagnose.

What developmental task should the nurse consider when caring for toddlers? 1.Trust 2. Industry 3. Autonomy 4. Identification

Answer: 3 Testing the self both physically and psychologically occurs during the toddler stage, after trust has been achieved. Trust is the task of infancy. The task of industry is accomplished between the ages of 6 and 12 years. Identification is not a developmental task. However, between the ages of 3 and 6 years a child starts to identify with the parent of the same sex.

A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, what should the nurse remember about clients with OCD? 1. Are unaware that the ritual serves no purpose 2. Can alter the ritual depending on the situation 3. Should be prevented from performing the ritual 4. Do not want to repeat the ritual but feel compelled to do so

Answer: 4 The repeated thought or act defends the client against even higher, more severe levels of anxiety. Clients usually do recognize that the ritual serves little or no purpose. Rituals are usually followed rigidly; setting limits on or altering a ritual increases anxiety. Preventing the client from performing the ritual may precipitate a panic level of anxiety.

A mother and her three young children arrive at the mental health clinic. The woman says that she is seeking help in leaving her husband. She reports that he has been beating her for years but just started hitting the children. What is the best initial action by the nurse? 1. Arranging for a staff member to watch the children so the mother and nurse can talk 2. Calling a facility where the mother and her children will be safe until the crisis is resolved 3. Determining whether the mother is ambivalent about this decision before making permanent plans 4. Suggesting that the mother and her husband return for couples counseling so the marriage can be saved

1. answer This emotionally charged topic should be discussed with the client in a confidential session; after the nurse has assessed the situation, the woman and the nurse can plan the family's future. Although a safe facility may be called, a determination of the client's ambivalence may be made, and couples counseling may be recommended eventually, all three actions are premature if a thorough assessment of the situation has not been made.

A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's what? 1. Developmental history 2. Available situational supports 3. Underlying unconscious conflict 4. Willingness to restructure the personality

2. answer Personal internal strengths and supportive individuals are critical to the development of a crisis intervention plan; they must be explored with the client. Although developmental history information may be helpful, it is not essential; factors concerning the current situation are paramount. Identifying unconscious conflicts takes a long time and is inappropriate for crisis intervention. Willingness to restructure the personality is a goal of psychotherapy, not crisis intervention.

Within a few hours of alcohol withdrawal the nurse should assess the client for the presence of what symptoms? 1. Irritability and tremors 2. Yawning and convulsions 3. Disorientation and paranoia 4. Fever and profuse diaphoresis

Answer: 1 Alcohol is a central nervous system depressant; irritability and tremors are the body's neurological adaptation to the withdrawal of alcohol. Tachycardia, irritability, and tremors are the early signs of withdrawal and will appear 24 to 48 hours after the last ingestion of alcohol. 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 a result of autonomic overactivity.

One morning a client tells the nurse, "My legs are turning to rubber because I have an incurable disease called schizophrenia." What is this statement an example of? 1. Hallucinations 2. Paranoid thinking 3. Depersonalization 4. Autistic verbalization

Answer: 3 The state in which the client feels unreal or believes that parts of the body are distorted is known as depersonalization or loss of personal identity. This is not an example of a hallucination; a hallucination is a sensory experience for which there is no external stimulus. The client's statement does not indicate any feelings that others are out to do harm, are responsible for what is happening, or are in control of the situation. The statement is not an example of autistic verbalization.

Personality disorders are identified in the DSM-V in clusters. How should the nurse describe the behaviors of an individual with a cluster A personality disorder? 1. Odd and eccentric 2. Anxious and fearful 3. Dramatic and erratic 4. Hostile and impulsive

1. answer! Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These clients are odd and eccentric and use strange speech, are angry, and have impaired relationships. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. These clients are anxious, fearful, tense, and rigid. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. These clients are dramatic, erratic, labile, impulsive, hostile, and manipulative.

According to Erikson, what will an individual who fails to master the maturational crisis of adolescence most often do? 1 Rebel at parental orders. 2 Experience role confusion. 3 Experience interpersonal isolation. 4 Become a substance abuser.

2. According to Erikson, adolescents are struggling with identity versus role confusion. Rebellion against parental orders reflects part of the struggle for independence; it does not indicate failure to resolve the conflicts of adolescence. Adolescents tend to be group oriented, not isolated; they struggle to belong, not to escape. Adolescents may experiment with drug and alcohol use, but most of them do not become abusers.

A client who has a long history of alcoholism has not worked for the past 10 years. When the nurse asks about daily activities the client responds, "I currently work in the office of a local construction company." Which mental mechanism should the nurse suspect that the client is using? 1. Regression 2. Sublimation 3. Compensation 4. Confabulation

Answer: 4 Confabulation is often used by people with alcoholism to cover lapses of memory that occur with Korsakoff syndrome; it is an unconscious means of self-protection. Regression is a return to a prior stage of development as a way to cope with stress. Sublimation is the channeling of unacceptable thoughts and feelings into socially acceptable behaviors. Compensation is replacement of a real or imagined deficit with a more positive attribute or trait.

A young client who has become a mother for the first time is showing signs of being 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? 1. Primary prevention 2. Tertiary prevention 3. Secondary prevention 4. Therapeutic prevention

Answer: 1 Primary prevention is directed toward health promotion and prevention of problems. Tertiary prevention is focused on rehabilitation and the reduction of residual effects of illness. Secondary prevention is related to early detection and treatment of problems. There is no category of prevention called therapeutic prevention.

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.

Answer: 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.

When planning for a client's care during the detoxification phase of acute alcohol withdrawal, what need should the nurse anticipate? 1. Checking on the client frequently 2. Keeping the client's room lights dim 3. Addressing the client in a loud, clear voice 4. Restraining the client during periods of agitation

Answer: 1 During detoxification frequent checks help ensure safety and prevent suicide, which is a real threat. Bright light is preferable to dim light because it minimizes shadows that may contribute to misinterpretation of environmental stimuli (illusions). The client who is going through the detoxification phase of acute alcohol withdrawal usually does not lose his sense of hearing, so there is no need to shout. Restraints may upset the client further; they should be used only if the client is a danger to himself or others

During the intake interview at a mental health clinic, a client in withdrawal reveals to the nurse long-term, high-dose cocaine use. Which signs and symptoms support the conclusion that the client has been abusing cocaine for a prolonged time? Select all that apply. 1. Sadness 2. Euphoria 3.Loss of appetite 4.Impaired judgment 5. Psychomotor retardation

Answer: 1, 5 Although cocaine is an alkaloid stimulant, depressant effects such as a decreased mood, hypotension, and psychomotor retardation are associated with long-term, high-dose use. Cocaine is a stimulant, and euphoria, loss of appetite, and impaired judgment are all associated with cocaine intoxication, not prolonged high-dose cocaine use.

For which clinical indication should a nurse observe a child in whom autism is suspected? 1. Lack of eye contact 2. Crying for attention 3. Catatonia-like rigidity 4. Engaging in parallel play

Answer: 1 Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.

An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis? 1. Easily distracted 2. Argues with adults 3. Lies to obtain favors 4. Initiates physical fights

Answer: 2 Oppositional defiant disorder is a repeated pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, usually exhibited before 8 years of age. Easy distraction, associated with attention deficit-hyperactivity disorder, reflects an inability to sustain focus on a task. Lying to obtain favors is associated with conduct disorder and reflects a violation of a societal norm. Initiating physical fights and violating the rights of others are associated with conduct disorder.

In response to a question posed during a group meeting, the nurse explains that the superego is that part of the self that says what? 1."I like what I want." 2. "I want what I want." 3. "I shouldn't want that." 4. "I can wait for what I want."

Answer: 3 Conscience and a sense of right and wrong are expressed in the superego, which acts to counterbalance the id's desire for immediate gratification. "I like what I want" does not reflect any part of the self. "I want what I want" is the id seeking satisfaction. A healthy ego can delay gratification and is in balance with reality.

When leading the first session of a newly formed group of clients in a mental health clinic, the nurse notes that group members frequently assume self-serving roles. What does the nurse understand about this? 1. Early group development involves these behaviors. 2. Some group members will need to be placed in another group. 3. Certain group members may be emerging to control attention seekers. 4. The group is attempting to reconcile conflicting viewpoints among its members.

1. answer These behaviors are a necessary phase of group development because they help members discover what they can expect from the leader and other members. It is inappropriate to assume at the first meeting that some clients will need to be switched to another group. Group factions are unlikely to emerge in the first session; moreover, factions seldom emerge to control disruptive group behavior. The group has not yet developed to the phase of reconciling conflict; conflict resolution and management occur only in operating groups.

The nurse is scheduled to be the co-leader of a therapy group being formed in the mental health clinic. When planning for the first meeting, it is of primary importance that the nurse consider what? 1. Number of clients in the group 2. Needs of the clients being included 3. Diagnoses of the clients being included 4. Socioeconomic status of the clients in the group

2. answer When planning a group, the nurse must ensure that clients have similar needs to promote relationships and interactions; diverse needs do not foster group process. Although important, the number of clients is not a primary consideration. Behavior and needs, rather than diagnoses, are of primary importance. The socioeconomic status of the clients in the group has little effect on group process.

A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discussing this therapy with the client? 1. Sleep will be induced and the treatment will not cause pain. 2. The treatment is totally safe with the new methods of administration. 3. The client may ask any question, but it is better not to talk about the therapy. 4. The client may experience some unrecoverable short-term and long-term memory loss.

Answer: 1 Clients fear ECT because they think it will be painful. If they are reassured that they will be asleep and will feel no pain, there will be less anxiety. No treatment requiring anesthesia is totally safe. Clients may not realize their own fears and therefore may not know what questions to ask; also, this response cuts off further communication. Temporary, not permanent, memory loss occurs.

A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary nurse approaches the client, who appears to be listening to voices, and comments, "You seem to be listening to something. Tell me what you hear." The primary nurse requests feedback from the psychiatric clinical specialist regarding this nursing intervention. How should the clinical specialist respond? 1. By reminding the nurse that once the content is known, there is no need to focus on the hallucinations, because doing so reinforces them 2. By giving positive feedback for the nurse's attempt to explore the content of the client's hallucinations and reinforcing the need to continue this approach 3. By recognizing this as a positive intervention and helping the nurse develop a plan of care that calls for a contract to refrain from acting on command hallucinations 4. By suggesting that the nurse use an open-ended approach and asking the nurse to discuss the correlation between positive behaviors observed and prescribed antipsychotics

Answer: 1 Once the content of the hallucination is known and it is not a command to harm the self or others, focusing on the hallucinations is not therapeutic; recognizing feelings, pointing out reality, and learning to use strategies to push aside hallucinations are therapeutic. Giving positive feedback reinforces the nurse's inappropriate approach with the client; continuing this approach reinforces the value of the hallucinations for the client, which is undesirable. This is a negative, not a positive, intervention; also, no data support the fact that the client is experiencing command hallucinations. Clear, concise, direct communication is more desirable when clients are experiencing hallucinations, which are usually frightening; although positive behaviors are a response to antipsychotic medications, these should not be the primary focus of this supervisory session.

What childhood problem has legal as well as emotional aspects and cannot be ignored? 1. School phobia 2. Fear of animals 3. Fear of monsters 4. Sleep disturbances

Answer: 1 School phobia is a disorder that cannot legally be ignored for long because children must attend school. It requires intervention to alleviate the separation anxiety and promote the child's increasing independence. Fear of animals and monsters and sleep disturbances all require parents to comfort the child, to reorient the child to reality, and to help the child regain self-control. Legally there are no requirements mandating treatment for these common childhood problems.

A 24-year-old woman states that she no longer enjoys any of the activities that she once found fun and pleasurable, such as socializing, sports, and hobbies. What term should the nurse use to describe this condition? 1. Anergia 2. Anhedonia 3. Grandiosity 4. Learned helplessness

Answer: 2 Anhedonia is the inability to experience pleasure in events or activities that once were enjoyable. Anergia is lethargy and a decreased level of energy. Grandiosity is a symptom seen during manic episodes in which an individual displays an inflated self-esteem. Learned helplessness is a theory proposing that depression occurs when an individual believes that he or she has no control over life situations. This results in the individual's giving up and becoming passive and dependent.

A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse? 1. "Tell me why you did this." 2. "You must have been upset to try to take your life." 3. "Of course you're good; we'll take excellent care of you." 4. "You've been through a rough time; let me take care of you

Answer: 2 Identifying and showing understanding of the client's feelings by giving feedback help establish a therapeutic relationship and promote exploration of feelings. Asking why the client attempted suicide is too direct; it does not allow the client time to reflect and explore feelings. Saying the client is good and promising to take care of the client negates the client's feelings and cuts off any further communication of feelings. Saying "Let me take care of you" encourages dependence; it does not permit exploration of feelings.

What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit? 1. Projection 2. Regression 3. Repression 4. Rationalization

Answer: 2 Regression is the defense mechanism that is commonly used by clients with schizophrenia, undifferentiated type, to reduce anxiety by returning to earlier behavior. Projection is an organized defense used by clients with schizophrenia, paranoid type, in which the delusional system is well systematized. Repression, or unconscious forgetting, is not a major defense used by clients with schizophrenia; if it were, they would not need to break with reality. Rationalization, in which the individual blames others for problems and attempts to justify actions, is seldom used by clients with schizophrenia.

A client who has severe anxiety starts to cry while talking with the nurse. The client is so upset that the crying becomes uncontrollable. What is the best response by the nurse? 1. "Talking about your problem is upsetting you." 2. "It's okay to cry; I'll just stay with you for now." 3. "Sometimes it helps to get it out of your system." 4. "You look upset; let's talk about why you're crying."

Answer: 2 Telling the client that it is alright to cry and offering to stay presents a nonjudgmental attitude that recognizes the client's needs. Pointing out the obvious is unnecessary and not therapeutic. Telling the client that it's good to get it out of the system implies that crying will make the client feel better and therefore is false reassurance. Saying the client looks upset and asking to talk about the client's problem is unrealistic; the anxiety level must be lowered before a discussion can begin

When a disturbed client who has a history of using neologisms says to the nurse, "My lacket huss kelong mon," how should the nurse respond? 1. Trying to learn the language of the client 2. Telling the client that these words cannot be understood 3. Communicating in simple terms directed toward the client 4. Recognizing that the client needs a nurse who can understand the fantasies expressed

Answer: 2 Telling the client that these words are not understood is a simple statement that provides feedback and points out reality. Neologisms have symbolic meaning only for the client. Although communicating in simple terms should be done, it does not address the problem. No one other than the client can understand the fantasies.

A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. What does the nurse remember is the main reason that clients use self-mutilation? 1. Control others 2. Express anger or frustration 3. Convey feelings of autonomy 4. Manipulate family and friends

Answer: 2 Typically, recurrent self-mutilation is an expression of intense anger, helplessness, or guilt or is a form of self-punishment. Self-mutilation is used not to control others but for self-validation; also, it is a means of blocking psychological pain by inducing physical pain. Self-destructive behaviors are not an expression of autonomy but rather an expression of negative feelings of anger, rage, and abandonment. Self-destructive behaviors represent not an attempt to manipulate others but rather a way to blunt emotional pain.

A nurse is interviewing an 8-year-old girl who has been admitted to the pediatric unit. Which statement by the child needs to be explored? 1. "Wow! This place has bright colors." 2. "Is my mother allowed to visit me tonight?" 3. "Those boys are so cute. I hope their room is next to mine!" 4. "I'm scared about being here. Can you stay with me awhile?"

Answer: 3 An 8-year-old child should be more concerned with same-gender relationships. A child who demonstrates a strong attraction to opposite-gender relations should be questioned further to explore the possibility of sexual abuse. A statement such as "Wow! This place has bright colors" is not unusual because 8-year-old children are usually attracted to colorful environments. A statement such as "Is my mother allowed to visit me tonight?" or "I'm scared about being here. Can you stay with me awhile?" is not unusual because 8-year-old children will want the support of a trusted person when experiencing stress.

A nurse is counseling a recently widowed client, who says, "His death has complicated my life even more than the hassles he caused when he was alive!" The nurse realizes the client is having difficulty with the grieving process and concludes that the relationship with the husband was probably what? 1. Loving 2. Long-term 3. Ambivalent 4. Subservient

Answer: 3 If the relationship was ambivalent, the surviving spouse now has feelings of both anger and guilt to resolve. A loving relationship evokes fewer feelings of guilt and is followed by a less complicated grieving process. The length of the relationship seems to have little to do with the ease or difficulty in completing the grieving process. Individuals in the subservient role usually have learned to accept directions and either find a new director or are relieved to have a chance to express their own feelings.

A client is not responding to antidepressant medications for treatment of major depression with suicidal ideation. After learning about electroconvulsive therapy (ECT), the client discusses the advantages and disadvantages with the primary nurse. The nurse concludes that the client understands the disadvantages of ECT when the client states that what is one major disadvantage of ECT? 1. The seizures may cause bone fractures. 2. Relief of symptoms requires many weeks of treatment. 3. Memory is impaired just before and after the treatment. 4. Loss of mental function occurs and continues for a long time.

Answer: 3 Impaired memory is an expected side effect of the therapy. Succinylcholine prevents the external manifestations of a tonic-clonic seizure, thereby minimizing fractures and dislocations. The therapy begins to elicit results in two or three treatments. There is no substantial loss of mental function after the treatment is completed.

The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse? 1. Holding the client by the arm to keep the client from leaving the group 2. Instructing the client in a loud voice to get on the bus so the group can go home 3. Informing the client in a matter-of-fact tone that everyone must remain with the group 4. Telling the client that the baseball player will not be permitted to give anyone an autograph

Answer: 3 Informing the client in a matter-of-fact tone indicates that negotiation is unacceptable. Holding the client by the arm is an inappropriate use of force. The nurse should contact the police if the client continues to refuse to leave. Raising the voice to a client indicates frustration and may be interpreted as threatening. Using the baseball player to meet control issues indicates to the client that the nurse is unable to maintain control of the situation.

A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use? 1. Projection 2. Repression 3. Regression 4. Conversion

Answer: 3 Regression is an unconscious defense mechanism that reduces anxiety by returning to behavior that was successful in earlier years. Regression commonly is used by clients with undifferentiated schizophrenia to reduce anxiety. Projection is the attributing of unacceptable feelings or thoughts to others- used by clients with paranoid schizophrenia. Clients with undifferentiated schizophrenia have psychotic manifestations that are extreme and do not have thought processes effective enough to use projection. Repression is unintentionally putting disturbing thoughts, feelings, or desires out of the conscious mind. Clients with schizophrenia are not able to do this and therefore have a need to escape from reality. Conversion is an unconscious defense mechanism in which a person develops physical symptoms that have no organic cause. Conversion serves the purpose of reducing anxiety. Conversion is not used by clients with undifferentiated schizophrenia

The nurse is interviewing a female adolescent with anorexia nervosa who is malnourished and severely underweight. Which statement leads the nurse to conclude that the client is experiencing secondary gains from her behavior? 1. "I'm as big as a house." 2. "I get straight A's in school." 3. "My mother keeps trying to get me to eat." 4 "My hair is beginning to fall out in clumps."

Answer: 3 The client's behavior has gotten attention for her; it provides a sense of power and control. "I'm as big as a house" reflects a disturbed perception about her body. Although clients with anorexia nervosa are concerned about social acceptance, perfectionism, and achievement and may obtain high grades in school, good grades are not a secondary gain related to the eating behaviors associated with anorexia nervosa. Hair falling out in clumps is a result of starvation, not a secondary gain.

A client's severe anxiety and panic are often considered "contagious." What action should be taken when a nurse's personal feelings of anxiety are increasing? 1. Refocusing the conversation to more pleasant topics 2. Saying to the client, "Calm down. You're making me anxious, too." 3. Saying, "Another staff member is coming in. I'll leave and come back later." 4. Remaining quiet so personal feelings of anxiety do not become apparent to the client

Answer: 3 The nurse who is anxious should leave the situation after ensuring continuity of care; the client will be aware of the nurse's anxiety, and the nurse's presence will be nonproductive and nontherapeutic. The client will probably sense the nurse's anxiety through nonverbal channels, if not through verbal responses. Refocusing and asking the client to calm down both meet the nurse's need; this response may make the client feel guilty that something was said that upset the nurse. The client will be aware of the nurse's anxiety, which will increase the client's own anxiety.

A client with a history of drug abuse begins group therapy. After attending the first meeting the client says to the nurse, "It helps to know that I'm not the only one with this type of problem." What concept does this statement reflect? 1. Altruism 2. Catharsis 3. Universality 4. Transference

Answer: 3 Universality is the sense that one is not alone in any situation; one purpose of group therapy is to share feelings and gain support from others with similar thoughts and feelings. Altruism in group therapy is giving support, insight, and reassurance to others, which eventually promotes self-knowledge and growth. Catharsis involves group members relating to one another through the verbal expression of negative and positive feelings. Transference occurs when a client unconsciously assigns to the therapist feelings and attitudes originally associated with another important person in the client's life.

A nurse is caring for an adolescent who has anorexia nervosa. The nutritional treatment of anorexia is composed of several guidelines. Which guidelines should the nurse emphasize? Select all that apply. 1. Increasing high-fiber foods 2. Eating just three meals a day 3. Increasing food intake gradually 4. Limiting mealtime to half an hour 5. Providing privileges for goal achievement

Answer: 3,4,5 Food intake should be increased by approximately 200 calories weekly. A gradual increase allows the client to adapt emotionally and physically to the increased volume. Thirty minutes is sufficient time for eating. Extended mealtimes place excessive attention on eating and increase anxiety and conflict. Goals should be set (e.g., gaining 2 lb (0.9 kg) per week and eating 90% of each meal). Behaviors that result in achievement of goals should be rewarded. Goals provide structure, and rewards motivate additional positive behaviors while promoting self-esteem. Consumption of high-fiber foods does not have to be increased. A variety of foods and textures should be eaten. Small, frequent meals should be offered.

A local business owner asks the mental health nurse to talk with employees about the principles of maintaining mental health in today's world. What is the nurse's primary intervention before planning the approach or content for the discussion? 1. Arranging for speakers who can help the employees 2. Performing a mental health assessment of the employees 3. Encouraging the employees to share how they avoid stress 4. Surveying the employees for related topics that interest them

Answer: 4 Beginning at the learner's level of understanding and including the learner in the planning foster acceptance and stimulate motivation. Arranging for speakers who can help the employees is premature. An outline of topics to be included should be developed first. Although a mental health assessment of the employees may eventually be done, it is not the priority at this time. Encouraging the employees to share how they avoid stress may be helpful; however, including the participants in the initial planning is more important.

What is the greatest difficulty for nurses caring for the severely depressed client? 1 Client's lack of energy 2 Negative cognitive processes 3 Client's psychomotor retardation 4 Contagious quality of depression

Answer: 4 Depression is contagious; it affects the nurse as well as the client. The client's lack of energy does not make nursing care difficult. Intervening with the client's negative thinking is an expected part of nursing care and does not create special difficulties for the nurse. The client's psychomotor retardation, or lack of energy, does not make nursing care difficult.

A 5-foot 5-inch (165 cm) 15-year-old girl who weighs 80 lb (36.3 kg) is admitted to a mental health facility with a diagnosis of anorexia nervosa. The nurse recognizes what factor as the most likely cause of her problem? 1. A desire to control her life 2. The wish to be accepted by her peers 3. The media's emphasis on the beauty of thinness 4. A delusion in which she believes that she must be thin

Answer: 1 Eating and weight loss become the means of control to decrease anxiety related to perfectionist thinking. Controlling one's self within the family seems to be more important than peer group acceptance. Although it is true that the media celebrates thinness, the response of the client with anorexia nervosa falls outside the usual range. Although fear of weight gain in the client with anorexia nervosa sometimes reaches delusional proportions, it is based on a belief that being fat is the problem that must be controlled.

A client comes to the crisis center because her spouse has stated that he wants a divorce. The client states that she is angry and feels rejected. What should the nurse encourage the client to do to cope with this emotional trauma? 1. Use other defense mechanisms. 2. Avoid talking with her spouse. 3. Date new people whenever possible. 4. Learn to constructively vent her anger.

Answer: 4 Coping mechanisms, such as venting anger, may help the client address the feelings of rejection. Defense mechanisms are usually subconscious and not under a person's control; specific coping approaches should be explored. Avoidance is a defense mechanism that may reduce anxiety, but it will not assist in problem-solving. Dating should not be encouraged until the client has worked through the current crisis.

After speaking with the parents of a child dying of leukemia, the primary healthcare provider gives a verbal do-not-resuscitate order but refuses to put it in writing. What should the nurse do? 1. Follow the order as given by the primary healthcare provider. 2. Refuse to follow the primary healthcare provider's order unless the nursing supervisor approves it. 3. Ask the primary healthcare provider to write the order in pencil on the child's chart before leaving the room. 4.Determine whether the family is in accord with the primary healthcare provider while following hospital policy.

Answer: 4 Determining whether the family is in accord with the primary healthcare provider while following hospital policy verifies family and provider agreement and uses institutional policy developed by the ethics committee. Neither the nurse nor the nursing supervisor should accept this inappropriate order. The order must be present in ink on the written record.

A nurse on the psychiatric unit is planning a discharge conference with a client and the client's family. What is the priority nursing action that should be included in the discharge plan? 1. Obtaining a more complete family history 2. Teaching the client about the medication to be taken 3. Discussing new issues that can be worked on at home 4. Exploring what has been learned from this hospitalization

Answer: 4 Evaluation and termination are the foci of a discharge planning conference; it is important for the nurse to assist the family in viewing the hospitalization as a learning experience. A more complete family history should have been obtained before the discharge conference, during which evaluation and future planning are the foci. Teaching the client about the medication to be taken and discussing new issues that could be worked on at home should have been done before the discharge conference, during which evaluation and future planning are the foci.

An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using? 1. Projection 2. Introjection 3. somatization 3. Rationalization

1. Projection The client is assigning to others those feelings and emotions that are unacceptable to herself. Introjection is treating something outside the self as if it is inside the self. Somatization is the unconscious transformation of anxiety into a physical symptom that has no organic cause. Rationalization is the use of a socially acceptable logical explanation to justify personally unacceptable material.

What is the basic therapeutic tool used by the nurse to foster a client's psychologic coping? 1. self 2. milieu 3. helping process 4. client's intellect

1. self The self is often the most important tool available to the nurse to help a client cope; to be therapeutic, the nurse must be present, actively listening, and attentive. The environment is important, but it is not the most basic tool. The nurse first must use the self before the helping process can begin. The client's intellect is not generally a therapeutic tool used by the nurse.

A 3-year-old child is brought to the emergency department by the mother, who reports that her child fell down the stairs and sustained injuries to the right arm and leg. During the physical assessment the nurse identifies a number of old bruises on the child's back, buttocks, and upper arms. What should the nurse say to the child to obtain additional information? 1. "Why did you fall down the stairs?" 2. "Did you really fall down those stairs?" 3. "Show me how you fell down the stairs." 4. "Your mommy must have told you to say you fell down the stairs."

Answer: 3 The response "Show me how you fell down the stairs" will allow the child to show what happened; it removes the pressure of verbalization. Children have difficulty answering "why" questions; asking why the child fell may add to the guilty feelings of the abused child. Asking, "Did you really fall down those stairs?" will confuse the child because it might become necessary to verify a lie. The response "Your mommy must have told you to say you fell down the stairs" will confuse the child because of his or her dependence on the mother; the child may be afraid of contradicting the mother.

A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is mostbeneficial for this client? 1. Directing the client repeatedly to eat the food 2. Explaining to the client the importance of eating 3. Waiting and allowing the client to eat whenever the client is ready 4. Having a staff member sit with the client in a quiet area during mealtimes

Answer: 4 By sitting with the client during mealtimes the nurse can evaluate how much the client is eating; this encourages the client to eat and begins the construction of a trusting relationship. Fewer distractions may help the client focus on eating. The client will not follow directions to eat because of the nature of the illness. Explaining the importance of eating and allowing the client to eat when ready are both unrealistic and will not ensure adequate intake.

A nurse in the mental health clinic concludes that a client is using confabulation when the client does what? 1. The flow of thoughts is interrupted. 2. Imagination is used to fill in memory gaps. 3. Speech flits from one topic to another with no apparent meaning. 4. Connections between statements are so loose that only the speaker understands them.

2. answer Using imagination to fill in memory gaps is the definition of confabulation; it is a defense mechanism used by people experiencing memory deficits. Interruption of the flow of thoughts is the definition of thought blocking. Flitting of speech from one topic to another with no apparent meaning is the definition of flight of ideas. The definition of associative looseness is connections between statements so loose that only the speaker understands them.

A client who has been admitted with a diagnosis of schizophrenia says to the nurse, "Yes, it's March. March is Little Women. That's literal, you know." What do these statements illustrate? 1. Echolalia 2. Neologisms 3. Flight of ideas 4. Loosening of associations

Answer: 4 Loose associations are thoughts that are presented without the logical connections that are usually necessary for the listener to interpret the message. Echolalia is the purposeless repetition of words spoken by others or repetition of overheard sounds. Neologisms are new meaningless words coined by the client or new, unique meanings given to old words. Flight of ideas is the rapid skipping from one thought to another; these thoughts usually have only superficial or chance relationships.

A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example? 1.Dissociation 2. Transference 3. Displacement 4. Identification

Answer: 1 Speaking in the third person reflects poor ego boundaries and dissociation from the real self. Transference is the movement of emotional energy and feelings that one has for one person to another person. Displacement is an attempt to reduce anxiety by transferring the emotions associated with one object or person to another. Identification is an attempt to increase self-esteem by acquiring the attributes or characteristics of an admired individual.

A client with a prolonged history of chronic schizophrenia, paranoid type, shows the nurse a small plastic keychain and says that it provides protection from evil forces. The client then quickly hides the keychain, yelling, "Don't take it away from me; it's the only thing that protects me." How should the nurse respond? 1. "You may keep it, because I know it's important to you." 2. "You need to give it to me, because you may hurt yourself." 3. "You're safe without the keychain, because there are no evil forces here." 4. "You'd better put it away, because someone might take it away from you."

Answer: 1 The keychain poses no threat to the client or others. It increases the client's sense of security and decreases anxiety. There is no evidence to indicate that the keychain poses any risk; removing it at this time will increase the client's anxiety. The client has not had time to develop trust in the nurse and will have difficulty with the statement regarding the absence of evil forces; it denies and belittles the client's feelings. Warning the client that someone on the unit may take the keychain away may add to the client's anxiety and will not help the nurse build trust.

A client has been diagnosed with generalized anxiety disorder (GAD). Which behavior supports this diagnosis? 1. Making huge efforts to avoid "any kind of bug or spider" 2. Experiencing flashbacks to an event that involved a sexual attack 3. Spending hours each day worrying about something "bad happening" 4. Becoming suddenly tachycardic and diaphoretic for no apparent reason

3. Spending hours each day worrying about something "bad happening" Using worrying as a coping mechanism is a behavior characteristic of GAD. Experiencing an accelerated heart rate and perfuse sweating for no apparent reason is consistent with a panic attack. Avoiding bugs and spiders would indicate a phobia. Flashbacks to traumatic events are characteristic of posttraumatic stress disorder (PTSD).

A nurse is speaking with a client who was sexually abused as a child. The client does not know what constitutes inappropriate touch by another person. What issue will have to be addressed with this client? 1. Increased libido 2. Phobic behavior 3. Boundary violations 4. Excessive aggression

3. answer Clients who have experienced childhood sexual abuse will have difficulty being aware of their personal boundaries and maintaining appropriate boundaries for themselves and others. Clients who have experienced childhood sexual abuse tend to have decreased, not increased, libidos. Phobic behavior, the irrational fear of an object or situation, is not necessarily a concern that the nurse should have for this client more than for other clients. Clients who have experienced childhood sexual abuse can exhibit aggressive behavior, but it does not directly address the identification of inappropriate touching.

A client in the outpatient clinic is denying that he is addicted to alcohol. He tells the nurse that he is not an alcoholic and that it is his nagging wife who causes him to drink. What is the most therapeutic response by the nurse? 1. "I don't think that your wife is the problem." 2. "Everyone is responsible for his own actions." 3. "Perhaps you should have marriage counseling." 4. "Why do you think that your wife is the cause of your problems?"

Answer: 2 The comment "Everyone is responsible for his own actions" encourages the client to accept responsibility and does not support denial as a defense mechanism. Although the comment "I don't think that your wife is the problem" may be true, it may also close off communication; with a decrease in communication the nurse cannot be effective in helping break through the denial. Although suggesting marriage counseling may be appropriate, it does not address the issue of denial. The comment "Why do you think that your wife is the cause of your problems?" enables the client to continue to avoid responsibility for his own behavior.

An older adult is admitted for evaluation of anemia and unsteady gait. While obtaining a health history, the nurse notes that the client seems to make up stories to fill in for memory lapses. How should the nurse document what the client is doing? 1. Lying 2. Denying 3. Fantasizing 4. Confabulating

Answer 4: Confabulation is the filling in of memory gaps as a protective mechanism. Lying is false or dishonest behavior that is conscious and deliberate and is used in an attempt to deceive or mislead; there is no evidence of this behavior. Denying is a refusal to believe or accept reality and is used as a protective defense mechanism; there is no evidence of this behavior. Fantasizing is a more-or-less connected series of mental images, such as those that occur in daydreams, that usually involve some unfulfilled desire; there is no evidence of this behavior.

A client who is being discharged with severe facial scarring from burns tells the nurse, "I've saved some oxycodone, and when I get home I'm going to take all of them. Don't tell anyone." What is the best response by the nurse? 1. "Are you going to kill yourself?" 2. "You don't want me to tell anyone?" 3. "Are you in a lot of pain right now?" 4. "Do you know that too much oxycodone is dangerous?"

Answer: 1 A direct assessment is necessary to determine whether the client is contemplating suicide. The client already has stated that the nurse should not tell anyone; reeliciting this information will only serve to delay further investigation and intervention. Pain management is not the priority at this time; pain may not be the reason for taking the medication. Teaching the client about oxycodone is not the priority at this time.

Before discharge of an anxious client, the nurse should teach the family that anxiety can be recognized as what? 1. A totally unique feeling 2. Fears specifically related to the total environment 3. Consciously motivated actions, thoughts, and wishes 4. A pattern of emotional and behavioral responses to stress

4. Answer Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. Anxiety is experienced to a greater or lesser degree by every person. The fear may be related to a specific aspect of the environment rather than the total environment. Anxiety does not operate from the conscious level.

A client in the psychiatric hospital is attempting to communicate by stating, "Sky, flower, angry, green, opposite, blanket." The nurse recognizes what term as describing this type of communication? 1. Echolalia 2. Word salad 3. Confabulation 4. Flight of ideas

Answer: 2 Word salad is an incoherent mixture of words. Echolalia is a pathologic repetition of another's words or phrases. Confabulation is the unconscious filling in of memory gaps with imagined or untrue experiences. Flight of ideas is a speech pattern of rapid transition from topic to topic. The client's statement is too limited to be considered flight of ideas.

What response from the nurse demonstrates an understanding of hallucinating behavior by a client? 1. Asking, "What are the voices telling you to do?" 2. Calmly noting that the "rat on the floor" is really a stuffed toy 3. Allowing the family to bring prepackaged foods from the store 4. Explaining to the family that the behavior will worsen during the night

Answer: 1 A hallucination involves false perceptions of sensory stimuli that may be visual, auditory, tactile, or olfactory. Hearing voices is a common hallucination, and it is appropriate for the nurse to clarify exactly what the client is hearing. When a misperception of a sensory stimuli can be rationally explained (e.g., mistaking a stuffed toy for a real animal), it is considered an illusion. Paranoia is an extreme, unfounded distrust expressed by an individual. Paranoid beliefs regarding poisoned foods are fairly common. When a client is at risk for insufficient nutritional intake, prepackaged foods may offer an acceptable alternative. Sundowning is the demonstration of psychotic behaviors similar to delirium that occur or worsen in the evening and nighttime hours.

What is a priority nursing intervention in the care of a drug-dependent mother and infant? 1. Supporting the mother's positive responses toward her infant 2. Requesting that family members share responsibility for infant care 3. Keeping the infant separated from the mother until the mother is drug free 4. Helping the mother understand that the infant's problems are a result of her drug intake

Answer: 1 A nurse should attempt to support the mother-child relationship; the mother is experiencing a developmental crisis while coping with drug addiction and possibly guilt. It is the client's right to decide who will share in the care of her child. The client needs contact with her new infant to facilitate bonding. Helping the mother understand that the infant's problems are a result of her drug intake will make the client feel guilty and will not facilitate positive action at this point

A client has the diagnosis of histrionic personality disorder. Which behavior should the nurse expect when assessing this client? 1. Boastful and egotistical 2. Rigid and perfectionistic 3. Extroverted and dramatic 4. Aggressive and manipulative

Answer: 3 Clients with histrionic personality disorder draw attention to themselves, are vain, and demonstrate emotionality and attention-seeking behavior. Boastful and egotistical behaviors are typical of clients with the diagnosis of narcissistic personality disorder. Rigid and perfectionistic behaviors are typical of clients with the diagnosis of obsessive-compulsive personality disorder. Aggressive and manipulative behaviors are typical of clients with the diagnosis of antisocial personality disorder.

What characteristic of an adolescent girl suggests to the nurse that she has bulimia? 1 History of gastritis 2 Positive self-concept 3 Excessively stained teeth 4 Frequent re-swallowing of food

Answer: 3 Dental enamel erosion occurs with repeated self-induced vomiting. History of gastritis is not associated with bulimia. Often body image is disturbed and there is low self-esteem. Habitual regurgitation of small amounts of undigested food (rumination) and re-swallowing of food are not associated with bulimia; emptying of the stomach contents through the mouth (vomiting) is associated with bulimia.

A client with bipolar I disorder, manic episode, is admitted to the mental health unit of a community hospital. When developing an initial plan of care for this client, what should the nurse plan to do? 1. Increase the client's gym time. 2. Isolate the client from peers. 3. Encourage increased nutritional intake. 4. Reinforce participation in unit programs.

Answer: 3 The client in a manic episode of the illness often neglects basic needs; these needs are a priority to ensure adequate nutrition, fluid, and rest. The hyperactivity of mania creates an increased need for calories. Although the client needs to expend excess energy, physical exhaustion and dehydration are real possibilities during the manic episode of the illness. Isolating the client from peers is counterproductive and punitive. The client is unable to actively participate in group activities at this time

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? 1. Undoing 2. Projection 3. Introjection 4. Intellectualization

3. answer 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. Undoing is taking some action to counteract or make up for a wrongdoing. Projection is attributing to another person or group one's own unacceptable attitudes or characteristics. Intellectualization is using logical explanations without feelings or an affective component.

A nurse is caring for a client with an obsessive-compulsive disorder. What is the basis for the obsessions and compulsions? 1. Unconscious control of unacceptable feelings 2. Conscious use of this method to punish themselves 3. Acceptance of voices that tell her that doorknobs are unclean 4. Fulfillment of a need to punish others by carrying out the procedure

Answer: 1 In carrying out the compulsive ritual the client unconsciously tries to control anxiety by avoiding acting on unacceptable feelings and impulses. The client does not consciously use this method to punish herself. Hallucinations are not part of this disorder. People with obsessive-compulsive disorder feel no need to punish others.\

A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child? 1.Play 2. Group 3. Family 4. Psychodrama

Answer: 1 It will be most effective for the child to play out feelings; when feelings are allowed to surface, the child can then learn to face them by controlling, accepting, or abandoning them. Group, family, and psychodrama therapies are not child-specific and are generally better suited to adolescents, young adults, and adults.

What is a primary component of the nursing plan of care for a client with the diagnosis of anorexia nervosa? 1.Observing the client after meals 2.Weighing the client before meals 3. Measuring the client's fluid balance 4. Limiting the client's interaction with peers

Answer: 1 Observing the client after meals is the only way the nurse can be certain that the client does not engage in purging. Weighing will not help the nurse assess the client's electrolyte or nutritional status. An accurate intake and output record is difficult to obtain unless the individual is closely observed throughout the day. There is no need to isolate the client from peers.

During a therapy group session, a female client begins to cry and tells the other group members that her husband has told her that he wants a divorce. What is the most appropriate initial response by the nurse? 1. Observing how the group responds to her statement 2. Asking her to explore the reasons that he wants a divorce 3. Suggesting that she and her husband seek marital counseling 4. Staying with the client outside the room until she stops crying

Answer: 1 The nurse should not intervene at this time because the client made the statement to the group. Initially the nurse should observe how the group responds to the client's statement. Next the nurse should nurture a supportive response by group members. Asking her to explore the reasons that he wants a divorce may be perceived as confrontational and intimidate the client and other group members. Suggesting that she and her husband seek marital counseling is inappropriate at this time. The group should focus on the client's current feelings. Staying with the client outside the room until she stops crying is unnecessary because the client is not a danger to herself or others. Also, it gives the message that feelings of sadness cannot be shared with the group.

According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage? 1. Trust 2. Identity 3. Initiative 4. Autonomy

Answer: 1 Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense of self; this results in identity diffusion and confusion. Without initiative, the individual will experience the development of guilt and feelings of inadequacy. Without autonomy, the individual has little self-confidence, develops a deep sense of shame and doubt, and learns to expect defeat.

A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD? 1. Less severe linguistic handicaps 2. Early onset, before 36 months of age 3. The only form that does not include seizures 4. The only form that does not include cognitive impairment

Answer: 2 Autism impairs bonding and communication and therefore becomes apparent early in life. Autism involves both delayed and deviant linguistic problems. About 25% of children with autism have a seizure disorder. Autism may, and often does, include cognitive impairment.

A nurse completes the assessment of a female client who cannot function because of an impending divorce. What is the most effective nursing intervention for this client at this time? 1. Helping her identify precipitating factors 2. Assisting her in exploring new coping abilities 3. Limiting her support system to promote independence 4. Developing her plan of care to fit her perception of the events

Answer: 2 Intervention is aimed at restoring equilibrium by helping the client develop new ways to cope and assisting with the exploration of available support systems. Identification of the precipitating factors should have taken place during the assessment phase. Limiting the circle of support will not lead to independence; instead, it will increase the client's vulnerability and precipitate feelings of abandonment. The client's perception may be distorted; the nurse should strive to help maintain a realistic perception.

An executive assistant experiences an overwhelming impulse to count and arrange the rubber bands and paper clips in his desk. The client feels that something dreadful will occur if the ritual is not carried out. Considering the client's symptoms, what does the nurse conclude about the rituals? 1. They are useful in our society as long as they can be controlled 2.They serve to control anxiety resulting from unconscious impulses 3. They are a displacement of general anxiety onto an unrelated specific fear 4. They serve to consciously limit the associated anxiety that otherwise is overwhelming

Answer: 2 Serving to control anxiety resulting from unconscious impulses is the psychoanalytical explanation for the development of obsessive-compulsive symptomatology. Compulsive rituals commonly result in interference with activities of daily living, and the individual becomes dysfunctional; the need to perform rituals cannot be controlled. A displacement of general anxiety onto an unrelated specific fear is the general description of phobias. The client is unable to consciously stop the behavior because anxiety will become overwhelming if the ritualistic defense is not used. The behavior is not overwhelming because it limits anxiety.

What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client who is 30 years of age? 1.Integrity versus despair 2. Intimacy versus isolation 3. Industry versus inferiority 4. Identity versus role confusion

Answer: 2 The major task of the young adult is to develop close, sharing relationships that may include a sexual partnership; the person develops a sense of belonging and avoids isolation. During the integrity-versus-despair stage, the adjusted older adult can look back with satisfaction and acceptance of life and resolve the inevitability of death; failure at these tasks results in despair. The middle school-aged child gains a sense of competence and self-assurance as social interactions and academic pursuits are mastered; failure in these tasks leads to feelings of inferiority. During adolescence the individual develops a sense of self, self-esteem, and emotional stability; failure to establish self-identity results in a lack of self-confidence and difficulty with occupational choices.

The nurse is interviewing the family about the onset of problems in a young client with the diagnosis of schizophrenia. In what stage of development does the nurse expect that the client's difficulties with reality testing began? 1. Puberty 2. Adolescence 3. Late childhood 4. Early childhood

Answer: 2 The usual age of onset of schizophrenia is adolescence or early adulthood. Signs and symptoms usually do not appear earlier in life.

A young child in whom sexual abuse is suspected asks the nurse, "Did I do something bad?" What is the mosttherapeutic response by the nurse? 1. "Do you think you did something bad?" 2. "Who said that you did something bad?" 3. "What do you mean by something bad?" 4. "Are you worried that I think you did something bad?"

Answer: 3 "What do you mean by something bad?" elicits further clarification of what the child means by "bad." The nurse must determine what the child means by the word "bad" before reflecting the term back to the child. "Who said that you did something bad?" is not helpful; it will do nothing to clarify the child's idea of what "bad" means or the child's feelings about what happened. Before the nurse can explore the child's concerns ("Do you think you did something bad?" or "Are you worried that I think you did something bad?"), the nurse must first understand the child's use of words and their meaning to the child.

A nurse is planning to teach a class of nursing assistants how to compare the behaviors of psychotic clients with the behaviors of people who function acceptably in society. What type of behavior is considered acceptable? 1. When defense mechanisms are rarely employed 2. If feelings and thoughts are expressed accurately 3. When it reflects the standards accepted by one's society 4. If methods used enhance achievement of short- and long-term goals

Answer: 3 An accepted practice in some parts of the world may be considered unacceptable behavior in others (e.g., pica). Every person needs relief from tension from time to time and makes use of defense mechanisms to accomplish this. If the behavior is aggressive or destructive, although it might accurately reflect the individual's thoughts and feelings, it is not considered acceptable. If the behavior is aggressive or destructive, even if it helped reach a goal, it is not considered acceptable.

According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to which developmental stage? 1. Trust versus mistrust 2. Industry versus inferiority 3. Generativity versus stagnation 4. Identity versus role confusion

Answer: 3 Erikson theorized that how well people adapt to the present stage depends on how well they adapted to the stage immediately preceding it—in this instance, adulthood. Trust versus mistrust, industry versus inferiority, and identity versus role confusion are all tasks of earlier stages of development. Although Erikson believed that the strengths and weaknesses of each stage are present in some form in all succeeding stages, their influence decreases with time.

A client is admitted to the mental health unit with the diagnosis of anorexia nervosa. What typical signs and symptoms of anorexia nervosa does the nurse expect the client to exhibit? 1. Slow pulse, mild weight loss, and alopecia 2. Compulsive behaviors, excessive fears, and nausea 3. Amenorrhea, excessive weight loss, and abdominal distention 4. Excessive activity, memory lapses, and an increase in the pulse rate

Answer: 3 In anorexia nervosa, weight loss is excessive (15% of expected weight); nutritional deficiencies result in amenorrhea and a distended abdomen. Although pulse irregularities and alopecia are associated with anorexia, weight loss is excessive, not mild. Although compulsive behaviors are common, excessive fears and nausea are not associated with anorexia nervosa. Memory lapses are not associated with anorexia nervosa; excessive exercising and pulse irregularities are.

When planning interventions to help a client with bipolar I disorder, manic episode, meet rest and sleep needs, what must the nurse remember about the manic client? 1. Experiences few sleep pattern disturbances 2. Requires less sleep than the average person 3. Is easily stimulated, and this interferes with sleep 4. Needs to expend energy to be tired enough to sleep

Answer: 3 Manic individuals readily respond to environmental cues. Increased stimulation increases activity; decreased stimulation decreases activity. Sleep pattern disturbances characteristically occur because of psychomotor activity. All individuals require adequate rest and sleep; hyperactive clients may become exhausted because of their high activity level. Expending energy only increases the tendency to remain awake.

A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? 1. Undoing 2. Projection 3. Suppression 4. Intellectualization

Answer: 3 Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.

A 16-year-old boy with a diagnosis of adolescent adjustment disorder and his family are beginning family therapy. What is the best initial nursing approach? 1. Setting long-term goals for the family 2. Letting the client express his feelings first 3. Having the parents explain their rationale for setting firm limits 4. Encouraging each family member to share how the problem is perceived

Answer: 4 Family therapy must include the whole family. Each member must be considered not just individually from his or her perspective but also as a member of the whole. Identification of the problem by the people involved is the priority. The family, not the nurse, sets goals. The nurse assists the family in setting goals by acting as a facilitator. Feelings should be shared eventually, but this is not the initial focus. Setting limits may or may not be a problem within the family.

A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients? 1. Reviewing the past is depressing. 2. Stimulating new situations are ideal. 3. Dependency increases as age progresses. 4. Staying healthy promotes a quality retirement.

Answer: 4 Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved. Reviewing the past is an essential part of the life review that older adults must engage in to eventually reach integrity. The person may be in despair when reviewing the past is depressing. Most older adults prefer familiar routines and environments and desire independence even when coping with the effects of aging and chronic illness.

A 20-year-old homeless client at 38 weeks' gestation visits the prenatal clinic for the first time. She is accompanied by her 21-year-old boyfriend, who is the father of the baby. The nurse becomes concerned because as they sit in the waiting room, they are sneezing and yawning and have teary eyes. With what substance are these withdrawal signs associated? 1. Heroin 2. Cocaine 3. Morphine 4. Phenobarbital

Answer: Heroin Research indicates that sneezing, yawning, and teary eyes are the first physical signs of withdrawal from heroin. Depression and irritability accompany withdrawal from cocaine. Restlessness, shakiness, hallucinations, and sometimes coma accompany withdrawal from morphine. Insomnia, seizures, weakness, sweating, and anxiety accompany withdrawal from phenobarbital.

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

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

The nurse should first discuss terminating the nurse-client relationship with a client during which phase? 1. Working phase, when the client initiates it 2. Orientation phase, when a contract is established 3. Working phase, when the client shows some progress 4. Termination phase, when discharge plans are being made

2. answer When the nurse and client agree to work together, a contract should be established and the length of the relationship should be discussed in terms of its ultimate termination. The client may discuss termination during the working phase; however, the subject should initially be discussed during the orientation phase. Termination and discharge plans may be discussed more thoroughly during this phase, but the subject should initially be discussed during the orientation phase.

The husband of a woman who gave birth to a baby 2 weeks ago calls the postpartum unit at the hospital, seeking assistance for his wife. He reports that he found his wife in bed and that the baby was wet, dirty, and crying in the crib. He says, "She says she just can't do it." What is the bestresponse by the nurse? 1. Encouraging him to express his feelings about the situation 2. Telling him to schedule an appointment with the gynecologist 3. Asking whether he can afford a home health aide for several weeks 4. Informing him that he should seek emergency intervention for his wife

Answer: 4 The inability to care for herself or her infant is a significant sign that the wife is depressed and in need of immediate intervention. The wife, not the husband, is the priority at this time. The wife has an emotional, not physiologic, problem at this time. Asking whether the family can afford a home health aide for several weeks is not the priority at this time; the wife's emotional condition is the priority.

An inpatient therapy group on a psychiatric unit has as its goal helping clients participate in life more fully by gaining insight and changing behavior. The nurse leader can best help the group achieve this goal by using a leadership style that is what? 1 Democratic and guiding 2 Autocratic and directing 3 Laissez-faire and observing 4 Passive and nonconfrontational

1. A democratic and guiding leader stimulates and directs the group to assist it in developing its maximal potential by facilitating and balancing the group's forces. An autocratic and directing leader makes most of the decisions and controls the group, thereby limiting group growth potential. A laissez-faire, observing leader allows group members to take over the group; if there are no members with leadership skills, little is gained from the group. A passive and nonconfrontational leader does not provide adequate leadership to make the group effective.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? 1. Become aware of their personal values 2. Gain information related to their needs 3. Make correct decisions related to their health 4. Alter their value systems to make them more socially acceptable

1. Answer Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

A nurse is conducting a group therapy session. Why is a group setting especially conducive to therapy? 1. It provides a new learning environment. 2. It decreases the focus on the individual. 3. It fosters one-on-one personal relationships. 4. It confronts individual members with their shortcomings

1. answer The group setting provides an individual with the opportunity to learn that others share the same problems and needs. The group also provides a safe arena in which new, healthier, more meaningful methods of relating to others can be explored. The focus is still on the individual, but more on the individual's learning how to relate to others. Groups promote interaction among many people rather than one-on-one relationships. Confronting individual members with their shortcomings may happen from time to time, with support given to the individual by the group, but it is not a main function of the group.

In addition to hallucinating, a client yells and curses throughout the day. What should the nurse do? 1. Ignore the client's behavior. 2. Isolate the client until the behavior stops. 3. Explain the meaning of the behavior to the client. 4. Seek to understand what the behavior means to the client.

4. Answer All behavior has meaning; before planning intervention, the nurse must try to understand what the behavior means to the client. Ignoring behavior does little to alter it and may even cause further acting out. Isolation may increase anxiety and precipitate more acting-out behavior. The nurse cannot explain the meaning of the client's behavior; only the client can.

When the nurse is managing the care of an acutely depressed client, which intervention demonstrates that the nurse recognizes the client's fundamental mental health need? 1. Role modeling a hopeful attitude regarding life and the future 2. Sharing that life has presented depressing situations for all of us at times 3. Devoting time with the client and trying to focus on happy, positive memories 4. Identifying the client's personal weaknesses and designing interventions to strengthen them

1. Role modeling has been shown to be an excellent tool in molding adaptive behavior. Depression affects the individual's ability to see hope in the future, and role modeling will help provide adaptation to similar feelings. Affirming that everyone has depressive situations in their lives does not foster a positive response in the depressed client. Reminiscing about happier times and events is likely to highlight the client's current loss of happiness rather than foster positive feelings. The depressed client generally has low self-esteem and is often too tired to engage in physical activities. When a client is depressed, the nurse should identify the client's personal strengths, not weaknesses, and focus on interventions to reinforce those strengths. Focusing on a client's weaknesses when the client is already depressed may initiate a deeper depression.

A nurse is assessing a client for the use of defense mechanisms. In the presence of which defense mechanism does the client express emotional conflicts through motor, sensory, or somatic disabilities? 1. Projection 2. Conversion 3. Dissociation 4. Compensation

2. Conversion The defense mechanism is called conversion because the individual reduces emotional anxiety to a physical disability. Projection occurs when people assign their own unacceptable thoughts and feelings to others. With dissociation there is separation of certain mental processes from consciousness as though they belonged to another; a dissociative reaction is expressed as amnesia, fugue, multiple personality, aimless running, depersonalization, sleepwalking, and other behaviors. Compensation is a mechanism used to make up for a lack in one area by emphasizing capabilities in another.

A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, which factor should the nurse consider? 1 Crying relieves depression and helps the client face reality. 2 Crying releases tension and frees psychic energy for coping. 3 Nurses should not interfere with a client's behavior and defenses. 4 Accepting a client's tears maintains and strengthens the nurse-client bond.

2. Crying is an expression of an emotion that, if not expressed, increases anxiety and tension; the increased anxiety and tension use additional psychic energy and hinder coping. Crying does not relieve depression, nor does it help a client face reality. It is not universally true that nurses should not interfere with a client's behavior and defenses. In most instances the client's defenses should not be taken away until they can be replaced by more healthy defenses. The nurse must interfere with behavior and defenses that may place the client in danger, but the client's current behavior poses no threat to the client. It is not always true that accepting a client's crying maintains and strengthens the nurse-client bond. Many clients are embarrassed by what they consider a "show of weakness" and have difficulty relating to the individual who witnessed it. The nurse must do more than just accept the crying to strengthen the nurse-client relationship.

Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings? 1 Behaviorist model 2 Psychoanalytic model 3 Psychobiologic model 4 Social-interpersonal model

2. The psychoanalytic model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. The psychobiologic model views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. The social-interpersonal model affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.

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 indicate that the client is hearing voices. When a nurse begins to walk toward the client, the client pulls out a large knife. What is the best approach by the nurse? 1 Firm 2 Passive 3 Empathetic 4 Confrontational

Answer: 1 A firm approach prevents anxiety transference and provides structure and control for a client who is out of control. A passive approach for a client who may be out of control does not provide structure, which may increase the client's anxiety. Although the nurse should always base a therapeutic response on empathy, an obviously empathetic response may indicate to the client that the behavior is acceptable. A confrontational approach in this situation may escalate the client's agitation and precipitate further acting out.

During an interview of a client with a diagnosis of bipolar I disorder, manic episode, what does the nurse expect the client to demonstrate? 1 Flight of ideas 2 Ritualistic behaviors 3Associative looseness 4 Auditory hallucinations

Answer: 1 Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode. Ritualistic behaviors are repetitive, purposeful, and intentional behaviors that are carried out in a stereotyped fashion; they are found in clients with obsessive-compulsive disorders. Associative looseness is the pattern of speech found in clients with schizophrenia; usual connections between words and phrases are lost to the listener and meaningful only to the speaker. Hallucinations are false perceptions generated by internal stimuli; they are found in clients with the diagnosis of schizophrenia.

A married woman is brought to the emergency department of a local hospital. Her eyes are swollen shut, and she has a bruise on her neck. She reports that she is being beaten by her husband. How does the nurse expect the husband to behave when he arrives at the emergency department? 1. Fearful 2. Confused 3. Charming 4. Indifferent

3. Abusers are often extremely charming to mask their abusive tendencies and convince the abused mate and others that change is possible. After an abusive episode there is often a "honeymoon" period because the tensions of the abuser have been released. Abusers mask their fears by becoming angry and aggressive. Abusers are not confused; they are manipulative of others. Abusers are rarely indifferent; they tend to be opinionated and demanding.

A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want my child to know about the diagnosis." How should the nurse respond? 1. "It's best for your child to know the diagnosis." 2. "Did you know that the cure rate for Hodgkin disease is high?" 3. "Would you like someone with Hodgkin disease to talk with you?" 4. "Let's talk about how you're feeling about your child's diagnosis."

4. answer Initiating a conversation about the client's feelings does not prejudge the parent; it encourages communication. Stating that it is best for the child to know the diagnosis disregards the parent's feelings and cuts off further communication. Asking the client about the cure rate may stop communication and does not recognize the parent's concerns. Offering to have someone with Hodgkin disease speak to the client is premature and does not recognize the parent's concerns.

A nurse educator is leading a class on supporting middle-aged adults who are experiencing midlife crises. What should the nurse include as the most significant factor in the development of this type of crisis? 1. The perception of their life situation 2. Many role changes that alter their experiences at this time 3. The anticipation of negative changes associated with old age 4. Lack of support from family members who are busy with their own lives

Answer: 1 The most significant factor in either precipitating or avoiding a crisis is not the events, but how the individual perceives them. Changes in roles may occur, but, again, the individual's perception of these changes is most influential. The anticipation of negative changes associated with old age may be a factor, but perception is most important. Lack of support from family members is not a significant factor; the family may provide support, yet a crisis may still occur.

A 15-year-old client is brought to the high school health office by two of her friends, who report, "We think she just took a handful of pills." The adolescent appears alert and refuses to speak. The school nurse's initial response should be to do what? 1. Ask the friends where she got the pills. 2. Ask the adolescent whether she took any pills. 3. Call the rescue squad to stand by for an emergency. 4 Call the adolescent's parents to tell them to come immediately.

Answer: 2 Asking the client is the most direct approach to ascertaining whether pills were ingested; the client will usually respond to this type of direct question. Asking the friends where she got the pills does not provide useful information. Calling the rescue squad to stand by for an emergency is not the initial response; a determination must first be made regarding the number of pills taken. Calling the adolescent's parents to tell them to come immediately is appropriate later; it is not the priority now.

A mental health nurse is participating in a therapy group. The nurse concludes that the group has reached the working stage when the members do what? 1. Appear happy in their group interactions. 2. Focus on a variety of needs and concerns. 3. Say what is expected and wanted by the others. 4. Show concern for the feelings of the group leaders.

Answer: 2 Focusing on a variety of needs and concerns is typical of the working stage of the group; trust has been established, and a willingness to discuss any problems or needs is present. Satisfaction with group interactions may occur at any stage; satisfaction occurs in social, as well as therapeutic, relationships. Saying what is perceived as being expected or showing concern for the feelings of group leaders occurs in the early stages of group therapy, before trust is established.

Which outcome best demonstrates a healthcare institution's commitment to providing a supportive environment for its psychiatric nursing staff? 1. Psychiatric nursing units are well staffed with qualified personnel. 2. The psychiatric units are equipped with the most modern client care equipment. 3. Psychiatric nurses are regularly recognized for their contributions to client healthcare. 4. The psychiatric nursing staff is represented in each client's multidisciplinary healthcare team.

Answer: 3 A supportive nursing environment is one that fosters and supports open, honest communication among all disciplines involved in a client's care. This demonstrates respect for the professional psychiatric nurses and their influence on client healthcare. A sufficient number of qualified nursing personnel is a requirement on any nursing unit and shows a commitment to client care but not necessarily support for the unit's nursing staff. A modern, well-equipped nursing unit shows a commitment to client care but not necessarily support for the unit's nursing staff. Recognition of professional levels of nursing care is likely to have a positive effect on nursing morale but does not necessarily foster a supportive nursing environment.

A client who was sexually assaulted 3 hours ago comes to the emergency department of the hospital. The priority is for the staff to help the client feel what? 1. Loved 2. Believed 3. Protected 4. Accepted

Answer: 3 Safety and security are basic needs that assume significance immediately after a sexual assault. Although all people have a need to belong and be loved, these are not priorities at this time and are not responsibilities of the staff. Although belief is important, it is not the priority. Although acceptance is important, it is not the priority.

A reasonable short-term outcome for clients who are functioning below the optimal level of mental health is to help them become better able to do what? 1. Understand the dynamics behind their inadequate interpersonal relations. 2. Confront their inadequacies in interpersonal relations and be more sociable. 3. Discuss feelings regarding their life experiences and their significant others. 4. Take actions that will increase their satisfaction with their relationships with others.

Answer: 3 The ability to discuss feelings about others and life situations is necessary for positive mental health. Understanding interpersonal dynamics, confronting inadequacies, and taking actions to increase satisfaction in relationships are all long-term, not short-term, outcomes.

A 13-year-old student visits the school nurse numerous times over the course of several weeks. The student has reported, "I worry about my parents because I don't want them to get a divorce. They tell me that they're happy, but I can't stop worrying. I'm having trouble sleeping, I'm always tired, and my grades have dropped." Which condition does the nurse consider that this student may be experiencing? 1. Panic disorder 2. Separation anxiety 3. Generalized anxiety 4. Acute stress disorder

Answer: 3 The data presented reflect generalized anxiety disorder (GAD), which includes three or more of these adaptations: uncontrollable worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances. The criteria for panic disorder include a panic attack followed by persistent concern and worry about another attack, with significant changes in behavior. The adaptations associated with separation anxiety are similar to those described but also include refusal to attend school or other activities without a parental figure. With acute stress disorder, three or more dissociative symptoms, including detachment, feeling of being in a daze, numbing, reduced awareness of surroundings, derealization, or dissociative amnesia, appear within 4 weeks of a traumatic event.

Which statement best explains the focus of a therapeutic milieu management? 1. Management of a therapeutic milieu is a nursing responsibility. 2.The nurse-patient relationship is dependent upon therapeutic milieu management. 3. Milieu management creates an environment that supports the client's therapeutic care. 4. Creating a therapeutic milieu requires a proactive approach on the part of the nurse.

Answer: 3 The focus of a therapeutic milieu is the creation and maintenance of an environment that supports and benefits a client toward achieving therapeutic goals. That management of a therapeutic milieu is a nursing responsibility, the nurse-patient relationship is dependent upon therapeutic milieu management, and creating a therapeutic milieu requires a proactive approach on the part of the nurse are true, but these statements do not best explain the focus of the management of the milieu.

A 13-year-old girl is brought to the emergency department by her mother, who tells the nurse that she just found out that her daughter has been sexually abused by her grandfather for almost 2 years. What is the nurse's priority intervention? 1.Keeping the family unit intact 2.Validating the truth of the child's accusations 3.Providing a safe, nonjudgmental environment 4. Securing psychiatric treatment for the grandfather

Answer: 3 Victims of sexual abuse need to feel safe and accepted when discussing their histories. The nurse's primary responsibility is toward the child, not the family. The story should initially be accepted as true. The nurse's primary responsibility is toward the child, not the grandfather.

A college student visits the health center and describes anxiety about having to declare an academic major. What developmental conflict, according to Erikson, is this client still attempting to resolve? 1. Initiative versus guilt 2. Integrity versus despair 3. Industry versus inferiority 4. Identity versus role confusion

Answer: 4 The client is demonstrating a search for self and has not resolved the developmental conflict of adolescence, identity versus role confusion. Initiative versus guilt is the developmental conflict of early childhood. Integrity versus despair is the developmental conflict of old age. Industry versus inferiority is the developmental conflict of middle childhood.

What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa? 1. Controlling 2. Empathetic 3. Focused on food 4. Based on realistic limits

answer: 4 Realistic guidelines reduce anxiety, increase feelings of security, and increase adherence to the therapeutic regimen. A controlling environment sets up a power struggle between these clients and the nurse. These clients need realistic rules and regulations that they identify as helpful, not as empathetic. Focusing on food is not therapeutic as it may result in a power struggle between these clients and the nurse.

A client is admitted to the emergency department after ingesting a tricyclic antidepressant in an amount 30 times the daily recommended dose. What is the immediate treatment anticipated by the nurse? 1. Administration of physostigmine as soon as possible 2. Closer monitoring to prevent further suicidal attempts 3. Gastric lavage with activated charcoal and support of physiologic function 4. IV administration of an anticholinergic in response to changes in vital signs

3. Gastric Lavage Gastric lavage with charcoal may help decrease the level of tricyclic antidepressant overdose. Supportive measures such as mechanical ventilation may be needed until the medical crisis passes. Physostigmine salicylate was used in the past to promote improvement in consciousness. Now its use is contraindicated because it can cause bradycardia, asystole, and seizures in clients with tricyclic antidepressant toxicity. Prevention of suicidal behavior is always advantageous; however, in this case immediate emergency intervention is necessary. The acetylcholine level is depressed as a result of the tricyclic antidepressant; anticholinergics are most effective in managing the side effects of antipsychotic and neuroleptic drugs, not tricyclic antidepressant drugs.

A nurse is considering Erikson's stages of psychosocial development while caring for a client. Which behavior is consistent with a problem involving trust versus mistrust? 1. Woman in an abusive relationship who refuses to leave the abuser 2. Man with paranoid schizophrenia who demands placement in a private room 3. Woman whose parents were chronic alcoholics and who has problems making friends 4. Man with borderline personality disorder who has been caught stealing from other clients

Answer: 3 Trust is learned in infancy. Being parented by individuals who were not able to consistently meet the client's basic physiologic and safety needs is likely to result in an inability to engage in healthy interpersonal relationships as an adult. The response of the client in an abusive relationship is based not on events that occurred during infancy but rather on events in adulthood. The responses of the clients with paranoid schizophrenia and borderline personality disorder are symptoms of a psychiatric disorder rather than of an event that occurred during infancy.

What should a nurse consider about the past experiences of clients who have immigrated to this country? 1. It affects all of their inherited traits. 2. There will be little impact on their lives today. 3. It is important that their values be assessed first. 4. How they will interact is permanently established.

3. Answer Past experiences are important and must be recognized because they help set the individual's values throughout life. Past experiences will not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds forever; new experiences continue to influence future responses.

A nurse is aware that a coworker's mother died 16 months ago. The coworker cries every time someone says the word "mother" and when the mother's name is mentioned. What does the nurse conclude about this behavior? 1. It is an expected response. 2. Most people cry when their mother dies. 3. The coworker may need help with grieving. 4. The coworker was extremely attached to the mother.

3. answer Crying is a release, but the individual should have developed effective coping mechanisms by this time. The coworker may need help with the grieving process. Excessive crying 16 months after the death of a loved one is not an expected response. People express grief in a variety of ways, not necessarily by crying. Concluding that the coworker was extremely attached to the mother is an assumption and is not a valid conclusion.

A client experiencing a tremendously stressful situation says, "My baby was diagnosed with terminal cancer 2 months ago. I'm either crying or walking around like I'm in a dream. I can't believe this is happening. What did we do to deserve something so horrible? The doctors can transplant almost every human organ, but they can't stop my baby from dying. I'm so angry. Most days I just want to take my child and run away." The nurse determines that the client is mainly expressing what? 1. Anger 2. Denial 3. Avoidance 4. Anticipatory grief

4. answer Anticipatory grief is an intellectual and emotional response to a potential loss. Signs include a sense of disbelief and numbness. Emotions swing from sadness to anger. Individuals express the desire to avoid the situation by running away and an intense feeling of anger toward the medical community for failing to save their loved one. Anger, denial, and avoidance are each a single part of the client's reaction.

A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small, shiny top that she is spinning. Later the father relates his concerns, stating, "She pushes me away. She doesn't speak, and she only shows feelings when I take her top away. Is it something I've done?" What is the most therapeutic initial response by the nurse? 1.Asking the father about his relationship with his wife 2. Asking the father how he held the child when she was an infant 3. Telling the father that it is nothing he has done and sharing the nurse's observations of the child 4. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase

Answer: 3 The nurse provides support in a nonjudgmental way by sharing information and observations about the child. This child exhibits symptoms of autism, which is not attributable to the actions of the parents. Asking the father about his relationship with his wife or how he held the child when she was an infant indirectly indicates that the parent may be at fault; it negates the father's need for support and increases his sense of guilt. Telling the father not to be concerned and stressing that the child will outgrow this developmental phase is false reassurance that does not provide support; the father recognizes that something is wrong.

During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several conditions that may have precipitated the delirium. Select all that apply. 1. Infection 2. Dementia 3. Dehydration 4. Urine retention 5. Restricted mobility

Answer: 3,4 Infections, especially urinary tract infections in older clients, may cause delirium because they may become systemic. A memory aid for recalling the causes of delirium is DELIRIUMS: Drugs, Emotional factors, Low arterial oxygen level, Infections, Retention of urine or feces, Ictal or postictal state, Undernutrition, Metabolic conditions, and Subdural hematoma. Dehydration and fluid and electrolyte imbalances may lead to delirium because of the decrease in fluid and change in concentrations of electrolytes in the brain. Retention of urine may progress to a urinary tract infection that becomes systemic, which can cause delirium. Dementia is a chronic, irreversible cause of mental status changes. It must be differentiated from delirium, which is treatable. Restricted mobility is not related to delirium.

A widow of 6 months is brought to a psychiatric hospital. During the assessment interview the client avoids eye contact, responds in a low voice, and is tearful. What is the best initial approach by the nurse? 1. "You'll find that you'll get better faster if you try to help us help you." 2. "I'm your nurse. I'll take you to the dayroom as soon as I get some information." 3. "Here, hold my hand. I know you're frightened, but I won't let anyone harm you." 4. "I know that this is difficult, but as soon as we're finished I'll take you to your room."

Answer: 4 The response "I know that this is difficult, but as soon as we're finished I'll take you to your room" should limit anxiety; it identifies the client's feelings and tells the client what will happen in the immediate future. "You'll find that you'll get better faster if you try to help us help you" is threatening and provides false reassurance; it puts responsibility on the client and does not permit the expression of feelings. Being with other people in a strange environment will add more stress to the new and already frightening experience of hospitalization. "Hold my hand. I know you're frightened, but I won't let anyone harm you" may lead the client to think that the environment is unsafe, which could increase her insecurity and anxiety.

A nurse at the mental health clinic is counseling a client who has lost three jobs and four roommates in the last 6 months. The client states that sometimes he or she has problems interacting with people. What is the most appropriate response by the nurse? 1. "Let's focus on the future rather than on these past experiences." 2. "That's a lot of changes. Tell me what happened with your roommates." 3. "It must be distressing to have had to adapt to these changes. Tell me how you did it." 4. "Tell me more about some of the specific problems you've experienced with these people."

Answer: 4 The response "Tell me more about some of the specific problem you've experienced with these people" invites the client to explore interpersonal problems more fully while showing interest in what the client is communicating. Past experiences may provide information about the nature of the problem. Asking the client what happened with the roommates is too direct and does not allow the client a choice of selecting those problems that are of particular concern. Noting that it must be distressing to have had to adapt to these changes and asking how the client did it implies that the client is coping adequately and does not focus on the client's difficulties with interpersonal relationships.