MH EXAM 3 quizzes

During postprandial monitoring, a client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response?

"i know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."

a young, handsome man with a diagnosis of antisocial personality disorder is being discharged from the hospital next week. he asks the nurse for her phone number so that he can call her for a date. the nurse's best response would be:

"i like you, but our relationship is professional"

the nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?

"i no longer feel that i deserve the beatings my husband inflicts on me."

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. which assessment findings should the nurse expect to note? SATA

- dental decay - loss of tooth enamel - electrolyte imbalances

which interventions are most appropriate for caring for a client in alcohol withdrawal? SATA

- monitor vital signs - provide a safe environment - address hallucinations therapeutically - provide reality orientation as appropriate

For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority?

The client will establish adequate daily nutritional intake

Nurse Sharie is assessing a parent who abused her child. Which of the following risk factors would the nurse expect to find in this case?

History of the parent having been abused as a child

Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

Identify anxiety-causing situations.

Nurse Rob has observed a co worker arriving to work drunk at least three times in the past month. Which action by Nurse Rob would best ensure client safety and obtain necessary assistance for the co worker?

Report the coworker's behavior to the appropriate supervisor.

a client with anorexia nervosa is a member of a pre-discharge support group. the client verbalizes that she would like to buy so new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. the client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. how should the nurse evaluate this behavior?

evidence of the client's disturbed body image

the spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "i should get out of this bad situation." which is the most helpful response by the nurse?

"what do you find difficult about this situation?"

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. during the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of PTSD? SATA

- "i keep reliving the robbery" - "I see his face everywhere i go" - "i might have died over a few dollars in my pocket"

During a home visit to a family of three: a mother, a father, and their child. the mother tells the community nurse that the father (who is not present) has hit the child on several occasions when he was drinking. the mother further explains that she has talked her husband into going to AA and asks the nurse not to interfere, so her husband won't get angry and refuse treatment. which of the following is the best response of the nurse?

the nurse commends the mother's efforts and also contacts protective services

For a female client with anorexia nervosa, nurse rose plans to include the parents in therapy sessions along with the client. what fact should the nurse remember to be typical of parents of clients with anorexia nervosa?

they tend to overprotect their children

the home health nurse visits a client at home and determines that the client is dependent on drugs. during the assessment, which action should the nurse take on plan appropriate nursing care?

ask the client about the amount of drug use and its effect

the nurse us caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. in formulating a nursing plan of care, which best intervention should the nurse include?

avoid using a whisper voice in front of the client

a client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. because of this hypersensitivity to a reaction from her, the client remains homebound. the home care nurse develops a plan of care that addresses which personality disorder?

avoidant

a hospitalized client, diagnosed with a borderline personality disorder, consistently breaks the unit's rules. this behavior should be confronted because it will help the client:

become more self-aware

a hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. i have to go. i don't want any more treatment. i have things that i have to do right away." the client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. after the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. what action should the nurse tale?

call the nursing supervisor

Elsa is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using?

denial

a person with antisocial personality disorder has difficulty relating to others because of never having learned to:

empathize with others

the nurse is monitoring a hospitalized client who abuses alcohol. which findings should alert the nurse to the potential for alcohol withdrawal delirium?

hypertension, changes in LOC, hallucinations

the nursing diagnosis that would be most appropriate for a 22-year old client who uses ritualistic behavior would be:

ineffective coping

the emergency department nurse is caring for an adult client who is a victim of family violence. which priority instruction should be included in the discharge instructions?

information regarding shelters

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. the nurse enters the client's room and notes that the client is engaged in rigorous push-ups. which nursing action is most appropriate?

interrupt the client and offer to take her for a walk

the nurse is caring for a client with anorexia nervosa. which behavior is characteristic of this disorder and reflects anxiety management?

observing rigid rules and regulations

A nurse in the emergency department is caring for a young female victim of sexual assault. the client's physical assessment is complete, and physical evidence has been collected. the nurse notes that the client is withdrawn, confused, and at times physically immobile. how should the nurse interpret these behaviors?

reactions to a devastating event

a client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. what is the priority nursing action for this client?

remain with the client until the anxiety decreases

the emergency department nurse is caring for a client who has been identified as a victim of physical abuse. in planning care for the client, which is the priority nursing action?

removing the client from any immediate danger

a client with a diagnosis of narcissistic personality disorder has been given a day pass from the psychiatric hospital. the client is due to return at 6 pm. At 5 pm the client telephones the nurse in charge of the unit and says "6 o'clock is too early. I feel like coming back at 7:30." the nurse would be most therapeutic by telling the client to:

return on time or restrictions will be imposed

a client with a diagnosis of borderline personality disorder has negative feelings toward the clients on the unit and considers them all to be "bad." the nurse understands this defense is known as:

splitting

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?

tell me more about the incident that causes you to feel like the rape just occurred