NCLEX Review Mental Health
A group of clients from a psychiatric unit, accompanied by staff members, are going to a professional baseball game. The purpose of visits into the community under the supervision of staff members is: 1. Helping clients adjust to stressors in the community 2. Helping clients return to reality under controlled conditions 3. Observing the clients' abilities to cope with a more complex society 4. Broadening the clients' experiences by providing exposure to cultural activities
3. Observing the clients' abilities to cope with a more complex society The nurse's observations can help identify those clients who are ready to cope with outside stress and those who are not. There is nothing to indicate that any of these clients needed to broaden their cultural experiences. Attendance at a ball game will not help clients adjust to community stressors or return to reality under controlled conditions.
For a nurse assessing disturbed children, the clue most indicative of severe emotional problems is the child's: 1. Physical complaints 2. Behavioral outbursts 3. Inadequate school performance 4. Lack of response to the environment
4. Lack of response to the environment Unresponsiveness to the environment may be an indicator of severe childhood depression, autism, or even schizophrenia. Physical complaints, behavioral outbursts, and inadequate school performance may all be seen in children without emotional problems in addition to those with emotional problems; this behavior alone does not indicate severe emotional problems.
A client who is receiving haloperidol (Haldol), 5 mg three times a day, complains of twitching of the fingers. What is the best response by the nurse? 1. "This is a temporary situation until your body adjusts to the medication." 2. "You need the medication that we're giving you. You'll get used to the side effects soon." 3. "Let's wait a few days and see whether the side effects of the drug you're taking go away." 4. "I'll ask the doctor to prescribe a medication that'll help overcome this. It's a side effect of the drug you're taking."
4. "I'll ask the doctor to prescribe a medication that'll help overcome this. It's a side effect of the drug you're taking." The finger twitching is a side effect of the medication that can be treated. This response validates the client's concern and assures the client that help is available to address the situation. This is not a temporary side effect. However, it is a reversible condition that can be treated with benztropine (Cogentin) or diphenhydramine (Benadryl). Twitching is not a sign that requires patience for adjustment but rather one that must be treated. Failure to address side effects increases the risk of the client's not following the medication regimen. Early treatment to reverse the twitching is important.
What is the prognosis for a normal productive life for a child with autism? D1. ependent on an early diagnosis 2. Often related to the child's overall temperament 3. Ensured as long as the child attends a school tailored to meet needs 4. Unlikely because of interference with so many parameters of function
4. Unlikely because of interference with so many parameters of function Research studies have shown that the prognosis for normal productive function in autistic people is guarded, particularly if there are delays in language development. Accurate diagnosis and early interventions have not been shown to promote a normal, productive life; however, early intervention may help individuals maximize their abilities. Although temperament may affect the child's response to treatment, it does not affect prognosis to any extent. Stating that success is ensured as long as the child attends a school tailored to meet needs is false reassurance and is not helpful.
A client with a history of aggressive, violent behavior is admitted to the psychiatric unit involuntarily. The nurse, who understands the need to use deescalation approaches during the preassaultive stage of the violence cycle, monitors the client's behavior closely for progression of signs of impending violence. List these client assessments in order of escalating aggression, from the lowest risk to the highest.
1. Increasing tension in facial expression 2. Having difficulty waiting to take turns during a group project 3. Pacing in the hall 4. Engaging in verbal abuse toward the nurse 5. Pushing another client while waiting in line to the dining room Increasing tension in facial expression indicates increasing anxiety, but the client is still maintaining self-control. Impulsivity, as demonstrated by the inability to take turns with others, indicates that the client is having some difficulty setting limits on his or her own behavior. When anxiety escalates to the point of hyperactivity and pacing behaviors, the client is attempting to cope with the anxiety and to discharge physical and psychic energy. Engaging in verbal abuse may precipitate physical abuse and is a sign that the client is not able to maintain self-control. The laying on of the hands in an offensive manner is a physical act of aggression.
An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance? 1. Reinforcing routines and supporting her usual habits 2. Helping her secure assistance with cleaning and shopping 3. Writing down and repeating important information for her use 4. Writing down and repeating important information for her use
1. Reinforcing routines and supporting her usual habits The client has been able to function well up to this time, and her usual behaviors and routines should be supported. The data presented do not show a need to get the client help with cleaning and shopping, to write down and repeat information, or to set goals and time limits for the client's visits with the nurse.
A client who has been taking a conventional antipsychotic for several days comes to the clinic complaining of neck spasms. The figure illustrates the client's physical status observed by the nurse. What extrapyramidal side effect has the client developed? 1. Torticollis 2. Tardive dyskinesia 3. Pseudoparkinsonism 4. Neuroleptic malignant syndrome
1. Torticollis Torticollis is an acute dystonia that involves muscle spasms of the head and neck. Torticollis develops within 1 to 5 days after beginning therapy with a conventional antipsychotic. Tardive dyskinesia is involuntary repetitious tonic muscular spasms that involve the face, tongue, lips, limbs, and trunk. Tardive dyskinesia takes several months to years to develop after the start of therapy with a conventional antipsychotic. Pseudoparkinsonism is an extrapyramidal tract response that includes masklike facies, shuffling gait, pill-rolling tremors, stooped posture, and drooling. Pseudoparkinsonism develops within several days to 1 month after the start of therapy with a conventional antipsychotic. Neuroleptic malignant syndrome is a severe, potentially fatal (10%) response to conventional antipsychotics. It is believed to be caused by an acute reduction in brain dopamine activity, precipitating hyperthermia, tachycardia, tachypnea, unstable blood pressure, hypertonicity, dyskinesia, incontinence, decreased level of consciousness, and pulmonary congestion. Neuroleptic malignant syndrome can occur during the first week of therapy but often occurs later during therapy.
For which adverse effect should the nurse continually assess a client who is receiving valproic acid (Depakene)? 1. Yellow sclerae 2. Motor restlessness 3. Ringing in the ears 4. Torsion of the neck
1. Yellow sclerae Yellow sclerae are a sign of jaundice; pancreatitis and hepatic failure are life-threatening adverse effects of valproic acid (Depakene). The client must have frequent liver function tests. Motor restlessness (akathisia) is associated with antipsychotic drugs. Ringing or buzzing in the ears (tinnitus) is associated with aspirin. Torsion of the neck (torticollis) due to contracted cervical muscles is associated with antipsychotic drugs. Test-Taking Tip: Pace yourself during the testing period and work as accurately as possible. Do not be pressured into finishing early. Do not rush! Students who achieve higher scores on examinations are typically those who use their time judiciously.
A male client who is taking clozapine (Clozaril) is seen by the nurse in the outpatient mental health clinic. The nurse interviews the client, sends a venous blood specimen to the laboratory, obtains the vital signs, and finally reviews all the collected information. Which complication associated with clozapine does the nurse suspect that the client is experiencing? 1. Anemia 2. Agranulocytosis 3. Orthostatic hypotension 4. Neuroleptic malignant syndrome
2. Agranulocytosis Clozapine (Clozaril) can cause bone marrow suppression. The expected white blood cell (WBC) value for an adult is 4500 to 10,000 mm3. The client has a reduction in WBCs, making him vulnerable to infection. A fever with complaints of a sore throat and weakness supports the conclusion that the client may have an infection. The red blood cell (RBC) count does not indicate anemia. The expected range of RBCs for an adult male is 4.6 to 6.2 ´ 106/mL3. The small change in the blood pressure from standing to sitting does not support the conclusion of orthostatic hypotension. Labile hypertension is associated with neuroleptic malignant syndrome. There are insufficient data to support the conclusion that the client is experiencing neuroleptic malignant syndrome. Although tachycardia and tachypnea are associated with neuroleptic malignant syndrome, the client's fever would be more than 100.6° F (38.1° C). Additional characteristics of neuroleptic malignant syndrome include labile hypertension, diaphoresis, drooling, increased muscle tone, and decreased level of consciousness.
A client has been found to have bipolar disorder and is being prescribed lithium carbonate (Lithium). In light of the information shown, the nurse provides teaching to the client. Select all that apply. 1. Lithium can affect WBC production and therefore increases her risk for infection 2. Her current thyroid function will require frequent assessments while she takes lithium 3. Hyponatrium could lead to lithium toxicity, so the healthcare provider must first be notified of the level 4. Because of the platelet count, neutropenic precautions will be initiated once the client starts lithium therapy 5. The current hemoglobin and hematocrit call for regular monitoring is needed once the lithium level is stabilized
2. Her current thyroid function will require frequent assessments while she takes lithium 3. Hyponatrium could lead to lithium toxicity, so the healthcare provider must first be notified of the level Lithium carbonate therapy can negatively affect thyroid function; the client's current TSH is at the high normal level and so frequent checks are appropriate. Low serum sodium levels would result in the kidneys' reabsorbing the lithium; this situation would lead to lithium toxicity. The health care provider must first be notified of the lab result. Lithium is not known to have a negative effect on WBC, platelet, or RBC production. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the hospital record (e.g., laboratory test results, results of diagnostic procedures, progress notes, health care provider orders, medication administration record, health history), physical assessment data, and nurse/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
The nurse manager hears a conversation between a nurse and a client that is focused on the details of their impending divorces. What is the nurse manager's response? 1. Waiting until the conversation ends and then telling the nurse that such topics must be discussed in strict privacy to ensure client confidentiality 2. Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated 3. Immediately explaining to both nurse and client that such conversations are inappropriate and that the nurse's assignment will be changed 4. Waiting until shift report and using that opportunity to discuss appropriate nurse-client boundaries with the attending nursing staff
2. Immediately asking to speak to the nurse privately and stating that sharing such personal information is nontherapeutic and not tolerated The nurse-client relationship should always remain client focused. Discussing personal issues with the client, even in an attempt to share similar experiences, is nontherapeutic and should be discussed immediately by the nurse's supervisor. Although the ease with which this conversation was overheard does raise concerns about the nurse's understanding of the client's right to confidentiality and privacy, there is a greater issue that needs immediate attention and should be addressed immediately. The nurse's management of the nurse-client relationship should be discussed privately. It may not be necessary to change the assignment. Although it may be useful to reinforce information on privacy with the entire staff, the situation requires an immediate private discussion between the nurse and the nurse manager to satisfactorily address the problem for the individual nurse.
A nurse facilitating a support group of widows and widowers recalls that research indicates that the probability of a spouse having a pathological or morbid grief response will be greater if: 1. The couple had an ambivalent relationship 2. The cause of the spouse's death was suicide. 3. The relationship between the spouses was satisfying 4. There was a long preparatory grief period before a spouse's death
2. The cause of the spouse's death was suicide. The survivors of a suicide feel more guilt and bitterness and go through a longer grieving process, and therefore the chances of a pathological grief response are increased. An ambivalent relationship between the spouses may result in a difficult grief response because of guilty feelings but should not cause a morbid grief response. Research documents that the more satisfying the relationship, the more likely that the mourner will establish a new relationship. With a preparatory grief period a person may have the opportunity to work through a part of the grief process before the death and have a shorter mourning period after the death.
To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors the central factors that influence development? 1. To provide appropriate psychosocial support to clients, a nurse must understand development across the life span. What theory is the nurse using in considering relationships and resulting behaviors the central factors that influence development? 1. Cognitive theory 2. Psychosocial theory 3. Interpersonal theory 4. Psychosexual theory
3. Interpersonal theory The interpersonal theory of human development by Harry Stack Sullivan highlights interpersonal behaviors and relationships as the central factors influencing child and adolescent development across six "eras"; the need to satisfy social attachments and a longing to meet biologic and psychological needs are two dimensions associated with this theory. Cognitive theory is associated with Jean Piaget; cognitive theory explains how thought processes develop, are structured, and influence behavior. Psychosocial theory is associated with Erik Erikson; psychosocial theory identifies social interaction as the source that influences human development. Erikson identified eight stages of human life, with each stage built on the previous stages and influenced by past experiences. Psychosexual theory is associated with Sigmund Freud; psychosexual theory views child development as a biologically driven series of conflicts and gratifying internal needs.
A client with schizophrenia, undifferentiated type, is receiving a typical antipsychotic/neuroleptic. For which extrapyramidal effects should the nurse be alert? 1. Shuffling gait, tremors, and restlessness 2. Nausea, vomiting, and muscle cramps 3. Drowsiness, disorientation, and slurred speech 4. Tachycardia, urine retention, and constipation
1. Shuffling gait, tremors, and restlessness Shuffling gait, tremors, and restlessness are common extrapyramidal signs (pseudoparkinsonism) that occur as side effects of neuroleptics; they are usually controlled with antiparkinsonian drugs. Nausea, vomiting, and muscle cramps are signs of lithium toxicity. Drowsiness, disorientation, and slurred speech are common side effects that occur with central nervous system depressants. Tachycardia, urine retention, and constipation are common side effects that occur with antidepressants.
A nurse is planning to teach a class of nursing assistants how to compare the behaviors of psychotic clients and people who function acceptably in society. What type of behavior is considered acceptable? 1. When defense mechanisms are rarely employed 2. If feelings and thoughts are expressed accurately 3. When it reflects the standards accepted by one's society 4. If methods used enhance achievement of short- and long-term goals
3. When it reflects the standards accepted by one's society An accepted practice in some parts of the world may be considered unacceptable behavior in others (e.g., pica). Every person needs relief from tension from time to time and makes use of defense mechanisms to accomplish this. If the behavior is aggressive or destructive, although it might accurately reflect the individual's thoughts and feelings, it is not considered acceptable. If the behavior is aggressive or destructive, even if it helped reach a goal, it is not considered acceptable.
A client is admitted to a mental health facility because of maladaptive coping behavior. How can the nurse best help the client develop healthier coping mechanisms? 1. By providing a stress-free environment 2. By promoting interpersonal relationships with peers 3. By allowing the client to assume responsibility for decisions 4. By setting realistic limits on the client's maladaptive behavior
4. By setting realistic limits on the client's maladaptive behavior Setting realistic limits on the client's maladaptive behavior provides structure that promotes learning acceptable behavior. No environment is stress free. The client may not be ready for relationships with peers or responsibility for decisions at this time.
When caring for a client with major depression, nurses usually have the most difficulty dealing with the: 1. Client's lack of energy 2. Negative nonverbal responses 3. Client's psychomotor retardation 4. Pervasive quality of the depression
4. Pervasive quality of the depression Depression is "contagious"; it affects the nurse as well as the client. The client's lack of energy should not make nursing care difficult. These clients usually do not offer negative responses; they offer no response.
The nurse's role in maintaining or promoting the health of the older adult should be based on the principle that: 1. Some physiological changes that occur as a result of aging are reversible 2. Thoughts of impending death are frequent and depressing to most older adults 3. Older adults can better accept the dependent state that chronic illness often causes 4. There is a strong correlation between successful retirement and maintaining health
4. There is a strong correlation between successful retirement and maintaining health The individual who can reflect back on life and accept it for what it was and is and who can adjust to and enjoy the changes retirement brings is less likely to develop health problems, especially stress-related health problems. The physiological changes of aging may not be reversible. Most emotionally healthy older individuals are not focused on thoughts of impending death. Dependence is often threatening and not easily accepted by older adults.
What is the best nursing intervention to encourage a socially withdrawn client to talk? 1. Focusing on nonthreatening subjects 2. Trying to get the client to discuss feelings 3. Asking simple yes-or-no questions of the client 4. Sitting quietly while looking through magazines with the client
1. Focusing on nonthreatening subjects Nursing care involves a steady attempt to draw the client into some response. This can best be accomplished by focusing on nonthreatening subjects that do not demand a specific response.The client is not ready yet to discuss feelings; the first step is to focus on nonthreatening subjects. Yes-or-no questions do not encourage communication. By sitting quietly with the client the nurse is showing acceptance of the client but doing nothing to encourage communication.
A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary? 1. Denial 2. Undoing 3. Displacement 4. Intellectualization
1. Undoing Undoing is atonement for or an attempt to dissipate unacceptable acts or wishes. Denial is the refusal to accept or perceive unpleasantness as it actually exists. Displacement is the discharge of pent-up feelings onto something or someone that is less threatening than the original source of the feelings. Intellectualization is the use of abstract thinking to minimize painful feelings.
What action should the nurse take when it becomes apparent that communication between the nurse and the client is consistently superficial? 1. Assessing the client's ability to understand the nurse's questions 2. Evaluating how actively the nurse has been listening to the client 3. Reinforcing to the client how important sharing is for successful recovery 4. Reviewing how the questioning techniques are being utilized by the client
2. Evaluating how actively the nurse has been listening to the client Effective active listening is critical to the development of meaningful, therapeutic communication between the nurse and the client. A lack of effective listening on the part of the nurse often times results in superficial, ineffective communication. Although there may be situations when assessing the client's cognitive abilities, reinforcing the importance of effective communication, or reviewing communication skills is an appropriate intervention, there are other, more commonly observed barriers to effective therapeutic communication.
An unmarried pregnant adolescent who is attending a crisis intervention group has decided to continue the pregnancy and keep the baby. Now the crisis intervention nurse's primary responsibility is to: 1. Praise the client for making a wise decision 2. Explore other problems that the client is experiencing 3. Make an appointment for the client to visit a prenatal clinic 4. Make an appointment for the client to visit a prenatal clinic
4. Make an appointment for the client to visit a prenatal clinic The crisis center nurse's main responsibility is to assist the client in using the problem-solving process; the client should be helped to explore alternative solutions and be given information regarding other agencies, facilities, and services. Although the client's decision should be supported, praising the client is a judgmental response. Exploring other problems that the client may be experiencing is not part of the immediate intervention during the crisis; the client may be encouraged to seek help later for other problems. Making an appointment for the client to visit a prenatal clinic is an option for which the client must take primary responsibility.
Clients with eating disorders often exhibit similar symptoms. What should the nurse expect an adolescent with anorexia nervosa to exhibit? 1. Affective instability 2. Repetitive motor mechanisms 3. Depersonalization and derealization 4. Disheveled and unkempt physical appearance
1. Affective instability Individuals with anorexia often display irritability, hostility, and a depressed mood. Repetitive motor mechanisms are associated with autism. Depersonalization and derealization are associated with individuals with schizophrenia. Clients with eating disorders are usually meticulous about dress and physical appearance; a disheveled appearance is associated with dementia or depression.
In an attempt to remain objective and support a client during a crisis, the nurse uses imagination and determination to project the self into the client's emotions. This technique is known as: 1. Empathy 2. Sympathy 3. Projection 4. Acceptance
1. Empathy Empathy is the projection of self into another's emotions to share the emotions and the other's state of mind; this technique helps the nurse understand the meaning and significance of the experience to the client. Sympathy is a shared expression of sorrow over a real or imagined loss. Projection is an unconscious defense mechanism, not a therapeutic technique. Acceptance does not require the nurse to project the self into the client's emotions; rather, it involves accepting the client and the emotions.
A client with a diagnosis of schizophrenia, undifferentiated type, is being admitted to the psychiatric unit. What clinical manifestations does the nurse expect when assessing this client? Select all that apply. 1. Excited behaviors 2. Loose associations 3. Inappropriate affect 4. Feelings of depression 5. Hypervigilant behavior
1. Excited behaviors 2. Loose associations 3. Inappropriate affect Excited behaviors, such as aggressive hitting or biting, often are associated with an acute onset of undifferentiated schizophrenia. Loose association is a characteristic related to thought disorders such as schizophrenia, undifferentiated type. The affect usually is inappropriate, rather than flat, in undifferentiated schizophrenia. Depression is not characteristic of undifferentiated schizophrenia. Hypervigilant behaviors generally are associated with paranoid schizophrenia, not undifferentiated schizophrenia.
A client arrives at the clinic and tells the nurse about various aches and pains since her spouse's death 3 months ago. The client appears depressed and tense. What is the initial nursing intervention? 1. Facilitating a discussion of the spouse's death 2. Focusing on teaching the client relaxation exercises 3. Asking the practitioner for a psychiatric consultation 4. Helping the client recognize ambivalence toward the spouse
1. Facilitating a discussion of the spouse's death Facilitating a discussion of the spouse's death will encourage the client to speak about the spouse and begin moving toward resolving the loss. Although relaxation exercises may be beneficial, the focus should be on the expression of feelings. A psychiatric consultation is not indicated by the data at this time. The data do not indicate ambivalence toward the spouse.
When helping a client cope with a crisis, the health care provider should follow the principles of intervention. Place the following interventions in order of their priority.
1. Intervening immediately 2. Stabilizing the client 3. Facilitating understanding of the event 4. Using the available resources 5. Encouraging self-reliance
A client with the diagnosis of schizophrenia, paranoid type, has been receiving a phenothiazine drug. The daycare center is planning a fishing trip. It is important that the nurse: 1. Provide the client with sunscreen 2. Caution the client to limit exertion during the trip 3. Give the client an extra dose of medication to take after lunch 4. Take the client's blood pressure before allowing him to participate in the outing
1. Provide the client with sunscreen Phenothiazines frequently cause a photosensitivity that can be controlled with sunscreen. Limiting activity is not a necessary precaution when phenothiazines are prescribed. The medication must be administered as prescribed. Participating in the outing should not negatively affect the client's blood pressure.
A nurse enters the room of an agitated, angry client to administer the prescribed antipsychotic medication. The client shouts, "Get out of here!" The nurse's best approach is to: 1. Say, "I'll be back in 15 minutes, and then we can talk." 2. Get assistance and give the medication by way of injection 3. Explain why it is necessary to comply with the practitioner's order 4. Tell the client, "You have to take the medicine that's been prescribed for you."
1. Say, "I'll be back in 15 minutes, and then we can talk." Saying, "I'll be back in 15 minutes, and then we can talk" allows the agitated, angry client time to regain self-control; telling the client that the nurse will return will decrease possible guilt feelings and implies to the client that the nurse cares enough to come back. Getting assistance and giving the medication by way of injection does not respect the client's feelings; it may decrease trust and increase feelings of anger, helplessness, and hopelessness. An agitated, angry client will not be able to accept a logical explanation. Continued insistence may provoke increased anger and further loss of control.
A 17-year-old teenager is found to have leukemia. Which statements by the teenager reflect Piaget's cognitive processes associated with adolescence? Select all that apply. 1. "My smoking pot probably caused the leukemia." 2. "I'm going to do my best to fight this awful disease." 3. "Now I can't go to the prom because I have this stupid disease." 4. "I know I got sick because I've been causing a lot of problems at home." 5. "This illness is serious, but with treatment I think I have a chance to get better."
2. "I'm going to do my best to fight this awful disease." 3. "Now I can't go to the prom because I have this stupid disease." 5. "This illness is serious, but with treatment I think I have a chance to get better." At 17 years of age the adolescent is in the formal operational stage of cognitive development and therefore able to understand the seriousness of leukemia and the need for treatment. The statement also reflects an adolescent's preoccupation with peer socialization. At 2 to 7 years of age children are in the preoperational stage of cognitive development. They believe that external, unrelated, concrete phenomena cause illness. At 7 to 10 years of age children are in the concrete operational stage of cognitive development. Because of their egocentrism, they believe that they are responsible for situations such as illnesses and are being punished for bad behavior.
As a young male client is undergoing a dialysis treatment, the nurse notes that he is not talking with the other clients and that his eyes are lowered and his jaw clenched. The nurse says, "You look discouraged." The client replies, "I'm a bother. My wife would at least get some insurance money if I died." Which is the most therapeutic response by the nurse? 1. "I can understand how you feel." 2. "You feel so bad you wish you were dead." 3. "We all have days when we feel like that. Let's talk about your diet." 4. "I know it's hard. Don't let it get you down; you need time to adjust."
2. "You feel so bad you wish you were dead." The response "You feel so bad you wish you were dead" reflects the use of paraphrasing to restate the content of the client's statement; it encourages further communication. Feelings are personal and cannot really be understood by others; this is an ineffective attempt to empathize and refocuses the attention on the nurse. Noting that everyone has days like the client's negates the client's feelings and changes the subject; the client needs to talk, and this response cuts off communication. "I know it's hard. Don't let it get you down; you need time to adjust" negates the client's feelings, makes feelings impossible to share, may make the client feel guilty for the feelings, and tells the client how to behave and feel. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude.
A single mother of two children who recently lost her job because her company is downsizing comes to the emergency department. The woman does not know what to do and is in crisis. The most critical factor for the nurse to determine during crisis intervention is the client's: 1. Developmental history 2. Available situational supports 3. Underlying unconscious conflict 4. Willingness to restructure the personality
2. Available situational supports Personal internal strengths and supportive individuals are critical to the development of a crisis intervention plan; they must be explored with the client. Although developmental history information may be helpful, it is not essential; factors concerning the current situation are paramount. Identifying unconscious conflicts takes a long time and is inappropriate for crisis intervention. Willingness to restructure the personality is a goal of psychotherapy, not crisis intervention.
An older adult client with dementia of the Alzheimer type frequently switches from being pleasant and happy to being hostile and unhappy without apparent external cause. How can the nurse best care for this client? 1. By pointing out reality to the client 2. By providing nursing care when the client is receptive 3. By encouraging the client to talk about personal feelings 4. By avoiding caring for the client when hostility is being exhibited
2. By providing nursing care when the client is receptive Because these clients experience lability of mood, it is best to attempt to establish a relationship and give care when they are feeling receptive. Although the mood swings may be pointed out to the client, the client may still have limited contact with reality. Also, repeated attempts to reorient the client may elicit agitated behavior. Encouraging the client to talk about personal feelings may be of limited help; the client may be unable to do this. Avoiding caring for the hostile client rejects the client when the client needs the nurse most.
At a therapy group session a client tearfully tells the other members about being fired during the past week. How should the nurse respond? 1. By asking the client to look at the reasons that this may have occurred 2. By quietly observing how the group members respond to the client's news 3. By suggesting that the client check the "help wanted" advertisements in the local paper 4. By requesting that the group help identify how the client may have precipitated the dismissal
2. By quietly observing how the group members respond to the client's news The nurse facilitator should not intervene at this point; the client addressed the statement to the group, and the group's response should be encouraged. Asking the client to look at the reasons that this may have occurred could be viewed as an aggressive question and may make other members fearful of contributing. Suggesting that the client check the "help wanted" advertisements in the local paper denies the client's feelings. Requesting that the group help identify how the client may have precipitated the dismissal could be viewed as an attack and might make other members fearful of contributing because they could also be attacked.
A nurse is teaching a client who is ready to be discharged from a health care facility. What is most important for the nurse to emphasize? 1. Returning to regular activities 2. Continuing in an aftercare clinic 3. Phoning the unit when stress increases 4. Joining a group for people with similar problems
2. Continuing in an aftercare clinic Close follow-up and continued monitoring of behavior and emotional state are necessary to enable the client to maintain a positive behavioral change. Returning to regular activities will depend on what the client's regular activities were. Phoning the unit when stress increases will foster dependence, not independence. A support group may or may not be effective.
An injured child is brought to the emergency department by the parents. While interviewing the parents, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? Select all that apply. 1. Demonstrating concern for the injured child 2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 4. Asking questions about the injury and the child's prognosis 5. Giving an explanation of how the injury occurred that is not consistent with the injury
2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 5. Giving an explanation of how the injury occurred that is not consistent with the injury The child is often made the scapegoat in the situation; the parents blame the child because they have unrealistic expectations of the child. Discrepancies or inconsistencies in the history result from attempts to present a story that is not based in fact. Discrepancies between the parental explanation for the child's injuries and the physical findings or discrepancies in the history that each parent gives are common because the information that is being provided is not based in fact. Abusive parents usually do not ask questions about the injury or prognosis and demonstrate little or no interest in their child's well-being.
The nurse explores the possibility of joining Narcotics Anonymous (NA) with a client who has a history of drug abuse. What is a major reason that NA is helpful in treating addictive behavior? 1. More change will take place within the group 2. Group members are supportive of one another's problems 3. Group members share a common background and history 4. Addiction problems are dealt with more effectively in a group
2. Group members are supportive of one another's problems Although members of the group may become impatient with one another's problems at times, the group is usually supportive. Members share common goals, and the opportunity is available to test out new patterns of behavior. The rate and degree of change are individually based variables. People with addiction problems have varied backgrounds; the only common denominator may be drinking. Although many clients function well in a group, some clients cannot.
A hyperactive, acting-out 9-year-old boy is started on a behavior modification program in which tokens are given for acceptable behavior. When he begins to lose a game he is playing with other children, he begins to kick the other children under the table and call them names. What is the most appropriate behavior modification technique for the nurse to use? 1. Ignoring the child's behavior 2. Placing the child in a short time-out 3. Taking the child's daily allotment of tokens away 4. Engaging the child in a conversation about good sportsmanship
2. Placing the child in a short time-out Placing the child in a short time-out will be most successful because it provides a period in which the hyperactive child can regain control. It is neither a positive nor a negative reinforcement of acting-out behavior; it prevents injury to the other children. Ignoring the behavior may force the child to act out even more to gain attention. Taking the child's daily allotment of tokens away will not change the acting-out behavior. Engaging the child in a conversation about good sportsmanship rewards acting-out behavior by providing special attention.
A health care provider prescribes haloperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication? 1. Driving at night 2. Staying in the sun 3. Ingesting aged cheeses 4. Taking medications containing aspirin
2. Staying in the sun Haloperidol (Haldol) causes photosensitivity. Severe sunburn may occur on exposure to the sun. There is no known side effect that affects night driving. Aged cheeses would be prohibited if the client were taking a monoamine oxidase inhibitor; people taking psychotropic medications should avoid alcohol. Aspirin is not contraindicated.
A 23-year-old woman is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." The nurse concludes that the client is using: 1. Denial 2. Projection 3. Introjection 4. Sublimination
2. projection Projection is the process of attributing one's thoughts about one's self to others. Denial involves pushing out of awareness one's own thoughts, wishes, or feelings that are unacceptable to one's own self. Introjection is the process of taking in someone else's values, beliefs, attitudes, or qualities. Sublimation is the channeling of unacceptable thoughts or feelings into acceptable activities.
A nurse is writing a plan of care in the medical record of a paranoid male client who has unjustifiably accused his wife of having many extramarital affairs. An intermediate goal for this client is: 1. "The client will develop faith in his wife." 2. "The client will develop better self-control." 3. "The client will develop feelings of self-worth." 4. "The client will develop insight into his behavior."
3. "The client will develop feelings of self-worth." Helping the client develop feelings of self-worth will reduce the client's need to use pathological defenses. Faith in his wife, or the lack of thereof, is not the basic underlying problem, merely a symptom of it. Self-control, or the lack thereof, is not the basic underlying problem, merely a symptom of it. Insight can develop only when the need to use the defense is reduced; this is a long-term goal.
In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed? 1. Anxiolytics 2. Barbiturates 3. Antipsychotics 4. Antidepressants
3. Antipsychotics Antipsychotics are used to control the extrapyramidal (parkinsonian) symptoms that often develop as a side effect of antipsychotic therapy. There is no documented use of anxiolytics with antianxiety agents because they do not have extrapyramidal side effects. Barbiturates do not have extrapyramidal side effects that respond to these drugs. Antiparkinsonian drugs usually are not prescribed in conjunction with antidepressants because antidepressants do not cause parkinsonian symptoms.
A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? Select all that apply. 1. Lack of appetite 2. Depressed mood 3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others
3. Repetitive activities 4. Self-injurious behaviors 5. Lack of communication with others Perseveration (repetition of a behavior pattern) is commonly demonstrated by children with autism; this behavior provides comfort. Self-stimulation through injurious behavior is associated with autism. Children with autism have difficulty communicating or do not communicate at all with others. There may be unusual eating habits and food preferences, but lack of appetite is not associated with autism. Mood disorders are usually not associated with autism.
A male adolescent with the diagnosis of antisocial personality disorder spends a great deal of time with a female adolescent client on the unit. One day the nursing assistant enters the female client's room and finds them in bed together. The nursing assistant reports the incident to the nurse. The nurse should: 1. Lock the bedroom doors. 2. Assign the same staff member to observe both clients several times an hour. 3. Call a unit meeting to talk about sexual activity among the clients on the unit. 4. Arrange a discussion with both adolescents and follow mandatory reporting guidelines related to child abuse.
4. Arrange a discussion with both adolescents and follow mandatory reporting guidelines related to child abuse. Both clients must be included in a discussion about this behavior to make certain that limits on future behavior are understood by both of them, and the nurse must adhere to mandatory reporting guidelines; these actions also place controls on the manipulative behavior often used by clients with an antisocial personality disorder. Locking the bedroom doors will cause the clients to find another place to meet; the response sets no limits on behavior, only addresses the location of the behavior. Assigning the same staff member to watch both clients several times an hour does not set any limits on behavior and puts a staff member in the policing role. Although a unit meeting may be necessary, the nurse must respond directly to the clients involved in this situation. Topics
A client has been placed in seclusion as a result of uncontrolled physical aggression directed toward both the staff and another client. In light of the events set forth in the documentation, the nurse manager will initially: 1. Include the client in a discussion with staff regarding the managing of the events 2. Compliment the staff on managing the potentially dangerous situation so therapeutically 3. Question the use of a phenothiazine like promazine (Sparine) to manage aggressive behavior 4. Ask for details regarding how the staff attempted to manage the client before seclusion was initiated
4. Ask for details regarding how the staff attempted to manage the client before seclusion was initiated Documentation must include descriptions of attempted interventions that support that the seclusion was the least restrictive management alternative. The client would benefit from a discussion regarding the events leading up to and during the seclusion, and the staff may have managed the event successfully, but there is an omission in the documentation that requires attention and so has priority. Phenothiazines are used to assist in managing such behaviors and were prescribed and administered accord to a physician's order.
A nurse in a hospice program cares for clients and family members who are coping with imminent loss. What is the most important factor in predicting a person's potential reaction to grief? 1. Family interactions 2. Social support system 3. Emotional relationships 4. Earlier experiences with grief
4. Earlier experiences with grief How a person has handled grief in the past provides clues to how he or she will cope with grief in the present. Although family interactions, social support system, and emotional relationships are all important, none is the paramount predictor of a client's reaction to grief.
A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of: 1. Providing individual and family therapy 2. Using positive reinforcement to reduce guilt 3. Uncovering unconscious conflicts and fantasies 4. Manipulating the environment to benefit the client
4. Manipulating the environment to benefit the client Any aspect of the treatment environment can be used to benefit the client in milieu therapy. Individual and family therapy are separate treatment modalities, not part of milieu therapy. Using positive reinforcement to reduce guilt is part of behavioral modification, not milieu therapy. Uncovering unconscious conflicts and fantasies is part of psychoanalytical, not milieu, therapy.
A nurse is caring for a client who has been experiencing delusions. According to psychodynamic theory, delusions are: 1. A defense against anxiety 2. The result of magical thinking 3. Precipitated by external stimuli 4. Subconscious expressions of anger
1. A defense against anxiety Delusions are a way the unconscious defends the individual from real or imagined threats. Magical thinking is the belief that one's thoughts and behaviors can control situations and other people. For example, having bad thoughts about someone can cause that person to die. This type of thinking is found in young children but is pathological in adults. Illusions are false interpretations of actual external stimuli. Delusions are precipitated by feelings of anxiety, not anger.
An overweight 12-year-old boy is brought to the clinic by his parents. The child tells the nurse that he dislikes school because his classmates tease him about his weight. He reports, rather sadly, "I'm always last when they pick sides in gym." The most therapeutic response by the nurse is: 1. "That hurts a lot when you want to be liked." 2. "Have you tried letting them know how that makes you feel?" 3. "Not everybody's a great athlete, and you have other strengths." 4. "Won't it be great when you lose weight and can do better in gym?"
1. "That hurts a lot when you want to be liked." The response "That hurts a lot when you want to be liked" identifies the child's feelings and lets the child know that the nurse understands them. "Have you tried letting them know how that makes you feel?" is an unrealistic response; the child is probably unable to express his feelings to peers and there is no way to predict how his peers will respond. "Not everybody's a great athlete, and you have other strengths" denies the child's feelings and offers little support. "Won't it be great when you lose weight and can do better in gym?" is unrealistic, and the nurse cannot be sure that the child will lose weight or whether weight loss will improve the child's athletic ability.
