(N129) NCLEX

A nurse assesses a client recently admitted to an alcohol detoxification unit. What common clinical manifestation should the nurse expect during the initial stage of alcohol detoxification? 1. Nausea 2. Euphoria 3. Bradycardia 4. Hypotension

1 Rationale: During the first stage of alcohol detoxification, nausea and anorexia are expected. Irritability, not euphoria, is experienced during this stage. Tachycardia, not bradycardia, is experienced during this stage. Hypertension, not hypotension, is experienced during this stage.

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

4 Rationale: 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 client comes to the mental health clinic with the complaint of a progressing inability to be in enclosed spaces. The primary healthcare provider makes the diagnosis of claustrophobia and prescribes desensitization therapy. The nurse recalls that desensitization therapy is used successfully with clients experiencing phobias because it is focused on what? 1. Imagery 2. Modeling 3. Role-playing 4. Assertiveness training

1 Rationale: Imagery is a therapeutic approach used to facilitate positive self-talk; mental pictures under the control of and initiated by the client may correct faulty cognitions. Modeling, role play, and assertiveness training are useful general behavioral approaches but are not specific desensitization techniques.

A newly admitted client with an obsessive-compulsive personality disorder frequently performs a handwashing ritual. When attempts are made to set limits on the frequency or length of the ritual, the client's anxiety escalates and the client becomes verbally aggressive. What is most important for the nurse to do when the client performs the ritual? 1. Allow the client sufficient time to carry out the ritual. 2. Promote reality by showing that the ritual serves little purpose. 3. Try to ascertain the meaning of the ritual by discussing it with the client. 4. Interrupt the ritual to demonstrate that the ritual does not control what happens.

1 Rationalee; Rituals provide a means for the individual to control anxiety. If not permitted to carry out the ritual, the client will probably experience unbearable anxiety. The client has exhibited verbally aggressive behavior in the past, and this behavior may escalate. Safety of the client and others becomes an issue. The client probably already understands that the ritual is useless but is unable to stop the activity. These clients have no idea of what the ritual means, only that they must continue the ritual. Interrupting the ritual will have the effect of increasing anxiety, possibly to a panic level.

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? Select all that apply. 1. Bouts of crying 2. Self-destructive acts 3. Presence of delusions 4. Feelings of worthlessness 5. Intense interpersonal relationships

1, 2, 4 Rationale: Clients who feel depressed and hopeless also tend to show their depression and hopelessness physically through crying. They may try to commit suicide to end the emotional pain they are suffering. They also tend to express feelings of worthlessness. Preoccupation with delusions is associated with clients with a diagnosis of schizophrenia, not depression. Clients who feel depressed and hopeless tend to be socially withdrawn and to not have the physical or emotional energy required for intense interpersonal relationships.

A nurse is caring for a client whose behavior is characterized by pathologic suspicion. What is the most therapeutic nursing action? 1. Providing distraction with reality-based activities 2. Trying to establish trust through consistency of care 3. Helping the client realize that the suspicions are unrealistic 4. Asking the client to explain the reasons for these suspicions

2 Rationale: Delusions are protective and can be abandoned only when the individual feels secure and adequate; as the client's sense of security increases, the client's anxiety will decrease. Providing distraction with reality-based activities is more helpful in regard to hallucinations than delusions. Before the client can realize that the suspicions are unrealistic, trust must be developed and the client's anxiety eased. The client will be unable to explain the reason for the feelings.

A nurse speaks with a client who has just experienced a panic attack. Which statement will be the most therapeutic in addressing the client's concerns? 1. "I would have been upset, too." 2. "You are concerned that this might happen again." 3. "Episodes like this one can be upsetting even though they do end." 4. "Your family must have thought that you were having a heart attack."

2 Rationale; Recurrence of attacks is a common concern. Stating that the nurse would have been upset too redirects the focus to the nurse, which is not therapeutic. Although recognizing that the panic attack must have been upsetting initially focuses on feelings, communication is then cut off when the nurse remarks that they do end. The focus should be on the client, not what the family believes.

A client with a dissociative identity disorder is to be discharged after a 2-week hospitalization. What does the nurse, evaluating the effectiveness of the short-term therapy, expect the client to verbalize? 1. The ability to deal openly with feelings 2. That many of the personalities can be ignored 3. The need for long-term outpatient psychotherapy 4. That the personalities serve no protective purpose

3 Rationale: A dissociative identity disorder is a complex, multifaceted problem that requires long-term therapy to achieve integration of the personalities. Each personality has the ability to deal openly with feelings, but the personalities need to be integrated. None of the personalities can be ignored, because their presence must be dealt with before integration can occur. The multiple personalities do serve a protective purpose. If they did not serve a protective purpose, they would be abandoned.

What should be the nurse's first intervention in the care of a client with a generalized anxiety disorder? 1. Encouraging the client to verbalize feelings of anxiety 2. Having the client list the behaviors used to reduce anxiety 3. Removing as many stimuli from the client's environment as possible 4. Administering as-needed medications prescribed by the primary healthcare provider

3 Rationale: Removing as many stimuli from the client's environment as possible helps reduce the client's anxiety by limiting the factors that must be confronted; decreasing stimuli usually decreases anxiety. Encouraging the client to verbalize feelings of anxiety will not decrease anxiety and may increase it. The anxiety level must be decreased before the client is asked to discuss coping strategies. Administering as-needed medications prescribed by the primary healthcare provider may or may not be necessary; it is not the first intervention before an assessment is completed.

A female graduate student who has become increasingly withdrawn and neglectful of her studies and personal hygiene is brought to the psychiatric hospital by her roommate. After a detailed assessment, a diagnosis of schizophrenia is made. Which characteristic is unlikely to be demonstrated by this client? 1. Neologisms 2. Low self-esteem 3. Concrete thinking 4. Organized speech and thoughts

4 Rationale: A person with this disorder will not always have organized speech or thought process. Neologisms, words that have meaning only to the client, are associated with schizophrenia. Low self-esteem is associated with schizophrenia because these people often experience internal stimulation, such as auditory hallucinations, that can be demeaning, as well as distortions of reality. Concrete thinking is symptomatic of schizophrenia.

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

4 Rationale: 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 is caring for a client with vascular dementia. What does the nurse expect of this client's mental status? 1. Diminished remote memory resulting from anoxia 2. Loss of abstract thinking related to emotional state 3. Inability to concentrate related to decreased stimuli 4. Difficulty recalling recent events related to cerebral hypoxia

4 Rationale; Cell damage seems to interfere with how input stimuli are registered, which affects the ability to register and recall recent events; vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structures. The remote memory usually is not impaired to any great degree. The loss of abstract thinking is related to cell damage, not the emotional state. The inability to concentrate is related to cell damage, not decreased stimuli.

Anorexia nervosa follows a cyclical pattern. Place the following statements in order of progression through this cycle, with 1 as the first step and 4 as the last step. 1. Self-esteem increases as weight is lost. 2. Secondary gains reinforce the anorectic client's behaviors. 3. Dieting is an attempt to maintain control. 4. Sociocultural attitudes exert pressure to attain an idolized body.

4, 3, 1, 2 Rationale: Sociocultural (fashion, "superwoman" issues, and the diet and fitness industry), biological, psychological, and familial factors all influence the development of anorexia nervosa [1] [2]. Dieting, exercise, purging, and laxatives are used to lose weight, with the resulting primary gain of a feeling of control over one's life. As weight is lost, the individual feels a sense of accomplishment, and self-esteem increases. Finally, secondary gains such as attention from parents and peers reinforce the behaviors associated with anorexia nervosa.

An adolescent who is extremely underweight and disappears into the bathroom after meals angrily says to the nurse, "I don't need to be here. I don't have any problems. Stop watching me." What is the most therapeutic response by the nurse, aimed at reducing the client's feeling of being threatened? 1. "I hear how frustrated you are to be here." 2. "If you don't follow the rules, you'll lose your privileges." 3. "Your feelings are part of your illness; later you'll feel better." 4. "I'll get you the medication your primary healthcare provider prescribed for anxiety."

1 Rationale: "I hear how frustrated you are to be here" is the best initial response; it encourages additional expression of feelings. "If you don't follow the rules, you'll lose your privileges" is not necessarily true, and the response is somewhat threatening and nontherapeutic. The response "Your feelings are part of your illness; later you'll feel better" is not therapeutic; also, it is false reassurance because the client may not feel better later. "I'll get you the medication your primary healthcare provider prescribed for anxiety" is not therapeutic; the client is verbally expressing feelings, and the behavior does not require medication at this time.

A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions? 1. Mild 2. Panic 3. Severe 4. Moderate

1 Rationale: A person with mild anxiety has a broad perceptual field and increased problem-solving abilities. Panic is characterized by a completely disruptive perceptual field. With severe anxiety, the perceptual field is reduced, as is the ability to focus on details. A moderately anxious person shuts out peripheral events and focuses on central concerns but has a decreased ability to problem solve.

A public health nurse is conducting an initial visit to an older depressed client who lives alone and performs all tasks of daily living. What is the nurse's most significant intervention at this time? 1. Supporting the client's usual routine 2. Assisting the client in setting new goals 3. Assisting the client in focusing on the future 4. Arranging for the client to have help in the home

1 Rationale: A routine is important to older adults, because it promotes a sense of control and security. Assisting the client in setting new goals is an important strategy for future planning, but it is not the primary goal for the client at this time. Older people may need to focus on the past as much as they do on the future; a life review is often conducted during this stage of development. Arranging for the client to have help in the home may be helpful but may not be welcomed by the client.

A client with a long history of alcohol abuse is admitted to the detoxification unit of an alcohol rehabilitation center. The nurse manager should assign the client to a room with what qualities? 1. Well lit and away from areas of activity 2. Without windows and close to the nurses' station 3. Illuminated by adequate lighting from the corridor 4. With dim lighting and shared by a quiet, withdrawn client

1 Rationale: A well-lit room away from areas of excessive activity helps reduce the fears and illusional experiences of a client experiencing alcohol withdrawal. The nurses' station usually is a busy place; a room nearby is not the ideal location for a client who is experiencing delirium. Noises can be frightening and may stimulate hallucinations or illusions. Bright lights from the corridor can cast shadows on the walls and ceiling of a darker room, increasing stimulation and creating illusions of frightening objects. Dim lights in the room increase stimulation, producing illusions and hallucinations; a stranger may increase the client's fear, restlessness, and confusion.

A client on a psychiatric unit who has been acting out for several weeks approaches the nurse and says, "I'm really sorry about how I've acted. I'll bet everyone thinks I'm an idiot." What is the best initial response by the nurse? 1. "You're wondering how others will react to you now." 2. "Some clients are concerned that you might lose control again." 3. "Everyone feels foolish sometimes; you didn't deliberately act that way." 4. "Nobody thinks you're a fool; everyone recognized that you were really struggling to keep control."

1 Rationale: Observing that the client is worried about the perception of the other clients best clarifies the client's major concern and encourages discussion of feelings. The nurse cannot legitimately speak for other clients; saying what other clients are thinking may increase the client's anxiety about the future. Saying that everyone feels foolish sometimes is an ineffective use of empathy, because it cuts off further communication; it also indicates that the nurse agrees that the client acted foolishly. Saying that everyone realized that the client was struggling is inappropriate, because the nurse cannot legitimately speak for other staff members and clients.

Ten minutes before lunch, a client with obsessive-compulsive behavior begins the ritual of changing clothes for the fourth time. How should the nurse respond to this behavior? 1. Tell the client to finish changing clothes and say that lunch can be eaten afterward. 2. Help the client change clothes quickly so lunch can be eaten at the scheduled time. 3. Lead the client to the dining room and explain that the clothes can be changed after lunchtime. 4. Inform the client that everyone is required to be in the dining room at a specific time, so there is no time to change clothes.

1 Rationale: Telling the client to finish changing clothes and explaining that lunch can be eaten afterward sets some limits on the compulsive act; it permits the ritual without reinforcing it but does not increase anxiety by removing the defense. Rushing the completion of the ritual will increase anxiety, because the ritual is being used as a defense. Leading the client to the dining room and explaining that the clothes can be changed after lunch will increase the client's anxiety and reinforce the need for the behavior. Preventing the ritual will increase anxiety, because the ritual is being used as a defense.

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

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

A client experiencing hallucinations tells a nurse, "The voices are telling me that I am evil." The client asks whether the nurse hears the voices. What is the most appropriate response by the nurse? 1. "I don't hear the voices, but I believe that you can hear them." 2. "It is the voice of your conscience and only you can control that." 3. "Those voices are coming from within you; only you can hear them." 4. "The voices are a symptom of your illness; don't pay attention to them."

1 Rationale: The nurse, demonstrating knowledge and understanding, accepts the client's perceptions even though they are hallucinatory by saying, "I don't hear the voices, but I believe that you can hear them." Telling the client, "It is the voice of your conscience and only you can control that," may increase the client's guilt and fear. Saying, "Those voices are coming from within you; only you can hear them," may increase the client's fear. The statement, "The voices are a symptom of your illness; don't pay attention to them," presents reality but negates the client's feelings and asks for an unrealistic response.

What should the nurse keep in mind about rituals when planning care for a client who uses ritualistic behavior? 1. They help the client control anxiety. 2. They are under the client's conscious control. 3. They are used by the client primarily for secondary gains. 4. They help the client focus on the inability to deal with reality.

1 Rationale: The rituals used by a client with obsessive-compulsive disorder help control the anxiety level by maintaining a set pattern of action. The client cannot consciously control the ritual. Rituals are used primarily to handle feelings of anxiety and generally are seen by the client as illogical; they provide few secondary gains. Rituals are a means of diverting attention from feelings of anxiety.

A client with a history of chronic alcoholism was admitted to a surgical unit after surgery to repair a severely fractured right ankle. The nurse is concerned that the client is experiencing manifestations of acute alcohol withdrawal when certain documentation and assessment data from the last 6 hours seem to indicate this problem. Which data are the cause of the nurse's concern? Select all that apply. 1. Tremors in both hands make it difficult for the client to hold a cup. 2. The client's systolic blood pressure has dropped 6 points over last 6 hours. 3. The client was observed falling asleep while talking on the telephone to family. 4. The client's bed linens and pajamas had to be changed during the night as a result of increased diaphoresis. 5. The usually cooperative client becomes verbally abusive when asked to lower the volume of the television.

1, 4, 5 Rationale: Diaphoresis and tremors are physical characteristics of alcohol withdrawal. Agitation is a psychosocial characteristic of alcohol withdrawal. Systolic blood pressure would rise rather than fall if the client were experiencing alcohol withdrawal. Insomnia, rather than drowsiness, is a physical characteristic of alcohol withdrawal.

What should the nurse do when planning continuing care for a moderately depressed client? 1. Encourage the client to determine leisure time activities. 2. Offer the client the opportunity to make some decisions. 3. Relieve the client of the responsibility of making any decisions. 4. Allow the client time to be alone to decide in which activities to engage.

2 Rationale: Allowing the client to make decisions that can be handled helps improve confidence. The client is depressed, and allowing the client time to be alone to decide in which activities to engage can result in total inactivity. Relieving the client of the responsibility of making any decisions will demoralize the client; also, it is impossible for one individual to make all the decisions for another.

A nurse works with school-age children who have conduct disorder, childhood-onset type. The nurse knows that these children are at risk for progression to another disorder during adolescence. For signs of which disorder should the nurse assess their current behavior? 1. Oppositional defiant 2. Antisocial personality 3. Pervasive developmental 4. Attention deficit-hyperactivity

2 Rationale: Children who exhibit behaviors associated with conduct disorder before the age of 10, rather than during adolescence, have a higher incidence of antisocial personality disorder during adolescence. If oppositional defiant disorder persists for at least 6 months, it may be a precursor to a conduct disorder. Pervasive developmental disorders are characterized by impairments in reciprocal social interaction and communication skills; types include autistic, Asperger, Rett, and childhood disintegrative disorders. They are not preceded by conduct disorder. Attention deficit-hyperactivity disorder is often dually diagnosed with oppositional defiant disorder or conduct disorder and may precede the development of Tourette syndrome.

A nurse is interviewing a client newly admitted to an outpatient program after withdrawal from alcohol. What behavior best indicates that the client has accepted that drinking is a problem? 1. Participates in scheduled counseling sessions 2. Attends Alcoholics Anonymous meetings daily 3. Volunteers to be a sponsor for another alcoholic 4. Apologizes to family members for causing distress

2 Rationale: Daily attendance at AA meetings usually indicates an acceptance of the problem and a desire for help. Attendance at counseling sessions is helpful but is not specific to the problem of alcoholism. Clients with alcohol problems should not sponsor other clients until sobriety has been maintained for a long period. Clients with alcohol problems may say that they are sorry many times but still not take responsibility for their drinking problem.

A child is found to have attention deficit-hyperactivity disorder (ADHD). What strategy should the nurse teach the parents to help them cope with this disorder? 1. Orient the child to reality. 2. Reward appropriate conduct. 3. Suppress feelings of frustration. 4. Use restraints when behavior is out of control.

2 Rationale: External rewards can motivate as well as increase self-esteem in the child with ADHD. Orienting the child to reality is unnecessary, because children with ADHD are alert and oriented. Feelings of frustration should not be suppressed; rather, the child should learn how to cope with these feelings in an acceptable manner. The use of restraints is contraindicated, because they are restrictive and punitive.

The practitioner prescribes a diet high in vitamin B1 (thiamine) for a client with a long history of alcohol abuse. The nurse concludes that the client understands the teaching about foods high in thiamine when the client makes which statement? 1. "I'll choose fish, aged cheese, and breads." 2. "I'll choose lean beef, organ meat, and nuts." 3. "I'll choose poultry, milk products, and eggs." 4. "I'll choose green vegetables, lentils, and citrus fruits."

2 Rationale: Lean beef, organ meats, and nuts all provide high levels of thiamine; other sources include legumes, whole and enriched grains, and lean pork. Of fish, aged cheese, and bread, only fish is considered a source of thiamine. Of poultry, milk products, and eggs, only eggs are considered a source of thiamine; this list contains sources of protein. Of green vegetables, lentils, and citrus fruits, only lentils (legumes) are considered a source of thiamine; most vegetables contain only traces of thiamine, and citrus fruits provide vitamin C.

During an assessment interview the client reports overwhelming, irresistible attacks of sleep. Which sleep disorder does the nurse conclude that the client is experiencing? 1. Insomnia 2. Narcolepsy 3. Sleep terror 4. Sleep apnea

2 Rationale: Narcolepsy is overwhelming sleepiness that results in irresistible attacks of sleep, loss of muscle tone (cataplexy), and hallucinations or sleep paralysis at the beginning or end of sleep episodes; the person usually awakens from the sleep feeling refreshed. Insomnia is difficulty initiating or maintaining sleep. Sleep terrors are recurrent episodes of abrupt awakening from sleep accompanied by intense fear, screaming, tachycardia, tachypnea, and diaphoresis with no detailed dream recall. Sleep apnea is a breathing-related sleep disorder caused by disrupted respirations or airway obstruction; sleep is disrupted numerous times throughout the night.

A mother of a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD) tells the nurse that when she is reading storybooks to her son, about halfway through the story he becomes distracted, fidgets, and stops paying attention. What should the nurse suggest to the mother? 1. "Talk with a louder voice." 2. "Shorten the rest of the story." 3. "Encourage your son to pay attention." 4. "Use therapeutic holding for the rest of the story."

2 Rationale: Shortening the story nonjudgmentally limits the activity while supporting the child's self-esteem; the child with ADHD cannot control his inattention and hyperactivity. The mother should select activities that are more interactive or interesting for the child to engage his attention. The child does not have a hearing problem, and speaking louder will not change the behavior. Inattention and hyperactivity cannot be controlled; encouraging the child to pay attention may precipitate feelings of doubt, shame, or guilt and reinforce low self-esteem. Using therapeutic holding for the rest of the story is unnecessary in this situation; therapeutic holding is used when a child is out of control and at risk for self-harm or violence toward others; it reassures the child that the adult is in control and promotes feelings of security and comfort.

A client is admitted to an alcohol rehabilitation center. On the fourth day after admission, the nurse detects a strong odor of alcohol on the client's breath. What is the nurse's first action? 1. Asking where the client got the alcohol 2. Locating and removing the alcoholic substance 3. Conveying the staff's disappointment in this behavior 4. Documenting and notifying the practitioner of the client's drinking

2 Rationale: The nurse should remove the substance before the client or other clients have an opportunity to consume more alcohol. The primary concern is not where the alcohol was obtained but instead protecting the client from consuming more. Making the client feel guilty could increase the desire for more alcohol. The client may drink the remaining alcohol while the nurse documents the information and notifies the practitioner.

A school nurse is caring for a 12-year-old child with school phobia. What should the nurse anticipate will be included in the initial treatment plan? 1. Allowing a parent to stay with the child during school 2. Having the child present somewhere in the school building during the day 3. Encouraging the child to attend school at brief intervals throughout the day 4. Providing home schooling until the child feels less anxious about attending school

2 Rationale: When the child is present in the school, even in the library or the nurse's office, the child can be helped to improve coping and eventually decrease the phobia through desensitization. Secondary gains from missing school are eliminated with this approach. Allowing a parent to stay with the child during school will be disruptive to the child's class and will focus unnecessary attention on the child. Having the child go in and out during the day will be disruptive and will not help desensitize the child. Providing home schooling until the child feels less anxious about attending school will reinforce the school phobia and make returning to school more difficult.

Schizophrenia is associated with both positive and negative symptoms. While assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion? Select all that apply. 1. Poverty of speech 2. Agitated behavior 3. Lack of motivation 4. Delusions of grandeur 5. Auditory hallucination

2, 4, 5 Rationale: Agitated and restless behaviors are positive symptoms of schizophrenia. A delusion is a fixed false belief that is resistant to reasoning; when a person believes that he or she is a famous, historical or fictional omnipotent character this is called a delusion of grandeur; a delusion is a positive symptom associated with schizophrenia. An auditory hallucination is a sensory perception involving the sense of hearing that occurs in the absence of an external stimulus and is a positive symptom associated with schizophrenia. Decreased verbalization, including a sudden stoppage in the flow of speech (blocking) and lack of inflection, is a negative symptom associated with schizophrenia. Lack of motivation (avolition) and apathy are negative symptoms associated with schizophrenia.

A client recently admitted to the psychiatric unit is pacing the floor and acting aloof and suspicious. The client tells the nurse that other people have all the control. What initial nursing intervention will be most helpful to the client? 1. Reviewing the client's history 2. Setting limits on the client's inappropriate behavior 3. Accepting the client's behavior because it is not directed specifically at the nurse 4. Meeting privately with family members to learn more about the client's behavior

3 Rationale: Clients who are aloof, suspicious, and accusatory can elicit negative feelings in the nurse. The nurse should recognize that these behaviors are indicative of the illness. Reviewing the client's history initially is not vital to helping the client; the nurse should try to meet the client's immediate needs. Setting limits at this time is not therapeutic and will increase the client's anxiety and suspiciousness. Meeting privately with family members to learn more about the client's behavior initially is not vital to help the client; the nurse should try to meet the client's needs at this time.

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? 1. Notify the healthcare provider. 2. Report this to the nurse manager. 3. Tell the client that the cigarettes were found. 4. Discard the cigarettes without commenting to the client.

3 Rationale: Honest nurse-client relationships should be maintained so that trust can develop. Although other healthcare team members may need to be informed eventually, the initial action should involve only the nurse and client. Discarding the cigarettes without commenting to the client does not promote trust or communication between the client and nurse.

A client with the diagnosis of dementia of the Alzheimer type, stage 1, is living at home with an adult child. To best address the functional and behavioral changes associated with this stage, what should the nurse encourage the daughter to do? 1. Place the client in a long-term care facility. 2. Provide for the client's basic physical needs. 3. Post a schedule of the client's daily activities. 4. Perform care so the client does not need to make decisions.

3 Rationale: In stage 1 of Alzheimer-type dementia [1] [2], clients have mild cognitive impairment with short-term memory loss; establishing a daily routine, posting it, and adhering to it provides a concrete, structured approach. Placing the client in a long-term care facility may be required during stage 3 or the end of stage 2 if the child is unable to cope with the client's functional and behavioral changes. In stage 1, clients can provide for their own basic activities of daily living such as bathing, dressing, and eating. Clients can make simple decisions in stage 1, and they have the right to make choices; an authoritarian approach may promote regression, anxiety, depression, or anger.

What is the priority discharge criterion for a client who is using ritualistic behaviors? 1. Verbalizes positive aspects about self 2. Follows the rules of the therapeutic milieu 3. Able to intervene when increasing levels of anxiety occur 4. Recognizes that hallucinations occur at times of extreme anxiety

3 Rationale: Knowing when and how to intervene to hold increasing anxiety at a manageable level will result from teaching the client to recognize situations that provoke ritualistic behavior and how to interrupt the pattern. No evidence is presented to indicate the client is hallucinating. Neither verbalizing positive aspects of the self nor following the rules of the clinical milieu is a priority.

A child would be demonstrating outwardly focused anger or aggression in an overt manner when engaging in which behavior? 1. Dominating a class discussion 2. Intentionally forgetting to do homework 3. Scribbling on a classmate's art assignment 4. Crying when told he or she must wait his or her turn

3 Rationale: Overt anger is demonstrated obviously or in an unconcealed manner that is hurtful, such as in damaging the artwork of another student. Examples of passive outwardly focused anger would be in dominating conversations or intentionally forgetting to do something that is required. Crying is a demonstration of inwardly focused anger that is objectively displayed.

A client comes to a trauma center reporting that she has been raped. She is disheveled, pale, and staring blankly. The nurse asks the client to describe what happened. What is the nurse's rationale for doing this? 1. It will help the nursing staff give legal advice and provide counseling. 2. Talking about the assault will help the client see how her behavior may have led to the event. 3. It will let the victim put the event in better perspective and help begin the resolution process. 4. Discussing the details will keep the victim from concealing the intimate happenings during the assault.

3 Rationale: Talking about what actually happened helps the client sort out the truth from confused thoughts and helps the client begin to accept what has happened as a part of her history. Legal counsel should come from a legal authority, not the nurse; the victim should be told of the legal services available. Sexual assaults are often planned. They are violent acts, and the perpetrators are responsible for their behavior. If the client does not want to discuss intimate details, this wish should be respected.

While walking to the examination room with the nurse, a toddler with autism suddenly runs to the wall and starts banging the head on it. What should the nurse's initial action be? 1. Allowing the toddler to act out feelings 2. Asking the toddler to stop this behavior 3. Restraining the toddler to prevent head injury 4. Telling the toddler that the behavior is unacceptable

3 Rationale: The child with autism needs protection from self-injury. Permitting the child to act out is possible only if the acting out does not place the child in jeopardy. The child with autism has difficulty following directions, especially when out of control. The child with autism cannot separate self from behavior; a punitive approach will decrease the child's self-esteem.

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention? 1. Encouraging the client to try to walk 2. Explaining to the client that there is nothing wrong 3. Avoiding focusing on the client's physical symptoms 4. Helping the client follow through with the physical therapy plan

3 Rationale: The physical symptoms are not the client's major problem and therefore should not be the focus of care. This is a psychological problem, and the focus should be in this domain. Encouraging the client to try to walk is focusing on the physical symptom of the conflict; the client is not ready to give up the symptom. The disorder operates on an unconscious level but is very real to the client; saying there is nothing wrong denies feelings. Psychotherapy, not physical therapy, is needed at this time.

A client with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, "The next time I see the dietician, I'm going to throw this tray at her!" What is the most appropriate response by the nurse? 1. Suggesting that the client calm down and explaining that sometimes trays get mixed up 2. Informing the client that the behavior is inappropriate and sending the client out of the dining room 3. Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietician is unacceptable behavior 4. Informing the client that throwing the tray at the dietician will make matters worse and may result in the client being placed in seclusion

3 Rationale: Validating the client's frustration and correcting the behavior are the most appropriate responses; safety is a priority. Suggesting that the client calm down and explaining that sometimes trays get mixed up does not validate the client's feelings. Sending the client out of the room without offering support and direction is not an appropriate nursing response. Threatening seclusion is an inappropriate nursing intervention.

Evaluation of clients with anorexia nervosa requires reassessment of behaviors after admission. Which finding indicates that the therapy is beginning to be effective? 1. Food is hidden in the client's pockets. 2. The client states that the hospitalization has been helpful. 3. The client has gained 6 lb (2.7 kg) since admission 3 weeks ago. 4. The client remains in the dining room eating for 1 hour after others have left.

3 Rationale; Weight gain of 6 lb (2.7 kg) since admission 3 weeks ago is objective proof that the client's eating behaviors have improved. "Stashing" of food is a characteristic of an eating disorder, not a sign of improvement. The statement that the hospitalization has been helpful is subjective information and may be manipulative. "Marathon meals" with little actual food ingestion are common in people with anorexia.

A client with vascular dementia (formerly known as multiinfarct dementia) has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vascular dementia should the nurse expect when assessing a client with this diagnosis? Select all that apply. 1. Memory impairment 2. Failure to identify objects 3. Exaggerated deep tendon reflexes 4. Episodic progression of symptoms 5. Inability to use words to communicate

3, 4 Rationale: The diagnosis of vascular dementia is made when there is evidence of focal neurological signs and symptoms such as exaggerated deep tendon reflexes, extensor plantar response, gait abnormalities, and muscle weakness and when computed tomography reveals multiple infarcts involving the cortex and underlying white matter. Usually the signs and symptoms associated with vascular dementia have a steplike progression because of further intermittent occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual, progressive loss of memory and cognitive abilities. Both vascular dementia and dementia of the Alzheimer type are associated with deficits in memory and cognition. Failure to identify objects despite intact sensory function (agnosia) is a cognitive disturbance associated with both vascular dementia and dementia of the Alzheimer type. Both vascular dementia and dementia of the Alzheimer type are associated with language disturbances such as inability to use or understand words (aphasia).

A client is admitted to the psychiatric unit after attempting suicide by taking an overdose of barbiturates. What is the most common precipitator of suicide that the nurse should consider when performing an assessment interview? 1. The desire to be perfect 2. Recent memory problems 3. Intense feelings of agitation 4. A severe overreaction to stress

4 Rationale: Common factors that contribute to suicide are feeling emotionally overwhelmed and overreacting to stressful life situations that the client is trying to escape. The desire to be perfect tends to generate anxiety and typically is not associated with depression and suicide. Memory problems are distressing, but they usually do not precipitate suicide attempts. Memory problems are associated with dementia. Feelings of agitation are commonly displayed by acting out through angry and aggressive behavior. Suicide attempts are usually precipitated by repressed anger and feelings of hopelessness.

The nurse determines that the plan for bolstering an overweight adolescent's self-esteem has been effective when, 3 months later, the adolescent's mother reports that the adolescent is doing what? 1. Seems to be doing average work in school 2. Has asked her how to bake bread and cookies 3. Imitates a sibling's manner of speech and dress 4. Joined a dirt bike group that meets at the school

4 Rationale: Joining a dirt bike group demonstrates a movement toward peer group activity and interests; exercise demonstrates an interest in an improved physical condition. There are no data to indicate that school is a problem. Average work in school and an interest in baking do not demonstrate an increase in self-esteem.

A nurse at the mental health center has been counseling the family of an adolescent client with anorexia about nutrition. Which statement made by a family member demonstrates an adequate understanding of the needs of the client? 1. "We won't have to worry about this passing fad for long." 2. "We'll monitor both of our teenagers' exercise habits closely." 3. "We need to watch more closely when we're all eating together." 4. "We should give our child more input into our meal planning."

4 Rationale: The anorexic client feels out of control in most situations. The client needs to assume responsibility for treatment associated with this lifelong problem; input into planning and preparation gives some responsibility to the client in addition to others in the family. Anorexia is not a passing fad. Close supervision takes away the client's responsibility in the treatment regimen and impedes the development of independence from the parents.

A client who has severe rheumatoid arthritis becomes depressed and is admitted to the psychiatric unit. The nurse begins to work with the client in one-on-one sessions to help with coping with the depressive episode. What is the best long-term outcome for this client? 1. The client will eat at least two meals per day with other clients. 2. The client will maintain self-care and attend structured activities. 3. The client will make a positive verbal comment to another client daily. 4. The client will decrease negative thinking about self, others, and life.

4 Rationale: The best long-term goal is that the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has been effective and the client may be discharged. Eating at least two meals per day with other clients is a short-term goal associated with a therapeutic milieu. Maintaining self-care and attending structured activities is a short-term goal and an expected behavior on an inpatient unit. Making a positive verbal comment to another client daily is an intermediate goal that helps the client focus on others; this goal is a step toward achieving long-term goals.

A client has been attending weekly outpatient psychotherapy sessions for several months. The nurse psychotherapist has been working with the client to help lessen obsessive-compulsive behaviors that have interfered with the client's work performance. What information about the client best validates the client's improvement? 1. States spending less time on ritualistic behaviors while at work 2. Discusses techniques used to provide distraction from obsessive thoughts 3. Reports spending an increased amount of time with friends in pleasurable activities 4. Receives a letter from a supervisor at work stating job performance has improved

4 Rationale: The letter provides objective validation that the client's work performance has improved. Although spending less time at work on compulsive behavior, coming up with techniques to lessen the need for the behavior, and spending more time with friends in pleasurable activities are all acceptable outcomes of therapy, they all represent subjective information reported by the client.

A child tells the school nurse, "My father has been getting into bed with me at night and touching me." What should the nurse do next? 1. Ask the child to describe the touching. 2. Tell the teacher to report any inappropriate behavior. 3. Contact the father to come to the school immediately. 4. Report the child's conversation to child protective services.

4 Rationale: The nurse is legally responsible for reporting suspected child abuse to the appropriate child protection agency. The agency must assess the situation and intervene if necessary to protect the child. Asking the child to describe the touching may worsen the psychological trauma; the nurse should listen and demonstrate concern. The nurse does not need any more data to have a reasonable suspicion of child abuse; the situation must be reported. Contacting the father may result in more abuse or in the child not reporting future abuse.

A school nurse is teaching a high school health class about inhalant abuse. What serious effect of using inhalants should the nurse discuss? 1. Esophageal varices 2. Acute electrolyte imbalances 3. Extrapyramidal tract symptoms 4. Death in one third of first-time users

4 Rationale: Use of inhalants, called "huffing," is most often seen in preadolescent males in rural areas, and it can be lethal in overdose. Esophageal varices are associated with alcoholic cirrhosis. Acute electrolyte imbalances are associated with alcoholic cirrhosis and are related to malnutrition, dehydration, and ascites. Extrapyramidal tract symptoms are associated with typical antipsychotic medications.

A client with bipolar disorder is exhibiting accelerating activity and flight of ideas. What is the best nursing intervention to limit the accelerating manic behavior? 1. Involving the client in a video game 2. Encouraging the client to join in group activities 3. Moving the client away from others until the agitation lessens 4. Engaging the client in conversation while walking slowly in the hall

4 Rationale: Walking will help the client discharge energy; by slowing the pace, the nurse may slow the client's activity. A video game is too stimulating and may worsen the client's hyperactivity. Group activities are too stimulating for this client and may worsen the hyperactivity. Isolating the client is too restrictive and is also punitive.

While admitting a young client with anorexia nervosa to the unit, the nurse finds a bottle of assorted pills in the client's luggage. The client tells the nurse that they are antacids for stomach pains. What is the best initial response by the nurse? 1. "Let's talk about your drug use." 2. "These pills don't look like antacids." 3. "Some people take pills to lose weight." 4. "Tell me more about these stomach pains."

4 Rationale; "Tell me more about these stomach pains" is a nonthreatening, open-ended response that focuses discussion and leaves the channel of communication open. Although "Some people take pills to lose weight" is a true statement, this response does not encourage discussion. Although "Let's talk about your drug use" and "These pills don't look like antacids" do not quite accuse the client of lying, both are threatening responses that question the client's truthfulness.