N481 Exam 1 HESI

Which communication technique is a part of therapeutic communication? - Asking for explanations - Showing sympathy to the client - Asking personal questions of the client - Providing relevant information to the client

- Providing relevant information to the client

What questions should a nurse ask when, during the assessment of an older adult, the nurse suspects suicidal intent? Select all that apply. 1"Do you think about killing yourself?" 2"How often do you have these thoughts?" 3"Do you have the means to kill yourself?" 4"Have you thought about your loved ones?" 5"How would you kill yourself if you decided to do it?" 6"Why do you think you won't be around much longer?"

1"Do you think about killing yourself?" 2"How often do you have these thoughts?" 3"Do you have the means to kill yourself?" 5"How would you kill yourself if you decided to do it?"

A client says, "Sky, flower, angry, green, opposite, blanket." Which term describes this type of communication? A. Echolalia B. Word salad C. Confabulation D. Flight of ideas

B. Word salad

Which statement indicates that a psychiatric nurse has successfully fostered a therapeutic nurse-client relationship? a. "My clients and I are partners in the planning that helps meet their physical and mental health needs." b. "Nurses and clients must develop a therapeutic relationship if appropriate mental and physical care is to be provided." c. "Mental health is achieved and maintained when the nurses and the clients exhibit respect and caring for each other." d. "Without a mutually satisfying relationship between patient and nurse, achieving mental and physical wellness is very difficult."

a. "My clients and I are partners in the planning that helps meet their physical and mental health needs."

When discussing standards for involuntary admission to a mental health facility, which factor is related to safety? Mental illness Severe disability Currently cutting Needs treatment

Currently cutting

A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction? Stay at the beside with the family and the deceased. Direct activities related to funeral arrangements. Mobilize the support systems for the family. Present the full reality of the loss to the family

Stay at the beside with the family and the deceased.

Which nursing actions best promote communication when obtaining a nursing history? Select all that apply. a. Establishing eye contact b. Paraphrasing the client's message c. Asking "why" and "how" questions d. Using broad, open-ended statement e. Reassuring the client that there is no cause for alarm f. Asking questions that can be answered with a "yes" or a "no"

a. Establishing eye contact b. Paraphrasing the client's message d. Using broad, open-ended statement

Which question would the nurse ask to test the older adult client's capacity for abstract thinking? a. How are a television and a radio alike? b. Can you give me today's date? c. What would you do if you fell and hurt yourself? d. Repeat the following numbers for me: 8, 6, 3, 8, 2

a. How are a television and a radio alike?

Which nursing intervention would be appropriate for the client in psychiatric crisis due to a panic attack? a. Remaining with the client until the crisis is over b. Reinforcing for the client that a panic attack is rarely fatal c. Communicating with the client using detailed sentences d. Introducing soft, soothing music into the environment to distract the client

a. Remaining with the client until the crisis is over

Which medications are used as the 1st line treatment for PTSD? a. Sertraline b. Paroxetine c. Phenelzine d. Venlafaxine e. Amitriptyline

a. Sertraline b. Paroxetine a & b are both SSRIs

Which behavior by the client exhibits denial after a recent diagnosis? a. attempts to minimize the illness b. lacks an emotional response to the illness c. refuses to discuss the condition with the client's spouse d. expresses displeasure with the prescribed activity program

a. attempts to minimize the illness

A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain my strength." Which stage of grieving would the nurse suspect the client is experiencing? a. bargaining b. frustration c. depression d. rationalization

a. bargaining

The objective of a therapy group is to assist the members to change behavior so they are able to participate in life in a more satisfying manner. Which leadership style is best to achieve this objective? a. democratic, guiding b. hierarchical, directing c. autocratic, controlling d. laissez-faire, observing

a. democratic, guiding

A survivor of a major earthquake exhibits a flattened affect, minimal eye contact, and monotone speech. Which defense mechanism is the survivor displaying? a. dissociation b. splitting c. introjection d. compensation

a. dissociation

Which phenomenon would the client be experiencing when they look at a linen sheet on a clothesline and think it's a ghost? a. illusion b. delusion c. hallucination d. confabulation

a. illusion

A client, diagnosed with BPD, declares that the whole staff is "bad" after being disappointed by one staff member. Which DM is the client using? a. splitting b. rationalization c. undoing d. reaction formation

a. splitting

Which defense mechanism would the nurse conclude a female client with obsessive compulsive disorder who washes her hands more than 20 times to ease her anxiety is using? a. undoing b. projection c. introjection d. displacement

a. undoing

Which statement from the client would alert the nurse that the client is experiencing a hallucination? a. "I am going to save the world because I am God." b. "My insides smell like they're going to just rot away." c. "Unless I gamble at least once a week, I feel extremely anxious." d. "It's crazy, but I keep thinking that something terrible will happen to my baby."

b. "My insides smell like they're going to just rot away."

The client gives a long, drawn out explanation with excessive and irrelevant detail before answering the nurse's question. Which mental process is the client displaying? a. flight of ideas b. circumstantiality c. thought blocking d. tangential thinking

b. circumstantiality

A client visits the mental health clinic because of an aversion to arachnids. The client reports screaming hysterically when a spider is in the vicinity. What defense mechanisms does the nurse conclude that the client is using? a. sublimation b. displacement c. repression d. introjection

b. displacement

Which speech pattern is a disturbed client displaying when they start to repeat phrases that others have just said? a. alogia b. echolalia c. neologism d. symbolic speech

b. echolalia

Which consideration is of priority importance when planning for a therapy group? a. age and ethnicity of clients in the group b. needs of the clients being included c. diagnoses of the clients being included d. socioeconomic status of the clients

b. needs of the clients being included

A client with schizophrenia repeatedly says, "No moley, jandu!" Which language disturbance is the client exhibiting? a. echolalia b. neologism c. concretism d. perseveration

b. neologism

Which behavior indicates that the nurse may be experiencing countertransference with a client? a. client likes to sit beside the nurse in group therapy b. nurse feels angry when a spouse is terse with a client c. client intentionally performs an action to get the nurse's attention d. nurse must repeatedly remind the client to go to group therapy

b. nurse feels angry when a spouse is terse with a client

A client sits huddled in a chair and later moves to assume the fetal position in a corner. Which DM is the client using? a. displacement b. regression c. dissociation d. reaction formation

b. regression

An anxious client reports pain in the abdomen and feeling empty and hollow, but a diagnostic workup reveals no physical cause. Which term reflects what the client is experiencing? a. dissociation b. somatization c. stress response d. factious disorder by proxy

b. somatization

Which sedative-hypnotics would the nurse identify as being used to treat insomnia associated with a panic disorder? SATA. a. phenelzine b. paroxetine c. alprazolam d. imipramine e. clonazepam

c. alprazolam e. clonazepam

When a client and the family are informed about ECT as a treatment option, the family urges the client to agree. Which ethical principle is involved in this decision-making? a. Justice b. veracity c. autonomy d. beneficence

c. autonomy

Which definition describes the defense mechanism of sublimation? a. returning to an earlier, less mature stage of development b. acting out a conscious behavior that is the opposite of an unconscious feeling c. channeling unacceptable impulses into socially appropriate behaviors d. excluding from consciousness thoughts that are psychologically disturbing

c. channeling unacceptable impulses into socially appropriate behaviors

A woman is afraid of the water, and she insists her teenage son doesn't want to go swimming or boating with his friends. Which DM is she displaying? a. dissociation b. introjection c. projection d. reaction formation

c. projection

A female clients tells the nurse that she hates her roommate. Later, the client tells the roommate, "I missed you. Where have you been?" Which defense mechanism is the client using? a. projection b. sublimation c. reaction formation d. compensation

c. reaction formation

Which DM is a client displaying when the client can no longer remember why an event was stressful, even though it happened just 3 days ago? a. denial b. regression c. repression d. dissociation

c. repression

A client has been diagnosed with GAD. Which behavior would the nurse expect to observe? a. making huge efforts to avoid "any kid of bug or spider" b. experiencing flashbacks to an event that involved a sexual attack c. spending hours each day worrying about something "bad happening" d. becoming suddenly tachycardic and diaphoretic for no apparent reason

c. spending hours each day worrying about something "bad happening"

Which defense mechanism is considered a conscious measure that is used to cope with anxiety? a. undoing b. projection c. suppression d. intellectualization

c. suppression

Which statement by the nurse indicates understand of DSM-5 criteria for PTSD? a. "Feelings of self-worth remain high." b. "PTSD does not occur in children under 6 years of age." c. "Clients will remember all details of the event." d. "Flashbacks must last longer than for 1 month."

d. "Flashbacks must last longer than for 1 month."

What should a nurse include in the initial plan of care for a client with the long-standing, obsessive-compulsive behavior of hand washing? a. Determine the purpose of the ritualistic behavior b. Limit the time allowed for the ritualistic behavior c. Suggest a symptom substitution technique to refocus the ritualistic behavior d. Develop a routine schedule of activities

d. Develop a routine schedule of activities to reduce the need for the ritualistic behavior

Which legal implication would the nurse understand about applying restraints to a client? a. The law allows restraining clients until a written prescription is obtained. b. A felony charge may be leveled against nurses who use any kind of restraints. c. Nurses are not obligated to report institutions that use restraints unlawfully. d. The nurse can be charged with assault and battery for using restraints improperly.

d. The nurse can be charged with assault and battery for using restraints improperly.

Which response by the nurse uses the technique of paraphrasing when after receiving chemotherapy, a client states, "I get so sick to my stomach. This medication is useless." a. You get sick to your stomach. b. Tell me more about how you feel. c. I'll get a prescription for an antiemetic. d. You don't think the medication is helping you.

d. You don't think the medication is helping you.

Which benefit is provided by milieu therapy? a. availability of individual and family therapy b. positive reinforcement to reduce guilt c. revelation of unconscious conflicts and fantasies d. environment provides structure, routine, and security

d. environment provides structure, routine, and security

A person with a hx of alcoholism says, "I've been drinking since last Friday to celebrate my son's graduation from college." Which DM is the person displaying? a. denial b. projection c. identification d. rationalization

d. rationalization

The nurse is caring for a group of clients on the psychiatric unit. Which clinical findings will alert the nurse that serotonin syndrome has developed in one of the clients? a. continuous involuntary movement of the tongue and jaw b. extremely high BP with headache and flushing c. blurred vision, urine retention, dry mouth, constipation d. restlessness, tachycardia, fever, diarrhea, altered mental status

d. restlessness, tachycardia, fever, diarrhea, altered mental status

An older client describes the current situation and then provides information that goes further and further off the topic. Which pattern of communication is the client using? a. perseveration b. thought blocking c. pressured speech d. tangential thinking

d. tangential thinking

Which factor is most important in predicting a persons reaction to imminent loss and grief? Family interactions social support system emotional relationships earlier experiences with grief

earlier experiences with grief