NCLEX -Silversteri -Psychosocial integrity

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need to always make the right decision

3 Rationale: Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. Options 1, 2, and 4 are incorrect.

The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client? 1. "If you didn't want our care, why did you come here?" 2. "Why are you being so difficult? I only want to help you." 3. "Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request." 4. "I will respect your feelings. I'll just leave this cup for you to collect your urine in. After breakfast, I will take more blood from you

3 Rationale: The therapeutic response "Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request," is the one that reflects the client's feelings and offers the client control of care.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. Which interpretation should the nurse make of this behavior? 1. The client needs to be admitted to the hospital. 2. The client needs to be referred to the psychiatrist as soon as possible. 3. The client requires further treatment and is not ready to be discharged. 4. The client is displaying typical behaviors that can occur during termination.

4. Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors. Typical behaviors include return of signs/symptoms of anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal behavior during the termination phase and does not necessarily indicate the need for hospitalization or treatment.

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development? 1. Egocentric judgment 2. Law-and-order orientation 3. Good boy-nice girl orientation 4. Social contract and legalistic orientation

Rationale: According to Kohlber's theory of moral development, during the 1. good boy-nice girl orientation, the child acts in a way to please other people. -Sharing is an example of this behavior. 2. A child in the egocentric judgment stage has no awareness of right or wrong. 3. A person in the law-and-order orientation stage obeys laws to maintain social order. During the social contract and legalistic orientation stage, a person is aware that others may have another set of values and opinions.

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? 1. A puzzle 2. Drawing 3. Checkers 4. Paint by number

Rationale: Concentration and memory are poor in a client with severe depression. When a client has a diagnosis of severe depression, 1. the nurse needs to provide activities that require little concentration. 2. Activities that have no right or wrong choices or decisions minimize opportunities for the client to put down himself or herself. 3. The nurse can also process the client's feelings by sitting with the client and talking or encouraging the client to write in a journal.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Giving advice, approval, or disapproval 6. Providing acknowledgment and feedback

1,2,4,6 Rationale: Some therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information and presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why, giving advice, and approving or disapproving are nontherapeutic.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? 1. Move the client next to the nurse's station. 2. Use a night light and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room.

2 Rationale: It is important to provide a consistent daily routine and a low-stimulation environment when the client is agitated and confused. Noise levels including a radio and television may add to the confusion and disorientation. Moving the client next to the nurses' station is not the initial intervention.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat 1. Open-ended questions and silence 2. Focusing on self-disclosure regarding food preferences 3. Stating the reasons that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition

ans: 1 Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their problem. Options 3 and 4 do not encourage the client to express feelings. The nurse should not offer opinions and should not state the reasons, but should encourage the client to identify the reasons for their behavior. Option 2 is not a client-centered intervention.

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Maintain an NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6. Provide reality orientation as appropriate.

1.3,4,6 Rationale: When the client is experiencing withdrawal from alcohol, the priority for care is 1. to prevent the client from harming himself or herself or others. 2. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. 3. The nurse would monitor the *vital signs* closely and report abnormal findings. 4. The nurse would frequently reorient the client to reality and would address hallucinations therapeutically. 5. Adequate nutritional and fluid intake must be maintained.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take? 1. Tell the client that this is not true and that we all have a purpose in life. 2. Remain with the client and sit in silence until the client verbalizes feelings. 3. Identify recent behaviors or accomplishments that demonstrate skill or ability. 4. Reassure the client that you know how the client is feeling and that things will get better

3 Rationale: ** Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. ** An effective plan of care is to provide successful experiences for the client that are challenging but will not be met with failure to enhance the client's personal self-esteem. ** Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of himself or herself. Options 1 and 4 offer false reassurances. Option 2 is not a therapeutic intervention with a depressed client.

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? 1. "I know you feel 'they are out to get you,' but it's not true." 2. "I can hear the voice, and she wants you to come to dinner." 3. "Sometimes people hear things or voices others can't hear." 4. "I talked to the voices you're hearing and they won't hurt you now."

3 Rationale: It is important for the nurse to reinforce reality with the client. Options 1, 2, and 4 do not reinforce reality but reinforce the hallucination that the voices are real.

The nurse in the primary health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client? 1. "These sensations are signs of a complication." 2. "These sensations probably will be permanent." 3. "These sensations lessen over several months and usually are gone after 1 year." 4. "It is nothing to worry about because women who have this type of surgery experience this problem."

3 Rationale: Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in women after mastectomy. 1. It is a result of injury to the nerves that provide sensation to the skin in those areas. 2. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve 1 year after surgery.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding? 1. Normal 2. Regressive 3. Indicative of the client's ambivalence 4. Evidence of the client's altered and distorted body image

4. Rationale: Altered or distorted body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and present with regressed behavior, the client's coping pattern relates to the basic issue of distorted body image. The client's behavior is not normal.

A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? Client Needs: Psychosocial Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Musculoskeletal Integrated Process: Nursing Process/Data Collection Priority Concepts: Pain, Sensory Perception Strategy(ies): Therapeutic Communication Techniques 1. "It is a normal response and indicates the presence of phantom limb pain." 2. "It is a normal response and indicates the presence of phantom limb sensation." 3. "It is an abnormal response and indicates that the client is in denial about the limb loss." 4. "It is an abnormal response and indicates that the client needs more psychological support."

ANS : 2 Rationale: Phantom limb sensations felt in the area of the amputated limb indicate a normal response. These can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area amputated. Whenever possible, clients should be prepared for these sensations. The client may also feel painful sensations in the amputated limb, called "phantom limb pain." The origin of the pain is less well understood, but the client should also be prepared for this whenever possible.

A client with Parkinson's disease is embarrassed about the symptoms of the disorder and is bored and lonely. The nurse should plan which approach as therapeutic in assisting the client to cope with the disease? 1. Plan only a few activities for the client during the day. 2. Cluster activities at the end of the day when the client is most bored. 3. Encourage and praise perseverance in exercising and performing ADL. 4. Assist the client with activities of daily living (ADL) as much as possible.

3 Rationale: The client with Parkinson's disease tends to become withdrawn and depressed and therefore should become an active participant in his or her own care to prevent this. Activities should be planned throughout the day to prevent daytime sleeping and boredom. The nurse gives the client encouragement and praises the client for perseverance. Activities such as exercise help prevent progression of the disease, and self-care improves self-esteem.

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3 Rationale: The nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 will assist with determining data related to the precipitating event that led to the crisis. Options 1 and 2 identify situational supports. Option 4 identifies personal coping skills.

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills? 1. "I will be more careful to make sure that my father's needs are met." 2. "Now that my father is moving into my home, I will need to change my ways." 3. "I feel better able to care for my father now that I know where to obtain assistance." 4. "I am so sorry and embarrassed that the abusive event occurred. It won't happen again."

3. Rationale: Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. 3. * Knowing where in the community*to turn for assistance with caring for aging family members can bring much-needed relief. Taking advantage of these alternatives is a positive alternative coping strategy, which many families use.

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which? 1. More than one assault 2. Refusing to admit the rape-trauma episode 3. Reexperiencing recollections of the trauma 4. Imagining the use of force in a sexual situation

3. Rationale: The major trauma of rape or sexual assault involves the victim's emotional reaction to being physically forced to do something against his or her will. The life-threatening nature of the crime and feelings of helplessness, loss of control, and the experiencing of self as an object of the perpetrator's rage combine to produce the victim's overpowering fear and stress. In this syndrome, which has been called "rape-trauma syndrome," the client reexperiences the trauma as evidenced by recurrent recollections of the event.

The nurse reviews the activity schedule for the day and determines that which supervised activity is the best option for the manic client? 1. Ping-pong 2. A paint-by-number activity 3. A brown bag lunch and a book review 4. A deep breathing and progressive relaxation group

ANS: 1 Rationale: The best supervised activity that the manic client could participate in is ping-pong. A person who is experiencing mania is overactive, full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow him or her to use excess energy but not endanger others during the process. 1. Ping-pong is an activity that will help expend the increased energy this client is experiencing and is a safe activity. 2. *Painting, reading, and progressive relaxation* are relatively *sedate* activities that require *concentration*, a quality that is lacking in the manic state. 3. Such activities may lead to increased frustration and anxiety for the client.

The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply. 1. Mutual learning 2. Increased feedback 3. Instilling a sense of belonging 4. Acutely manic clients can attend 5. Opportunity to practice individual roles 6. An opportunity to practice new skills in a relatively safe environment

ANS: 1,2,3,6 Rationale: Besides cost savings, advantages that a group format has over individual therapy include increased feedback, an opportunity to practice new skills in a relatively safe environment, mutual learning, and instilling a sense of belonging. Acutely manic clients should not attend these groups. Also, there is an opportunity to practice group roles and not individual ones.

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at naptime. 4. Hang mobiles with black-and-white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

Rationale: Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to also do so. Additional interventions include playing a music box, radio, or television or having a ticking clock or metronome nearby. Hanging a bright, shiny object within 20 cm to 25 cm of the infant's face in the midline and hanging mobiles with contrasting colors (e.g., black and white) provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk of nursing (bottle-mouth) caries. 1,4,5

A Hispanic-American mother brings her child to the clinic for an examination.Which is most important when gathering data about the child? 1. Avoiding eye contact 2. Using body language only 3. Avoiding speaking to the child 4. Touching the child during the examination

Rationale: In the Hispanic-American culture, eye behavior is significant. It is believed that the "bad/evil eye" can be given to a child if a person looks at and admires a child without touching the child. Therefore, touching the child during the examination is very important. Although avoiding eye contact indicates respect and attentiveness, this is not the most important intervention. Avoiding speaking to the child and using body language only are not therapeutic interventions. 4

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? 1. Maintain strict bed rest. 2. Monitor the vital signs every 2 hours. 3. Perform firm fundal massage every 2 hours. 4. Keep the client and her family members informed of her progress.

Rationale: Keeping the client and her family informed about her condition will help minimize fear and apprehension. Maintaining strict bed rest, monitoring vital signs, and performing fundal massage every 2 hours address physiological needs.. 4

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement? 1. "The technician is not going to hurt you but is going to help." 2. "Are you fearful and think that others may want to hurt you?" 3. "What makes you think that the technician wants to hurt you?" 4. "The technician will leave and come back later for your blood

Rationale: Option 2 is the only option that recognizes the client's need. This response helps the client focus on the emotion underlying the delusion but does not argue with it. If the nurse attempts to change the client's mind, the delusion may, in fact, be even more strongly held. Options 1, 3, and 4 do not focus on the client's feelings. 2.

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply. 1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 3. The authority of women is equal to that of men. 4. They remain secluded and avoid helping each other. 5. They use both traditional and alternative health care, such as healers, herbs, and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.

Rationale: The Amish society maintains a culture that is distinct and separate from the non-Amish society, but they are not completely secluded especially in their own community and Amish families help each other. Family life has a patriarchal structure, and although the roles of women are considered equally important to those of men, they are very unequal in terms of authority. Amish society rejects materialism and worldliness. Members value living simply, and they may choose to avoid technology, such as electricity and cars. They highly value responsibility, generosity, and helping others, and they often work as farmers, builders, quilters, and homemakers. The Amish use traditional health care and alternative health care, such as healers, herbs, and massage. They believe that health is a gift from God but that clean living and a balanced diet help maintain it. They may choose not to have health insurance and instead maintain mutual aid funds for those members who need help with medical costs. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment. At death, women are usually buried in their bridal dresses. ans: 1,2,5,6

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention? Client Needs: Psychosocial Integrity Cognitive Ability: Applying Content Area: Mental Health Integrated Process: Nursing Process/Implementation Priority Concepts: Communication, Mobility Strategy(ies): Subject 1. Ask direct questions to encourage talking. 2. Leave the client alone and intermittently check on them. 3. Sit beside the client in silence and verbalize occasional open-ended questions. 4. Take the client into the dayroom with other clients so they can help watch him.

3 Rationale: Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond. The nurse would not leave the client alone. Fortunately, with pharmacotherapy and improved individual management, severe catatonic symptoms rarely occur. Option 4 relies on other clients to care for this one, which is an inappropriate expectation. Asking direct questions of this client is not therapeutic. Option 3 is the best action because it provides for client supervision and communication as appropriate.

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record

Rationale: The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret. 2

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? 1. Identifying the client's ability to function 2. Identifying the client's potential for self-harm 3. Inquiring about the client's feelings that may affect coping 4. Inquiring about the client's perception of the cause of the neighbor's death

Rationale: The client must first deal with feelings and negative responses before the client is able to work through the meaning of the crisis. Option 3 pertains directly to the client's feelings. Options 1, 2, and 4 do not directly address the client's feelings.

The nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child? 1. Blocks 2. A music video 3. A 10-piece puzzle 4. Large picture books

answer : 3 Rationale: In the preschooler, play is simple and imaginative, and it includes activities 1. such as dressing up, paints, crayons, and simple board and card games. 1-1/ Ten-piece puzzles are also appropriate and aid with fine motor development. 2. Blocks are most appropriate for the toddler. 3. A music video is most appropriate for the adolescent. 4. Large picture books are most appropriate for the *infant*

The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all t 1. Outlandish behaviors 2. Takes a shower every other day 3. Purposeless arousal and movement 4. Occasional episodes of mild depression 5. Grandiose delusions of being King Arthur 6. Incessant talking that includes sexual innuendos

. 1.3.5.6 Rationale: Mania is a mood characterized by 1. excitement, 2. euphoria, 3. hyperactivity, 4. excessive energy, 5. decreased need for sleep, 6. and impaired ability to concentrate or 7. complete a single train of thought. It is a period when the 8. *mood is predominantly elevated* , *expansive*, or *irritable*. Taking a shower every other day and occasional periods of depression are not symptomatic of mania.

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply. Client Needs: Psychosocial Integrity Cognitive Ability: Analyzing Content Area: Mental Health Integrated Process: Nursing Process/Planning Priority Concepts: Caregiving, Collaboration Strategy(ies): Subject 1. Promoting self-care and independence 2. Acting as an intermediary between the client and family 3. Accompanying the client to all group therapy sessions 4. Facilitating communication of distressing thoughts and feelings 5. Helping clients examine self-defeating behaviors and test alternatives 6. Assisting clients with problem solving to help facilitate activities of daily living

1,4,5,6 Rationale: A therapeutic nurse-client relationship may be loosely defined, but specific goals and functions must include facilitating communication of distressing thoughts and feelings, assisting clients with problem solving to help facilitate activities of daily living, helping clients examine self-defeating behaviors and test alternatives, and promoting self-care and independence. Acting as an intermediary between the client and family and accompanying the client to all group therapy sessions are not necessary or reasonable goals and functions in the nurse-client relationship.

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns? 1. Tell the client that preoperative fear is normal. 2. Explain all nursing care and possible discomfort that may result. 3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery.

Rationale: The client is concerned about having surgery and needs to discuss it. This will offer the client the opportunity to verbalize his or her current and specific understanding. Explanations should begin with the information that the client knows. Option 1 is a block to communication and minimizes the client's feelings. Giving unsolicited explanations may produce additional anxiety and not address the real concerns of the client. 3

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurs

Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate. 3,5.6

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event? Client Needs: Psychosocial Integrity Cognitive Ability: Evaluating Content Area: Mental Health Integrated Process: Nursing Process/Data Collection Priority Concepts: Anxiety, Coping Strategy(ies): Comparable or Alike Options, Subject 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2. Rationale: A situational crisis is associated with a life event. 1. External situations that could precipitate a situational crisis include *I) loss or change of a job*, *II) the death of a loved one*, *III) abortion*, *IV) change in financial status*, *V) divorce* *VI) severe illness*. Options 1, 3, and 4 identify *adventitious crises*. An adventitious crisis relates to I) a crisis, disaster, or event that is not a part of everyday life, is unplanned, and is accidental.

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? 1. Watch the behavior escalate before intervening. 2. Attempt to talk with the client to de-escalate the behavior. 3. Offer to take the client to an examination room until he or she can be treated. 4. Inform the client that he or she will be asked to leave if the behavior continues.

ANS: 3 Rationale: Safety of the client, other clients, and staff is of prime concern. Option 3 is in effect an isolation technique that allows for separation from others and provides for a less stimulating environment where the client can maintain dignity. When dealing with an impaired individual, trying to talk may be out of the question. Waiting to intervene could cause the client to become even more agitated and a threat to others. Option 4 would only further aggravate an already agitated individual.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Follow through about the consequences of behavior in a nonpunitive manner. 3. Ensure that the client knows that he or she is not in charge of the nursing unit. 4. Assist the client with developing a means of setting limits on personal behavior. 5. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

1.2.4.6 Rationale: Interventions for dealing with the client exhibiting manipulative behavior include 1. setting clear, consistent, and enforceable limits on manipulative behaviors; 2. being clear with the client regarding the consequences of exceeding limits set; f ollowing through with the consequences in a nonpunitive manner; and assisting the client with developing a means for setting limits on personal behaviors. 3. *Enforcing rules and informing* the client that he or she will not be allowed to attend therapy groups are *violations* of a client's rights. 4. Ensuring that the client knows that he or she is not in charge of the nursing unit is inappropriate; power struggles need to be avoided.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? 1. The mother should restrict the daughter's socializing time with her friends. 2. The mother should restrict the amount of chocolate and caffeine products in the home. 3. The mother should keep her daughter out of school until she can adjust to the school environment. 4. The mother should consider taking time off of work to help her daughter readjust to the home environment.

ANS: 2 Rationale: Clients with anxiety disorder should abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Options 1 and 3 are unreasonable and are an unhealthy approach. It may not be realistic for a family member to take time away from work.

An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply 1. Is it in the best interest of society? 2. Is it covered by the client's insurance? 3. Does its use violate the client's rights? 4. Is this therapy in the best interest of the client? 5. How many days before positive results are seen? 6. Has the client's family given permission for this therapy?

1,3,4 .Rationale: Aversion therapy, also known as aversion conditioning or negative reinforcement, is a technique used to change behavior. In this therapy, a stimulus attractive to the client is paired with an unpleasant event in hopes of associating the stimulus with negative properties. Before beginning this therapy, the following questions must be answered by the therapist, treatment team, or society: (1) Is the therapy in the best interest of society? (2) Does it violate the client's rights? (3) Is it in the best interest of the client?

The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child? 1. The child is withdrawn. 2. The child is upset with the parents. 3. The child is exhibiting a normal pattern. 4. The child has adjusted to the hospitalized setting.

Rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home. The parents of hospitalized toddlers are frequently distressed by such behavior. The toddler normally engages in parallel play and plays alongside (but not with) other children. Options 1, 2, and 4 are incorrect. 3