Mental Health Mid-term #2

Which statement is true regarding substance addiction and medical comorbidity? Comorbid conditions are thought to positively affect those with substance addiction in that these patients seek help for symptoms earlier. Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities. Most substance abusers do not have medical comorbidities. There has been little research done regarding substance addiction disorders and medical comorbidity.

Conditions such as hepatitis C, diabetes, and HIV infection are common comorbidities.

Which statement concerning syndromes seen in other cultures but not seen in our own, such as amok should be considered true? Myths, or rumors, because they have not been sufficiently studied to be classified as real. Dissociative disorders such as dissociative identify disorders Physical disorders, not mental disorders Culture-bound syndromes that are not dissociative disorders

Culture-bound syndromes that are not dissociative disorders

The nurse is providing teaching to a preoperative client just before surgery. The client is becoming more and more anxious and begins to report dizziness and heart pounding. The client also appears confused and is trembling noticeably. Considering the scenario, what decision should the nurse make? To reinforce the preoperative teaching by restating it slowly. Do not attempt any further teaching at this time. Have a family member read the preoperative materials to the client. Have the client read the teaching materials instead of providing verbal instruction.

Do not attempt any further teaching at this time.

A client hospitalized for a psychotic relapse is being discharged home to family. Which topic is important to address when teaching both the client and the family to recognize possible signs of impending mania? Decreased social interaction Increased appetite Increased attention to bodily functions Decreased sleep

Decreased sleep

A Gulf War veteran is entering treatment for post-traumatic stress disorder. What assessment is of greatest importance to this particular client? Find out if the client uses acting-out behavior. Establish whether the client has chronic hypertension related to high anxiety. Ascertain how long ago the trauma occurred. Determine the use of chemical substance for anxiety relief

Determine the use of chemical substances for anxiety relief

Which of the following statements about dissociative disorders is true? Dissociative symptoms are usually always negative. Dissociative symptoms are usually a cry for attention. Dissociative symptoms are not under the person's conscious control. Dissociative symptoms are under the person's conscious control.

Dissociative symptoms are not under the person's conscious control.

Which of the following describe the symptoms of the manic phase of bipolar disorder? (Select all that apply.) Select all that apply. Distractibility Low self-esteem Excessive energy Withdrawal from environment Racing thoughts Purposeless movement Pressured speech Fatigue and increased sleep

Distractibility excessive energy racing thoughts purposeless movement pressured speech

A manic client tells a nurse "Bud. Crud. Dud. I'm a real stud! You'd like what I have to offer. Let's go to my room." What is the best initial approach to managing this behavior? Enforcing consequences by responding, "Let's walk down to the seclusion room." Reprimand the client by stating, "What an offensive thing to suggest!" Clarifying the nurse-client relationship by stating, "I don't have sex with clients." Distracting the client by suggesting, "It's time to work on your art project."

Distracting the client by suggesting, "It's time to work on your art project."

Using Maslow's model of needs, the nurse providing care for an anxious client identifies which intervention as being a priority? Assessing the client for strengths upon which a nurse-client relationship can be based Assessing the client's ability to fulfill appropriate developmental level tasks Planning one-on-one time to assist in identifying the fears trigger the client's anxiety Evaluating the client's ability to learn and retain essential information regarding their current condition

Assessing the client for strengths upon which a nurse-client relationship can be based

A nurse is about to interview an older client whose glasses and hearing aid were placed in the bedside drawer for safe keeping. Before beginning the interview, which nursing intervention that will best facilitate data collection? Assist the client in putting on glasses and hearing aid. Give the client her glasses and hearing aid. Ask the client if she needs her glasses and hearing aid. Explain the importance of wearing her hearing aid and glasses.

Assist the client in putting on glasses and hearing aid

The nurse caring for a client experiencing a panic attack anticipates that the psychiatrist would order a stat dose of which classification of medications? Anticholinergic medication. Standard antipsychotic medication. A short-acting benzodiazepine medication. Tricyclic antidepressant medication.

a short-acting benzodiazepine medication

Which medication is FDA approved for treatment of anxiety in children? Sertraline Clomipramine Duloxetine Fluoxetine

Duloxetine

What stress-reduction technique should a nurse teach an individual experiencing severe performance anxiety? deep breathing. journal keeping. restructuring and setting priorities. assertiveness.

deep breathing

Which approach to reducing client stress is most effective for children experiencing postoperative pain? Guided Imagery Meditation Breathing exercises Journal keeping

guided imagery

A depressed client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse should identify this cognitive distortion as what response? Discounting positive attributes Catatonia Learned helplessness Self-blame

learned helplessness

When a hyperactive manic client expresses the intent to strike another client, what is the initial nursing intervention? question the client's motive. initiate physical confrontation. prepare the client for seclusion. set verbal limits.

set verbal limits

A client frantically reports to the nurse that "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." The nurse should assess the client at what level of anxiety? mild. panic. moderate. severe.

severe

Self-help groups are useful for reducing stress because they provide the individual with the stress mediator that take what form? Cognitive reframing Cultural support Social support Life satisfaction

social support

When a client is prescribed lorazepam 1 mg po four times a day (qid) for 1 week for generalized anxiety disorder, the nurse should which intervention as the priority? question the physician's order because the dose is excessive. explain the long-term nature of benzodiazepine therapy. teach the client to limit caffeine intake. tell the client to expect mild insomnia.

teach client to limit caffeine intake

What factor exerts the greatest influence on the degree to which various life events upset a specific individual? The effect of the individual's health-sustaining behaviors The individual's degree of spirituality The individual's perception of the event The amount of social support available to the individual

the individual's perception of the event

What action should the nurse take on learning that a manic client's serum lithium level is 1.8 mEq/L? Advise the client to curtail salt intake for 24 hours. Continue to administer medication as ordered. Advise the client to limit fluids for 12 hours. Withhold medication and notify the physician.

withhold medication and notify the physician

A client experiencing a panic attack keeps repeating, "I'm dying, I can't breathe.". What action by the nurse should be most therapeutic initially? Asking the client what he means when he says, "I am dying." Encouraging the client to take slow, deep breaths Offering an explanation about why the symptoms are occurring Verbalizing mild disapproval of the anxious behavior

Encouraging the client to take slow, deep breaths

The nurse is planning care for a 14-year-old. The nurse demonstrates an understanding of the developmental task appropriate for this client by providing which experience? Spending one-on-one time with staff to establish trust Assign them to help clean up the dayroom to develop a sense of industry Encouraging them to talk about their school plans to help achieve identity Providing them with the opportunity to select which unit activities they will participate in to gain autonomy

Encouraging them to talk about their school plans to help achieve identity

Panic attacks in Latin American individuals often involve demonstration of which behavior? Blushing Repetitive involuntary actions Offensive verbalizations Fear of dying

Fear of dying

Which side effects of lithium can be expected at therapeutic levels? Coarse hand tremor and gastrointestinal upset Nausea and thirst Ataxia and hypotension Fine hand tremor and polyuria

Fine hand tremor and polyuria

A 31-year-old client admitted with acute mania tells the staff and the other clients that he is on a secret mission for the President of the United States. He states, "I am the only one he trusts, because I am the best!" What term will the nurse use when documenting this behavior? Flight of ideas Grandiosity Rapid cycling Unpredictability

Grandiosity

A bipolar client tells the nurse, "I have the finest tenor voice in the world. The three tenors who do all those TV concerts are going to retire because they can't compete with me." What term should the nurse use to identify this behavior? Limit testing Flight of ideas Grandiosity Distractibility

Grandiosity

When approaching a client who is acting out aggressively, what interventions should the nurse implement to assure personal safety? Take the client to his/her room so that his/her privacy will be protected. Stand close to the client for reassurance and to convey caring. Call security and wait until they arrive before approaching the client. Have other staff as backup, and stay out of the client's personal space.

Have other staff as backup, and stay out of the client's personal space.

What is the focus of the SAFE-T assessment tool? (Select all that apply.) Select all that apply. Identify level of suicidal risk. Introduce antidepressant medication therapy Stress collaboration with the client Facilitate hospitalization. Development of client focused treatment.

Identify level of suicidal risk. Stress collaboration with the client Development of client focused treatment.

The nurse providing anticipatory operant conditioning guidance to the mother of a toddler should advise that childhood temper tantrums are best handled by which intervention? Scolding the child when he/she displays tantrum behaviors Ignoring the tantrum and giving attention when the child acts appropriately Giving the child what he/she is asking for Spanking the child at the onset of the tantrum behaviors

Ignoring the tantrum and giving attention when the child acts appropriately

Which nursing diagnosis for a psychiatric client is correctly structured and worded? Hopelessness related to severe chronic depression Spiritual distress as evidenced by client stating "God has abandoned me because I'm a bad person" Defensive coping related to lack of insight associated with illicit drug use Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"

Imbalanced nutrition: less than body requirements related to poor self-concept as evidenced by reporting "I'm not worthy of eating"

A nurse expresses an exclusive belief in the biological model for mental illness when stating "it's the only one I really believe." What conclusion should be drawn from this statement? The biological model has been proven to be successful in finding the cause of most symptoms of mental illness. In believing only in the biological model, other influences on mental health including cultural, environmental, social, and spiritual influences are not taken into account. The biological model is the most popular theory among leading psychiatrists and therefore the one that should be fully embraced. The biological model is the oldest and most reliable model for explaining mental illness.

In believing only in the biological model, other influences on mental health including cultural, environmental, social, and spiritual influences are not taken into account.

What principle forms the basis of nursing outcome planning? The goal of nursing action is to create a dependency between the client and the caregiver. Nursing interventions are designed to solve individuals' problems for them. Individuals have the right to outcomes that is reflective of their abilities. Nurses have the best understanding of client problems and so they direct outcome selection.

Individuals have the right to outcomes that is reflective of their abilities

What would a client experience during a progressive relaxation session? Having a nurse enter the client's energy field to rebalance it and bring harmony Instruction in sequential tensing and relaxing of various muscle groups until the entire body is relaxed Being attached to a machine that monitors a physical parameter and receiving audible feedback about the state of that parameter Being led into a positive imaginary sensory experience

Instruction in sequential tensing and relaxing of various muscle groups until the entire body is relaxed

Which of the following symptoms would lead a provider to suspect that a client is experiencing PTSD? (Select all that apply.) Select all that apply. Talking with strangers about the events of the accident Irritability Flashbacks of the accident Difficulty concentrating Visiting the scene of the accident over and over Hypervigilance Mania

Irritability Flashbacks of the accident Difficulty concentrating Hypervigilance

While intoxicated a client unsuccessfully attempted suicide by using a gun. This method of using a gun to attempt suicide should be described in what terms? It is high risk, or a hard method. Considering the results, it is a nonlethal means. It was not an actual suicide attempt because the client was intoxicated. It is low risk, or a soft method.

It is high risk, or a hard method.

The nurse is caring for an adult client who experienced severe physical abuse from the age of 2 through 12. What information should the nurse provide the client concerning the function of the "id" and the ability to function as an adult? t provides an individual with the ability to differentiate believed and real experiences. It has control over the emotional frustration felt as an adult. It is severely damaged by abuse experienced before the age of 5 years. it is the source of one's survival instincts.

It is the source of one's survival instincts

The record mentions states that the client habitually relies on rationalization. The nurse might expect the client to present with what behavior? Behaves in ways that are the opposite of his or her feelings. Misses appointments. Justifies illogical ideas and feelings. Makes jokes to relieve tension.

Justifies logical ideas and feelings

A nurse is providing care to a 28-year-old client diagnosed with bipolar disorder who was admitted in a manic state. According to Maslow's Hierarchy of Needs theory, the nurse should identify which client symptom as having priority? Rapid, pressured speech Grandiose thoughts Lack of sleep Hyperactive behavior

Lack of sleep

What tool should the nurse use in assessing the amount of stress a client has experienced in the past year? Life-Changing Event Questionnaire NANDA Handbook DSM-IV-TR Quick Mental Status Assessment

Life-changing event questionnaire

The nurse is working with a client experiencing depression stemming from low self-esteem. The client is distrustful of unit staff and "just wants to go home." Initially what is the nurse's priority? Making the client feel physically and emotionally safe Teaching the client effective coping skills identifying the client's positive traits Focusing on preparing the client for a speedy discharge

Making the client feel physically and emotionally safe

The plan of care for a client who has elaborate washing rituals specifies that response prevention is to be used. Which scenario is an example of response prevention? Telling the client that he or she must relax whenever tension mounts Not allowing the client to seek reassurance from staff Having the client repeatedly touch "dirty" objects Not allowing the client to wash hands after touching a "dirty" object

Not allowing the client to wash hands after touching a "dirty" object

A 72-year-old client diagnosed with Parkinson's disease is demonstrating behaviors associated with anxiety and has had several falls lately and is reluctant to take medications as prescribed. When the healthcare provider orders lorazepam, 1 mg PO bid, the nurse questions the prescription based primarily on what fact? The client is at risk for falls. The client should be treated with cognitive therapies because of his advanced age. The client has a history of nonadherence with medications. The client may become addicted faster than younger clients.

The client is at risk for falls.

When the nurse asks whether a client is having any thoughts of suicide, the client becomes angry and defensive, shouting, "I'm sick of you people! All you ever do is ask me the same question over and over. Get out of here!" What fact concerning hostility should the nurse's response be based upon? The client is probably experiencing transference. The client may be angry at someone else and projecting that anger to staff. The client is getting better and is able to be assertive. The client may be at high risk for self-harm.

The client may be at high risk for self-harm.

A 21-year-old client asks the nurse, "What's wrong with my brain that's causing me to be so angry and aggressive?" The nurse's response should be grounded on what research-supported basis? The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression. The diminishment of stress hormones causes anger and aggression. No abnormalities of the brain have been identified that correlate with anger and aggression. Personality type plays a much greater part in anger and aggression than physical factors.

The limbic system, the prefrontal cortex, and neurotransmitters have been implicated in playing a part in aggression.

What is the priority outcome for a toddler who has been sexually abused? The child will be able to verbalize exactly what happened to her. The child will no longer demonstrate inappropriate sexual behavior. The sexual abuse will cease immediately. The mother will learn coping techniques to support the child.

The sexual abuse will cease immediately.

A student nurse on the psychiatric unit expresses being uncomfortable discussing possible suicidal ideations with clients because "It might put ideas in their head about suicide." What is the nurse's best response to this student's concern? "If I were you, I'd ask the health provider to talk to the patient about that subject." "I'm glad you are thinking that way. They may not have thought of suicide before, and we don't want to introduce that." "Actually, it's a myth that asking about suicide puts ideas into someone's head." "You are right; however, because of professional liability, we have to ask that question."

"Actually, it's a myth that asking about suicide puts ideas into someone's head."

A new psychiatric technician mentions to the nurse, "Depression seems to be a disease of old people. All the depressed clients on the unit are older than 60 years." How should the nurse respond to this statement? "Depression is seen in people of all ages, from childhood to old age." "Depression is most often seen among the middle adult age group." "The age of onset for most depressive episodes is given as 18 years." "That is a good observation. Depression does mostly strike people older than 50 years."

"Depression is seen in people of all ages, from childhood to old age."

Which statement, made by a female adult concerning her boyfriend, should cause the nurse to suspect that the client is at risk for being emotionally abused? "He has a good job and keeps control of all the finances but our electricity still got turned off last week." "I didn't tell him I was coming because he is under so much stress at work I didn't want to add to it." "He yells a lot and calls me names, but that's because I am so stupid and make so many mistakes." "He has always had a fiery temper."

"He yells a lot and calls me names, but that's because I am so stupid and make so many mistakes."

Which statement by a patient who has been taught cognitive reframing indicates that the teaching was successful? "I can be successful if I do all the things required to learn the job." "I can never learn all there is to know for the job." "I do not have the ability to handle that job." "I may be fired from the job but eventually I will find something else to do with my life."

"I can be successful if I do all the things required to learn the job."

Consider both Sullivan's term security operations and Freud's term defense mechanisms. Which statement suggests that the client's specialized treatment goal has been successfully met? "I'm experiencing much less anxiety about school now." "I know that I'm not the only person who has a difficult time in school." "Going back to school is hard and I'll need support." "I really think I can succeed in school now."

"I know that I'm not the only person who has a difficult time in school."

A 38-year-old client is admitted with major depression. Which statement made by the client alerts the nurse to a common accompaniment to depression? "I still pray and read my Bible every day." "I've heard others say that depression is a sign of weakness." "I still feel bad about my sister dying of cancer. I should have done more for her!" "My mother wants to move in with me, but I want to independent."

"I still feel bad about my sister dying of cancer. I should have done more for her!"

Which statement, made by a patient admitted with a diagnosis of depression, indicates the need for further assessment? "I think things will be better soon." "I don't have a good support system, but I am planning on joining a recovery group." "I know a lot of people care about me and want me to get better." "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself."

"I think things will be better soon."

A 16 year old being treated on an adolescent psychiatric unit has become angry and is in the hallway yelling, "It's not fair! You all hate me! I hate this place!" When the client begins pounding on the wall the nurse should attempt to de-escalate the situation by providing which response? "Stop that right now! I will not allow you to behave like that!" "I will help you calm down. Do you want to go to your room and talk or go to the quiet room?" "You will have to go into seclusion and restraints right now in order to be safe." "You may yell and bang your fists but you must do it in your own room so you don't upset the other patients."

"I will help you calm down. Do you want to go to your room and talk or go to the quiet room?"

A client prescribed fluoxetine demonstrates an understanding of the medication teaching when making which statement? "I will not take any over-the-counter medication while on the fluoxetine." "I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away." "I will report increased thirst and urination to my provider." "I will make sure to get plenty of sunshine and not use sunscreen to avoid a skin reaction."

"I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away."

Which statement would best show acceptance of a depressed, mute client? "It is important for you to share your thoughts with someone who can help you evaluate your thinking." "I would like to sit with you for 15 minutes now and again this afternoon." "Each day we will spend time together to talk about things that are bothering you." "I will be spending time with you each day to try to improve your mood."

"I would like to sit with you for 15 min now and again this afternoon"

A 17-year-old client confides to the nurse that they have been thinking of ways to kill a peer. What response should the nurse give when the client states, "you have to keep it a secret because its confidential information"? "I will have to share this with the treatment team, but we will not share it with your parents." "Yes, I will keep it confidential. We have laws to protect clients' confidentiality." "I will keep it a secret, but you and I need to discuss ways to deal with this situation appropriately without committing a crime." "Issues of this kind have to be shared with the team and your parents."

"Issues of this kind have to be shared with the team and your parents."

A client being prepared for discharge tells the nurse, "Dr. Jacobson is putting me on some medication called naltrexone. How will that help me?" Which response is appropriate teaching regarding naltrexone? "It helps your mood so that you don't feel the need to do drugs." "It is a sedative that will help you sleep at night, so you are more alert and able to make good decisions." "It will keep you from experiencing flashbacks." "It helps prevent relapse by reducing drug cravings."

"It helps prevent relapse by reducing drug cravings."

A depressed, socially withdrawn client tells the nurse, "There is no sense in trying. I am never able to do anything right!" The nurse can best address this cognitive distortion with which response? "Is this part of the reason you think no one likes you?" "Let's look at what you just said that you can never do anything right.'" "Tell me what things you think you are not able to do correctly." "That is the most unrealistic thing I have ever heard."

"Let's look at what you just said that you can never do anything right.'"

Which statement, made by a client diagnosed with dissociative identity disorder, demonstrates effective understanding in response to the question, "What exactly are the 'alters'? your provider told you about?" illustrates that the education provided has been effective? "So, alters are based in mysticism and religiosity, such as demons." "So, alters are never aware of each other." "So, alters are just like me, but they have no memory of the trauma I went through." "So, alters are separate personalities with their own characteristics that take over during stress."

"So, alters are separate personalities with their own characteristics that take over during stress."

A patient admitted with anxiety asks, "What exactly are stressors?" What is the nurse's best response to the patient's question? "Instead of focusing on what stressors are, let's explore your coping skills." "Stressors are events that happen that threaten your current functioning and require you to adapt." "Stressors are complicated neuro stimuli that cause mental illness." "It's best if you ask questions like that of your provider for a complete answer."

"Stressors are events that happen that threaten your current functioning and require you to adapt."

Which response should the nurse provide a client who asks, "Why you need to conduct an assessment interview"? "The assessment interview lets you have an opportunity to express your feelings." "You are able to tell me in detail about your past so that we can determine why you are experiencing mental health alterations." "We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment." "I need to find out more about you and the way you think in order to best help you."

"We will be able to form a relationship together where we can discuss the current problems and come up with goals and a plan for treatment."

A cognitive therapist would help a client restructure the thought "I am stupid!" to which statement? "I am not as smart as others." "Things like this should not happen to anyone." "What I did was stupid." "Things usually go wrong for me."

"What I did was stupid"

The nurse best assesses the client's spiritual life by asking which question? "Do you practice a specific religion?" "To whom do you turn in times of crisis?" "Do you attend church regularly?" "What role does religion play in your life?"

"What role does religion play in your life?'

A client who is demonstrating a moderate level of anxiety tells the nurse, "I am so anxious, and I do not know what to do." Which response should the nurse make initially? "Try not to think about the feelings and sensations you're experiencing." "Let's try to focus on that adorable little granddaughter of yours." "Why don't you sit down over there and work on that jigsaw puzzle?" "What things have you done in the past that helped you feel more comfortable?"

"What things have you done in the past that helped you feelm more comfortable?"

A 26-year-old client is brought to the emergency room by a friend. The client is unable to give any coherent history. Which response should the nurse provide when the client's friend offers to provide information regarding the client? "Yes, however, we will have to get a release signed from the client for you to be able to talk with me." "There is no need for that as I will call his primary care provider to obtain the information we need." "Yes, I will be happy to get any information and history that you can provide." "I'm sorry, but I cannot take any information from you as it would violate confidentiality laws."

"Yes, I will be happy to get any information and history that you can provide."

The nurse in an emergency department notices a patient's spouse, pacing in the hallway, muttering silently, and looking angrily around the emergency department. Which statement should the nurse make to the spouse to help prevent escalation and/or violence? "Hey, what's up? You look out of control." "You need to stay calm for your spouse's sake." "I am calling security to deal with your behavior." "You appear upset. Can I help you with anything?"

"You appear upset. Can I help you with anything?"

Which client behavior illustrates eustress? A man is laid off from his job. A bride is planning for her wedding. An adolescent gets into a fight at school. A college student fails an exam.

A bride is planning for her wedding.

Which room placement would be best for a client experiencing a manic episode? A shared room with a client with dementia A single room near the nurses' station A shared room away from the unit entrance A single room near the unit activities area

A single room near the nurses station

The nurse is conducting an admission interview with a client who was raped 2 weeks ago. When asked about the rape, the client becomes very anxious and upset and begins to sob. What should be the nurse's response to the client's reaction? Reassure the client that anything she says to you will remain confidential. Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable. Use silence as a therapeutic tool and wait until the client is done sobbing to continue discussing the rape. Push gently for more information about the rape because the information needs to be documented.

Acknowledge that the topic of the rape is upsetting and reassure the client that it can be discussed at another time when she feels more comfortable.

What is a desired outcome for the maintenance phase of treatment for a manic client? Adhere to follow-up medical appointments. Take medication more than 50% of the time. Use alcohol to moderate occasional mood "highs." Exhibit optimistic, energetic, playful behavior.

Adhere to follow-up medical appointments

A client's daughter states, "My mother lives with me since my dad died 6 months ago. For the past couple of months, every time I need to leave the house for work or anything else, Mom becomes extremely anxious and cries that something terrible is going to happen to me. She seems OK except for these times, but it's affecting my ability to go to work." This information supports that the client may be experiencing which anxiety-related disorder? Social anxiety disorder Agoraphobia Panic disorder Adult separation anxiety disorder

Adult separation anxiety disorder

A client admitted with major depression and suicidal ideation with a plan to overdose is preparing for discharge and asks you, "Why did I get a prescription for only 7 days of amitriptyline?" The nurse's response is based on what fact? Amitriptyline is very expensive, so the client may have to buy fewer at a time. The health care provider wants to see whether any side effects occur within the first week of administration. Amitriptyline is lethal in overdose. The goal is to see how the client responds to the first week of medication to evaluate its effectiveness.

Amitriptyline is lethal in overdose.

A client is diagnosed with generalized anxiety disorder (GAD). The nursing assessment supports this diagnosis when the client reports which information? Repeated verbalizing prayers results in a relaxed feeling. Being unable to work for the last 12 months. Eating in public makes the client extremely uncomfortable. Symptoms started right after being robbed at gunpoint.

Being unable to work for the last 12 months

The nurse is caring for a client on day 1 post-surgical procedure. The client becomes visibly anxious and short of breath, and states, "I feel so anxious! Something is wrong!" What action should the nurse take initially in response to the client's actions? Reassure the client that what they are feeling is normal anxiety and do deep breathing exercises with her. Reassure the client that you will stay until the anxiety subsides. Call for staff help and assess the client's vital signs. Use the call light to inquire whether the client has been prescribed prn anxiety medication.

Call for staff help and assess the client's vital signs.

A 19-year-old college sophomore who has been using cocaine and alcohol heavily for 5 months is admitted for observation after admitting to suicidal ideation with a plan to the college counselor. What would be an appropriate priority outcome for this client's treatment plan while in the hospital? Client will be medically stabilized while in the hospital. Client will take a leave of absence from college to alleviate stress. Client will return to a pre-drug level of functioning within 1 week. Client will state within 3 days that they will totally abstain from drugs and alcohol.

Client will be medically stabilized while in the hospital.

Which statement about antidepressant medications, in general, can serve as a basis for client and family teaching? They tend to be more effective for men. They often cause the client to have diurnal variation. Recent memory impairment is commonly observed. Onset of action is from 1 to 3 weeks or longer.

Onset of action is from 1 to 3 weeks or longer

Jacob, a college student whose friend recently committed suicide, rates his stress as low. Melissa was also friend with the person who committed suicide, but she rates her stress as high. The difference in how Jacob and Melissa rate their stress may be explained by which coping mechanism? Projection Denial Perception Repression

Perception

A 4 years old is referred to the outpatient mental health clinic after being in a severe car accident during which the child's mother died. The father states that the child is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. The child states, "It's my fault because I'm bad." What trauma induced disorder does this data support? Acute stress disorder (ASD) Posttraumatic stress disorder (PTSD) Dissociative identity disorder Adjustment disorder

Posttraumatic stress disorder (PTSD)

The treatment team meets to discuss a client's plan of care. Which of the following factors will be priorities when planning interventions? Availability of immediate family to come to meetings Financial ability Current college performance Readiness to change behaviors

Readiness to change behaviors

What are the physiologic responses associated with successful guided imagery? Select all that apply. Reduction of obsessive thoughts Reduction of anxiety Increase in appetite Improved sleep patterns Reduction of muscle pain

Reduction of obsessive thoughts Reduction of anxiety Increase in appetite Improved sleep patterns Reduction of muscle pain

The client's priority nursing diagnosis has been established as risk for self-directed violence: suicide related to multiple losses. What is the priority outcome for this client? Attend self-help group daily. Refrain from attempting suicide. State absence of feelings of powerlessness. Be placed on suicide precautions.

Refrain from attempting suicide

Which statement is true regarding culture and protective factors against suicide? Asian Americans have the highest rates of suicide. American Indians and Pacific Islanders have the lowest rates of suicide. Religion and the importance of family are protective factors for Hispanic Americans. Older women have the highest risk for suicide among African Americans.

Religion and the importance of family are protective factors for Hispanic Americans.

Which nursing intervention demonstrates the theory behind operant conditioning? Showing the client how to be assertive without being aggressive Rewarding the client with a token for avoiding an argument with another client Explaining to the client the consequences of not following unit rules Demonstrating deep breathing techniques to a group of clients

Rewarding the client with a token for avoiding an argument with another client

A client diagnosed with bipolar disorder has a nursing care plan that includes several nursing diagnoses listed. Match the nursing diagnosis to the level of priority (1 to 4).

Risk for injury self-care deficit, bathing, and hygiene knowledge, deficient non-adherence

What is the priority nursing diagnosis for a hyperactive manic client during the acute phase of treatment? Impaired verbal communication Risk for injury/suicide Ineffective role performance Risk for other-directed violence

Risk for injury/suicide

Which of the following persons has the highest risk factors for physical abuse? Rose, a 77-year-old woman living with her daughter and son-in-law Penny, a 28-year-old wife whose husband has a diagnosis of an anxiety disorder Roland, a 53-year-old man with cardiovascular disease living with his son Emma, a 7-month-old baby who has colic and doesn't sleep through the night

Rose, a 77-year-old woman living with her daughter and son-in-law

A client states, "I will always be alone because nobody could ever love me." The nurse recognizes that the client is expressing what cognitive-behavioral concept? Actualization Aversion Schema Emotional consequence

Schema

A 43-year-old client being seen in the mental health clinic states, "I have always been a practicing Jew, but in the past few months I am questioning everything. I just don't know if I believe in it anymore." Which of the following nursing diagnoses best describes the client's comment? Ineffective coping Risk for self-harm Hopelessness Spiritual distress

Spiritual distress

A cultural characteristic that may be observed in a teenage, female Hispanic client in times of stress would include what behavior? Report both nausea and vomiting xhibit stoic behavior Suddenly tremble severely Laugh inappropriately

Suddenly tremble severely

What is the major reason for the hospitalization of a depressed client? Inability to go to work Suicidal ideation Psychomotor agitation Loss of appetite

Suicidal ideation

Which of the following is true of the relationship between bipolar disorder and suicide? Clients need to be monitored only in the depressed phase because this is when suicides occur. As long as clients with bipolar disorder adhere to their medication regimen, there is little risk for suicide. Suicide is a serious risk those diagnosed with bipolar disorder commit suicide. Clients with bipolar disorder are not considered high risk for suicide.

Suicide is a serious risk those diagnosed with bipolar disorder commit suicide.

A client, whose friend recently committed suicide, asks the nurse about some ways to help cope with the stress regarding the event. Which option should the nurse discuss with the client? Isolation for a short time so that the pain isn't reinforced by explaining her feelings over and over Talking with friends and attending a loss support group Starting a hobby to keep her mind off the troubling event Antianxiety medication to help her relax

Talking with friends and attending a loss support group

The mother of a 4-year-old daughter states that the child has recently begun, "Touching her vagina and rubs herself down there all the time." The child drew a picture showing two people with one on top of the other and said they were "doing sex." Based on the assessment description, what conclusion should the nurse explore further? There is a possibility that the child has been sexually abused. Educate the mother to normal developmental behavior in a 4-year-old child. The mother should be enrolled in parenting classes to improve her parenting skills. The child's exposure to graphic sexual images on television should be monitored closely.

There is a possibility that the child has been sexually abused.

A 26-year-old patient who abuses heroin states, "I've been using more heroin lately because I've begun to need more to feel the effect I want." What effect does this statement describe? Intoxication Withdrawal Addiction Tolerance

Tolerance

What older concept of care is being used currently to help in violence reduction in disruptive clients? Aired grievances Shared governance Learned helplessness Trauma-informed care

Trauma-informed care

Nurses working in emergency departments and walk-in clinics should be aware that some victims of violence may present with which assessment characteristic? Vague physical complaints such as insomnia or pain Extreme anger and unpredictable behavior Psychosis and/or mania as a result of long-term abuse Family members described as supportive

Vague physical complaints such as insomnia or pain

When the nurse remarks to a depressed client, "I see you are trying not to cry. Tell me what is happening." The nurse should be prepared to implement which intervention? Prompting the client if the reply is slow Reviewing the client's medical record to support the client's response Repeating the question if the client does not answer promptly Waiting quietly for the client to reply

Waiting quietly for the client to reply

According to Freud, a client experiencing dysfunction of the conscious as part of the mind will have problems with which aspect of memory? Recent memory All memories Painful memories Long-term memory

all memories

A client diagnosed with hypertension uses an automatic cycling blood pressure cuff with audible changing tones. The client uses relaxation techniques to lower her blood pressure and is informed of her ongoing success by the tone. This process describes this technique? guided imagery. therapeutic touch. biofeedback. assertiveness training.

biofeedback