NUR 221 PrepU Psychiatric and Mental Health Nursing.

A nurse is coordinating outpatient care for a 38-year-old client who is homeless and has a history of chronic schizophrenia. Which one intervention would be best for the nurse to suggest for this client? A. Job planning workshops at a local community college. B. A life and social skills group. C. A mediator between the client and the client's family. D. Solitary games and activities.

B. A life and social skills group Rationale: A client with a history of chronic schizophrenia is in need of learning activities of daily living, communication, and other social skill deficits caused by their chronic illness. A job-planning workshop is outside the client's capabilities at this time. The need for a family mediator is not indicated. Solitary games and activities would not build the social structure and skills necessary for this client's progress.

Which intervention is essential when caring for a client who is experiencing delirium? A. Manipulating the environment to increase orientation. B. Identifying the underlying causative condition or illness. C. Decreasing or discontinuing all previously prescribed medications. D. Controlling behavioral symptoms with low-dose psychotropics.

B. Identifying the underlying causative condition or illness. Rationale: The most critical aspect of caring for the client with delirium is to institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.

A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest? A. Dystonia. B. Neuroleptic malignant syndrome. C. Tardive dyskinesia. D. Akathisia.

B. Neuroleptic malignant syndrome. Rationale: The client's signs and symptoms suggest neuroleptic malignant syndrome, a life-threatening reaction to neuroleptic medication that requires immediate treatment. Tardive dyskinesia causes involuntary movements of the tongue; mouth; and muscles of the face, arms, and legs. Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.

A registered nurse is caring for a group of clients on a psychiatric unit. Which task can the nurse delegate to the licensed practical/vocational nurse? A. Assessing a client who is withdrawing from alcohol and methamphetamine. B. Redressing lacerations on the wrists of a client who attempted suicide. C. Preforming a suicide assessment on a client recently admitted with depression. D. Educating a client on the newly prescribed escitalopram and zolpidem.

B. Redressing lacerations on the wrists of a client who attempted suicide. Rationale: A licensed practical/vocational nurse (LPN/LVN) can take care of stable clients with expected outcomes. LPN/LVNs can differentiate between normal and abnormal findings. A dressing change is an appropriate task to delegate to the LPN/LVN. A registered nurse (RN) must complete any task that requires nursing judgment. Providing education and assessing requires an RN.

The multidisciplinary team is meeting for the morning rounds. While discussing the care plan for a 45-year-old client experiencing command auditory hallucinations, which would be the priority assessment finding for the nurse to report to the team? A. The client missed breakfast and lunch meals in the community room. B. The client has refused to perform daily hygiene tasks. C. The client is pacing and mumbling that they don't want to hurt anyone. D. The client is not speaking or communicating with the staff.

C. The client is pacing and mumbling that they don't want to hurt anyone. Rationale: Maintaining a safe environment is the priority for care. The client pacing and mumbling is a risk for violence, self-directed or directed toward others. The other clients described do not pose a risk to staff or others. The key word here is "priority," and this client has a potential or risk for harm to self or others.

A young woman comes to the mental health clinic for routine medication follow-up. She has been married for 2 years and reports that she and her husband are ready to start a family. The client has a diagnosis of bipolar disorder and has been well managed with divalproex for at least 3 years. What is the most essential counsel for the nurse to give? A. "Learning to reduce stress now is important to reduce your chances of developing postpartum depression." B. "Pay careful attention to eating healthy from this point on to maximize the health of both mother and baby." C. "Schedule an appointment for a complete gynecological exam if you haven't had one in the past year." D. "Check with your health care provider as divalproex carries an increased risk for birth defects."

D. "Check with your health care provider as divalproex carries an increased risk for birth defects." Rationale: All of these options need to be addressed. However, it is vital that this young woman receive counseling about the serious birth defects that have an increased incidence with the taking of divalproex during the first trimester of pregnancy. These problems include craniofacial abnormalities (cleft palate), organ malformations (holes in the heart and urinary tract problems), limb deficiencies, and developmental delays. The chances of preeclampsia and premature labor are also increased.

A client admitted to the nursing unit with bipolar disorder, manic phase, is accompanied by his wife. The wife states that her husband has been overly energetic and happy, talking constantly, purchasing many unneeded items, and sleeping about 4 hours a night for the past 5 days. When completing the client's daily assessment, the nurse should be especially alert for which finding? A. Vertigo. B. Gastritis. C. Bradycardia. D. Exhaustion.

D. Exhaustion. Rationale: The client in the manic phase experiences insomnia, as evidenced by his sleeping only for about 4 hours a night for the past 5 days. The client experiencing an acute manic episode is not capable of judging the need for sleep. Therefore, the nurse should assess the amount of rest the client is receiving daily to prevent exhaustion. The development of vertigo, gastritis, or bradycardia typically does not result from acute mania.

A client with recurrent, endogenous depression has been hospitalized on the psychiatric unit for 3 days. He exhibits psychomotor retardation, anhedonia, indecision, and suicidal thoughts. Which goal of nursing care should have highest priority? A. Maintain a calm environment. B. Provide for contact between the client and his wife. C. Reassure the client of his worthiness. D. Use measures to protect the client from harming himself.

D. Use measures to protect the client from harming himself. Rationale: Whenever a client is suicidal, steps must be taken to prevent the client from self-harm. Other goals of care are less important than being sure the client does not carry out the threat of suicide. All suicide threats should be taken seriously, and proper precautions should be taken to protect the client from self-harm.Providing for contact between the client and his wife is not the highest priority, may not be therapeutic, and would require the client's consent.Reassuring the client of his worthiness is not as high a priority as is his safety. Furthermore, reassurance is not helpful because logical explanation will not change the client's negative thinking. Interventions designed to increase the client's self-esteem are important but are not the highest priority.Maintaining a calm environment is helpful but is not a priority.

A client diagnosed with a cognitive disorder is showing signs of confusion, short-term memory loss, and a short attention span. Which therapy group would be best suited for this client? A. Medication management. B. Reality orientation. C. Insight oriented. D. Problem solving.

B. Reality orientation. Rationale: Because the client has confusion, short-term memory loss, and a short attention span, a reality-orientation group is recommended to help the client maintain an optimal level of functioning, decrease isolation, and increase self-esteem. Focus is on the "here and now" and provides reality testing, structure, and social support.A client with a cognitive disorder is unlikely to benefit from an insight-oriented group, where the focus is on role relationships.Short-term memory loss and confusion interfere with the ability to learn about medication management and the ability to describe and solve problems.

After several months of taking olanzapine, the client reports that he is no longer hearing voices of any kind. Which statement would confirm that the client is developing insight into his illness? A. "That olanzapine is the best medicine I have ever had." B. "I think I may be able to get a little part-time job soon." C. "I didn't realize how sick I could get from a chemical brain imbalance." D. "My mom is proud of me for staying on my medicines."

C. "I didn't realize how sick I could get from a chemical brain imbalance." Rationale: Insight into the illness is demonstrated when the client recognizes the relationship between the chemical imbalance and his illness and symptoms. Stating that the olanzapine is the best medicine or that the client's mother is proud of him for staying on his medicines reflects awareness about the effect of medications and the need for compliance. Stating that he may be able to get a part-time job indicates an awareness of his increased capacity for work.

A client with paranoid schizophrenia is recently admitted to the psychiatric unit. The client is hesitant to eat the food provided and states "I know they poisoned this food before putting it on my plate." What is the priority nursing action? A. Have the family bring in the client's favorite food. B. Ask the client which poison is inside the food. C. Request a cannabinoid appetite enhance from the provider. D. Bring the client food in unopened containers.

D. Bring the client food in unopened containers. Rationale: Clients with paranoid schizophrenia are often concerned about the safety of their food. Bringing the client food in unopened containers may ease this paranoia. Because the client was recently admitted to the unit, requesting an appetite enhancer from the health care provider is not the priority action at this time. The nurse should attempt other strategies first. Having the family bring in food is passing the buck. The nurse should seek out strategies to help this client situation. Asking the client which poison is in the food is exploring the paranoia, which is not an appropriate nursing action.

A client hospitalized for depression remains extremely depressed and expresses increasing suicidal ideation to the client's primary nurse. What should be the nurse's priority intervention? A. Encouraging the client to express their feelings of isolation. B. Ensuring that the client is not permitted to use anything that would be potentially dangerous. C. Exploring the client's feelings of grief and loss. D. Encouraging attendance at group cognitive-behavioral therapy on the unit.

B. Ensuring that the client is not permitted to use anything that would be potentially dangerous. Rationale: Although grief, loss, and isolation are impacting the client's depressed state, the priority intervention is to prevent the client from self harm. All of the interventions listed are appropriate, but ensuring safety from potential danger is the priority.

A nurse is caring for an elderly client in a long-term care facility. This client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first? A. Referring the client to a mental health professional. B. Removing items that the client could use in a suicide attempt. C. Communicating a nonjudgmental attitude. D. Setting aside time to listen to the client.

B. Removing items that the client could use in a suicide attempt. Rationale: The nurse's first responsibility is to protect the client from self-harm. Listening and being nonjudgmental are important elements of the nurse's communication with the client but aren't immediate priorities. After the client's safety has been established, the client would benefit from a referral to a mental health professional.

The nurse is about to administer lithium carbonate to a client with bipolar disorder in a mania state. What is the nurse's action after assessing the client's lithium level to be 1.0 mEq/L (mmol/L)? A. Administer the lithium carbonate. B. Hold the lithium carbonate. C. Repeat the lithium level. D. Notify the healthcare provider.

A. Administer the lithium carbonate. Rationale: To treat acute mania, the client's serum lithium level should be between 0.6 and 1.2 mEq/L (mmol/L). The serum lithium level shouldn't exceed 2 mEq/L (mmol/L). The nurse must monitor the client continuously for signs and symptoms of lithium toxicity, such as diarrhea, vomiting, drowsiness, muscular weakness, ataxia, stupor, and lethargy. The nurse must also keep in mind that even a normal lithium level can become toxic. Notifying the healthcare provider of the normal level with a client in mania is not appropriate. There are no signs and symptoms of toxicity, so the medication should not be held. There is no reason to repeat the level.

A nurse should intervene when a depressed client makes which statement? A. "Television doesn't interest me anymore." B. "Nobody cares about me." C. "I've gained some weight." D. "I have trouble falling asleep."

B. "Nobody cares about me." Rationale: The client's statement "Nobody cares about me" may indicate the presence of suicidal ideation. Major themes associated with suicide are loneliness, abandonment, psychic pain, loss, helplessness, and hopelessness. The nurse should ask the client directly about suicidal thoughts and plans. Sleep disturbances are a sign that the depression still exists, but they do not indicate suicidal ideation. Thus, the statement regarding difficulty falling asleep does not require immediate intervention by the nurse. Change in appetite and decreased interest in usual activities are common symptoms of depressed mood.

The client with major depression and suicidal ideation has been taking bupropion 100 mg PO 3 times daily for 5 days. Assessment reveals the client to be somewhat less withdrawn, able to perform activities of daily living with minimal assistance, and eating 50% of each meal. At this time, the nurse should monitor the client specifically for which behavior? A. Visual disturbances. B. Increased libido. C. Suicide attempt. D. Seizure activity.

C. Suicide attempt. Rationale: The nurse must monitor the client for a suicide attempt at this time when the client is starting to feel better because the depressed client may now have enough energy to carry out an attempt. Bupropion inhibits dopamine reuptake; it is an activating antidepressant and could cause agitation. Although bupropion lowers the seizure threshold, especially at doses greater than 450 mg/day, and visual disturbances and increased libido are possible adverse effects, the nurse must closely monitor the client for a suicide attempt. As the client with major depression begins to feel better, the client may have enough energy to carry out an attempt.

Which question should the nurse ask to best determine the seriousness of a client's suicidal ideation? A. "Does your family know you're here?" B. "How are you planning on harming yourself?" C. "How long have you been thinking about harming yourself?" D. "Have you made out a will?"

B. "How are you planning on harming yourself?" Rationale: To determine the seriousness of the suicidal ideation, the nurse must ask directly about the intent and the plan. The nurse needs to determine whether the client has a concrete plan and will act on his or her thoughts. Then, the nurse assesses the lethality of the method, immediacy, means to complete suicide, and possibility of rescue. Asking the client "Have you made out a will?" is not as important and does not necessarily imply that he or she is planning self-harm. Many individuals have made out wills without planning self-harm. Asking the client "Does your family know you're here?" provides no information about the client's intent and plan. Asking the client "How long have you been thinking about harming yourself?" does provide information that the client is thinking about self-harm. However, it does not provide information about the client's immediate intent and plan.

A nurse is caring for a client with schizophrenia who states, "I can't handle the voices anymore! It's over! I've done all I can." Which statement by the nurse is best? A. "Are you thinking of hurting yourself?" B. "What do you mean by that statement?" C. "Have you felt like this before?" D. "Have you been taking your medications?"

A. "Are you thinking of hurting yourself?" Rationale: Risk of suicide is greater in patients with a serious illness, including mental or emotional disorders. The nurse should recognize the client's statement as a warning for possible self-harm. With this concern, the nurse should ask the client a yes/no question regarding self-harm. Using an open-ended question is therapeutic, but assessing the risk of self-harm requires a more direct approach. Asking about medications or past feelings should wait until after the risk for self-harm is determined.

The nurse is caring for a client taking risperidone 2 mg daily. It is most important for the nurse to follow up on which client statement? A. "I take my medication every morning before breakfast." B. "I'm constantly sick and feel like I always have a fever." C. "Sometimes I get dizzy if I stand up quickly." D. "I've been exercising regularly and lost 5 pounds."

B. "I'm constantly sick and feel like I always have a fever." Rationale: A major adverse reaction of risperidone is agranulocytosis. Therefore, it is a priority for the nurse to follow up if the client reports constantly being sick. Risperidone can be given without regard to meals; taking it at the same time every day is encouraged. Clients are encouraged to exercise regularly; the nurse should monitor the client taking risperidone for weight gain. Orthostatic hypotension is a common side effect of risperidone, and the nurse should follow up; however, the priority concern is agranulocytosis. Additionally, the client indicates experiencing dizziness "sometimes" but the feeling sick "constantly."

The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine, 10 mg twice a day. The healthcare provider prescribes a selective serotonin reuptake inhibitor (SSRI), paroxetine 20 mg to be given every morning. What action should the nurse take? A. Give the medication as prescribed. B. Question the health care provider about the prescription. C. Question the dosage prescribed. D. Ask the health care provider to prescribe benztropine for adverse effects.

B. Question the health care provider about the prescription. Rationale: The nurse should question the health care provider about the prescription because the client who has been taking an MAOI such as phenelzine must wait 14 days after stopping the MAOI before starting an SSRI such as paroxetine. Serotonin syndrome, a potentially lethal consequence, can occur when combining an MAOI and an SSRI. Serotonin syndrome is characterized by hyperreflexia, hyperthermia, myoclonus, and other symptoms similar to neuroleptic malignant syndrome. Giving the medication as prescribed can result in serious adverse consequences, as described previously. The dosage is accurate. Benztropine is not given with an SSRI; it is an antiparkinsonian agent usually prescribed for the adverse effects of antipsychotic medication.

The child of a client with Alzheimer's disease reports feeling guilty for wishing, at times, that the parent would die. What is the nurse's best response? A. "Everyone in your situation must feel like that at times." B. "There is no reason to feel guilty. You've given your parent excellent care." C. "Being responsible for your parent's care must be difficult." D. "Perhaps you should consider putting your parent in a nursing home."

C. "Being responsible for your parent's care must be difficult." Rationale: This response directly addresses the child's feelings and encourages the child to talk about them. The other responses aren't therapeutic. Saying that everyone must feel that way at times is a cliché; it doesn't reflect this particular family member's situation. Suggesting a nursing home may make the child feel more guilty. Saying there is no reason to feel guilty suggests that the child's feelings aren't valid.

Which statement indicates increased insight by the client about her newly diagnosed paranoid schizophrenia being stabilized on medications? A. "Since I feel better, I know I can restart school next week." B. "The voices go away when I tell them to, except if I'm really nervous." C. "I'd feel better if I knew there wasn't poison in my food." D. "Now that the voices are gone, I can decrease my medicines."

B. "The voices go away when I tell them to, except if I'm really nervous." Rationale: The statement about the voices occurring if the client is nervous reflects awareness that stress and anxiety can increase the positive symptoms of schizophrenia. Decreasing the medications because the voices are gone reveals a lack of awareness about the need for the medications to control the client's symptoms. Stating that there is still poison in her food demonstrates a lack of insight into the client's delusions. Restarting school in a week reflects an unrealistic expectation for a client who is newly diagnosed and being stabilized on medications.

The nurse has given a client with schizophrenia discharge instructions. Which statement by the client would indicate understanding of the teaching? Select all that apply. A. "Anxiety makes it more likely I will hear voices." B. "Possible bad effects from the pills only last a few days." C. "If I am having trouble sleeping or eating, I will call the mental health center." D. "I can't drink even one or two beers." E. "I can skip a pill when I am feeling too tired from them."

A. "Anxiety makes it more likely I will hear voices." C. "If I am having trouble sleeping or eating, I will call the mental health center." D. "I can't drink even one or two beers." Rationale: In schizophrenia, the client and the family need to receive teaching in order to manage the illness and to prevent a relapse. In the initial phase of the illness, teaching will need to be continued at the health care provider's office or the local mental health center. The client needs to understand that difficulty with eating or sleeping or increased anxiety can increase symptoms. Alcohol even in small amounts depresses the CNS and can interfere with pharmacological actions of medications. Reactions to the client's medications like tardive dyskinesia, dystonia, or the other extra-pyramidal side effects may take longer periods of time. The client needs to report any unusual symptoms.

After the nurse has taught the client who is being discharged on lithium about the drug, which client statement would indicate that the teaching has been successful? A. "I'll call my health care provider right away for any vomiting or muscle weakness." B. "If I forget a dose, I can double the dose the next time I take it." C. "I need to restrict eating any foods that contain salt." D. "I should increase my fluid intake to five to six 8-oz glasses (1,200 to 1,420 mL) of water each day."

A. "I'll call my health care provider right away for any vomiting or muscle weakness." Rationale: A client receiving lithium is at risk for toxicity, evidenced by diarrhea, vomiting, ataxia, tremor, drowsiness, lack of coordination, or muscle weakness. Thus, the client's statement about notifying the health care provider about possible signs of lithium toxicity reflects accurate knowledge about the drug and successful teaching. The other client statements demonstrate unsuccessful teaching. Eliminating salt from the diet, doubling the dose to make up for a missed dose, and drinking fewer than ten to twelve 8-oz glasses (2,400 to 2,840 mL) of water per day can all lead to lithium toxicity.

A student nurse has observed the behavior of a client who was admitted to an inpatient psychiatric unit. The client attempts to get the student's attention during the shift and during lunch tries to regain the nurse's attention by shouting, "You're just like my mother. You pay attention to everyone else but me!" Which of the following would indicate to the nursing instructor that the student correctly identified the client's behavior? A. A demonstration of transference. B. Evidence that the nursing staff is failing to meet the client's needs. C. Evidence of family abuse. D. A demonstration of resistance to therapy.

A. A demonstration of transference. Rationale: The unconscious transfer of qualities originally associated with another relationship to a nurse or therapist is referred to as transference. Quite often these qualities are those of a parent, family member, or authority figure, and may provoke responses that are not appropriate to the new situation to which they are ascribed. Resistance is also unconscious, but has to do with the discomfort over the possible change that may result from therapy. Defense mechanisms and transference are expected aspects of therapy and arise in the client themselves, not because the nurse is failing to meet client needs or as a result of previous family abuse.

A 32-year-old female client is admitted for treatment of postpartum depression. Select the four (4) strategies the nurse will take when assessing the client's feelings about the condition. A. Listen when the client is speaking. B. Reassure the client that the hospitalization will be brief. C. Develop a rapport with the client. D. Relay a similar situation that occurred with a friend. E. Explore the client's perception of the condition. F. Respond when the client's roommate interrupts the conversation. G. Use open-ended questions.

A. Listen when the client is speaking. C. Develop a rapport with the client. E. Explore the client's perception of the condition. G. Use open-ended questions. Rationale: Effective communication is essential to improve health outcomes. It is through communication that the nurse will learn how the client is responding to a health condition. Open-ended questions provide the greatest opportunity for the client to respond. The first step in the nurse-client relationship is developing a rapport with the client. This communicates trust and reduces the client's anxiety when discussing care needs.Active listening is an essential part of communication. Hearing what the client says about the condition helps determine care needs. Exploring the client's perception of the condition is essential. It is through this action that the nurse learns how the condition is affecting the client's mental, emotional, and physical status. Discussing, or comparing, the client's condition to someone else is not supportive and does not help determine the client's response to the illness. False reassurance is a barrier to communication. This will also not help learn the client's response to the illness. The environment should support the communication process. The nurse should focus on the client and not be distracted or need to address another client's needs.

The nurse is working with a client with depression and suicidal ideation. The nurse heard the client say, "I am disappointed because thought I'd be feeling better by now since I started medication and therapy a week ago." What would be the primary nurse therapist's most therapeutic response? A. "Try to be patient and hopeful. The medication takes several weeks to reach a therapeutic level." B. "It takes time and can be frustrating to experience the physical and emotional symptoms of depression all while you learn more about yourself and try new strategies as your medication takes effect." C. "I'm glad you are taking ownership of your problems and trying to see how you can move things along for your recovery." D. "It probably took a while for you to get into this state, and you can't expect for things to get better overnight."

B. "It takes time and can be frustrating to experience the physical and emotional symptoms of depression all while you learn more about yourself and try new strategies as your medication takes effect." Rationale: The validation of the client's experience, alongside some realistic information giving about the biologic, psychological, and social components of the illness, is the most therapeutic response. Responding casually that "it took a while to get into this state" assumes some sort of personal responsibility that is not complete, as does suggesting that the nurse is pleased the client is taking ownership and can move recovery along. This does not adequately address the biologic basis of the illness. Suggesting the client simply needs to wait for the medication to work, however, fails to recognize the psychological and social components of the illness and suggests a passive view of recovery.

After the nurse teaches a client with bipolar disorder about lithium therapy, which client statement indicates the need for additional teaching? A. "I should drink about 8 to 10 8-oz (240 to 300 mL) glasses of water each day." B. "It's okay to double my next dose of lithium if I forget a dose." C. "It's important to keep using a regular amount of salt in my diet." D. "I need to take my medicine at the same time each day."

B. "It's okay to double my next dose of lithium if I forget a dose." Rationale: The therapeutic and toxic range of lithium is very narrow. If the client forgets to take a scheduled dose of lithium, the client needs to wait until the next scheduled time to take it because taking twice the amount of lithium can cause lithium toxicity. The client needs to maintain a regular diet and regular salt intake. Lithium and sodium are eliminated from the body through the kidneys. An increase in salt intake leads to decreased plasma lithium levels because lithium is excreted more rapidly. A decrease in salt intake leads to increased plasma lithium levels. The client needs to drink 8 to 10 8-oz (240 to 300 mL) glasses of water daily to maintain fluid balance and decrease thirst. Decreased water intake can lead to an increase in the lithium level and consequently a risk of toxicity. Lithium must be taken on a regular basis at the same time each day to ensure maximum therapeutic effect.

A client with a major depressive disorder comes to the mental health clinic for a follow-up visit. The client has been taking escitalopram for 3 months and tells the nurse that he is feeling "like my old self again." Now the client wants to stop taking medication. "I don't want to be dependent on meds like my father." What is the nurse's best initial response to him? A. "After another 3 months of stability, it might be safe for you to go off the escitalopram." B. "Research indicates that people who have had two major depressive episodes have a 70% chance of having a third episode." C. "After two significant episodes, you'll need to take an antidepressant indefinitely." D. "It's likely that you can learn to manage your depression with a regular exercise regime and a healthy diet."

B. "Research indicates that people who have had two major depressive episodes have a 70% chance of having a third episode." Rationale: After two episodes of a major depressive disorder, the likelihood of a third episode increases to 70%. This information would be useful to convey prior to discussing the importance of continuing his medication. This client also has a family history of depression. A healthy diet and exercise are very significant adjuncts to the therapeutic plan but may not be sufficient as stand-alone therapy.

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is most likely the occurrence that is disturbing to this client? A. A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom. B. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. C. There are three staff members and one health care provider (HCP) in the nurse's station working on charting. D. There is only one other client in the dayroom; the rest are in a group session in another room.

B. A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. Rationale: The tape and television are competing, even conflicting, stimuli. Crime events portrayed on television could be misperceived as a real threat to the client. A low number of clients and the presence of a few staff members quietly working are less intense stimuli for the client and not likely to be disturbing.

The client who has been taking venlafaxine 25 mg PO three times a day for the past 2 days states, "This medicine isn't doing me any good. I'm still so depressed." Which response by the nurse is most appropriate? A. "Perhaps we'll need to increase your dose." B. "Let's wait a few days and see how you feel." C. "It takes about 2 to 4 weeks to receive the full effects." D. "It's too soon to tell if your medication will help you."

C. "It takes about 2 to 4 weeks to receive the full effects." Rationale: The client needs to be informed of the time lag involved with antidepressant therapy. Although improvement in the client's symptoms will occur gradually over the course of 1 to 2 weeks, typically it takes 2 to 4 weeks to get the full effects of the medication. This information will help the client be compliant with medication and will also help in decreasing any anxiety the client has about not feeling better. The client's dose may not need to be increased; it is too early to determine the full effectiveness of the drug. Additionally, such a statement may increase the client's anxiety and diminish self-worth. Telling the client to wait a few days discounts the client's feelings and is inappropriate. Although it is too soon to tell whether the medication will be effective, telling this to the client may cause the client undue distress. This statement is somewhat negative because it is possible that the medication will not be effective, possibly further compounding the client's anxiety about not feeling better.

A nurse observes a male client who is hyperactive and intrusive sitting very close to a female client with his arm around her shoulders. The nurse hears the male client tell a sexually explicit joke. The nurse approaches the client and asks him to walk down the hallway. Which statement by the nurse should benefit the client? A. "She won't want to be around you with that kind of talk." B. "I think a time-out in your room would be appropriate now." C. "Telling sexual jokes and touching others is not permitted here." D. "You need to be careful about what you say to other people."

C. "Telling sexual jokes and touching others is not permitted here." Rationale: The nurse clearly informs the client about behavior that is unacceptable on the unit, such as voicing jokes with sexual content and touching others. Setting limits on behavior provides safety and security to the client and conveys to the client that he is worthy of help. Saying, "She will not want to be around you with that kind of talk" and "You need to be careful about what you say to others" does not clearly inform the client about behaviors that are unacceptable and implies that the client can control behaviors if he chooses. A time-out in the client's room does not inform the client about the inappropriateness of his behaviors and could be interpreted by the client as punitive as well as diminishing his self-esteem.

The family of a 22-year-old client with bipolar disorder is having difficulty coping with the client's rapid mood swings, irritability, grandiose delusions, and overly inclusive behaviors. Following a visit to the unit, the parents and the nurse discuss how the family can deal with the client's behaviors and help their child. Which response, if made by the family, would indicate to the nurse that the teaching was effective? A. "We should ask the client to move back to our house and take away their checkbook and driver's license." B. "We should call the police when the client becomes manic and have our child involuntarily committed." C. "We need to help our child establish a routine for work and school and monitor their mood." D. "We need to make sure the client is taking their medication correctly and to help them get out of debt."

C. "We need to help our child establish a routine for work and school and monitor their mood." Rationale: A normal routine and careful monitoring of the client's mood assists the client in taking action when their routine or mood becomes disrupted. Maximum independence within a supportive community is a priority. Advising the family to follow the client's medications and to monitor their spending, or to restrict spending and driving, will create a controlling relationship and promote tension. This will increase caregiver burden and create disagreements over illness management and financial responsibilities. Waiting to call the police is also incorrect and indicates that the situation has spiraled out of control. The parents may resort to this to protect themselves and their property, but a more proactive solution is to teach the client to keep a routine and monitor their mood.

The client with bipolar disorder is approaching discharge after being hospitalized with her first episode of acute mania. The client's husband asks the nurse what he can do to help her. What recommendation for the husband should the nurse anticipate including in the teaching plan? A. Help the client to be free from worry and anxiety. B. Relieve the client of all responsibilities. C. Communicate openly and offer support. D. Remind the client to control her symptoms.

C. Communicate openly and offer support. Rationale: The nurse should encourage the husband to support and communicate openly with his wife to maintain effective family-client interactions. During any illness, open communication and support helps the relationship between husband and wife. It is unrealistic for any individual to be free from anxiety or worry and impossible for the husband to be able to control what his wife may think or feel. Relieving the client of all responsibilities is unrealistic and not helpful. The client needs to resume activities as soon as she can manage them. Reminding his wife to control her symptoms is not appropriate and indicates that the husband needs further teaching about this condition.

The wife of a client with bipolar disorder, manic phase, states to the nurse, "He's acting so crazy. What did he do to get this way?" The nurse bases the response on which understanding of this disorder? A. It is caused by underlying psychological difficulties. B. It is the result of a genetic inheritance from someone in the family. C. It is caused by disturbed family dynamics in the client's early life. D. It is the result of an imbalance of chemicals in the brain.

D. It is the result of an imbalance of chemicals in the brain. Rationale: Bipolar disorder is a biochemical disorder caused by an imbalance of neurotransmitters in the brain. Manic episodes seem to be related to excessive levels of norepinephrine, serotonin, and dopamine. Psychopharmacologic therapy aims to restore the balance of neurotransmitters. In the past, it was thought that bipolar disorder may have been caused by early psychodynamics or disturbed families, but the current view emphasizes the role of biology. Bipolar disorder could be genetic or inherited from someone in the family, but it is best for the client and family to understand the disease concept related to neurotransmitter imbalance. This understanding also helps them to refrain from placing blame on anyone. Siblings and close relatives have a higher incidence of bipolar disorder and mood disorders in general when compared with the general population.

The client with a diagnosis of bipolar disorder, manic phase, states to the nurse, "I am the Queen of England. Bow before me." The nurse interprets this statement as important to document as which area of the mental status examination? A. Psychomotor behavior. B. Mood and affect. C. Attitude toward the nurse. D. Thought content.

D. Thought content. Rationale: The client's statement, "I am the Queen of England. Bow before me," is an example of a grandiose delusion and refers to thought content of the mental status examination. Examples of psychomotor behavior to be documented would include excited, typically exaggerated and repetitive physical movements, and excessive talking and gesturing. Mood is a subjective state, and affect is an observable expression of emotion. Mood is what a client tells you she is feeling, and affect is what you see the client feeling. For example, the client may state that she feels sad or happy in reference to mood. Affect refers to the display of physical emotion, commonly described as "appropriate" or "flat." Attitude toward the nurse refers to the client's behavior in the presence of the nurse during the mental status examination (pleasant and cooperative, irritable, and guarded).

Which variables should the nurse judge as likely to indicate high risk when assessing a client's potential for suicide? Select all that apply. A. Age 60 and older. B. Financial distress. C. Living alone. D. Angry behavior. E. Previous suicide attempts.

A. Age 60 and older. B. Financial distress. C. Living alone. E. Previous suicide attempts. Rationale: Risk factors for completed suicide are hopelessness, medical illness, severe anhedonia (loss of ability to feel pleasure), male gender, Caucasian or Native American/First Nations ethno-racial background, living alone, age 60 or older, unemployment, financial distress, or previous suicide attempt. Anger is a low-risk factor for suicide.

A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior? A. Avolition. B. Tangential. C. Word salad. D. Perseveration.

A. Avolition. Rationale: Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is a behavior in which a group of words are put together in a random fashion without logical connection. A person exhibiting tangential behavior never gets to the point of the communication. In perseveration, a person repeats the same word or idea in response to different questions.

A client is sitting in the dining area and laughing out loud, shaking her head, and whispering behind her hand. Suddenly the client begins banging her head against the wall. Which intervention by the nurse is most appropriate? A. Calmly walk over to the client and say, "Tell me what's going on." B. Call the operator and page the emergency response team immediately to the unit. C. Stand in the doorway and say, "I'll have to put you in restraints if you don't stop that." D. Approach the client calmly and say, "You need to write your feelings down in your journal."

A. Calmly walk over to the client and say, "Tell me what's going on." Rationale: Asking the client to tell the nurse what is going on encourages the client to discuss altered perceptions rather than feel guilt or shame, while supporting the client with your presence. Approaching the client to encourage journal writing is incorrect because clients experiencing psychosis have difficulty following abstract instructions and focusing attention. Calling the operator and paging the emergency response team immediately to the unit is incorrect because the client is not exhibiting violence toward others and verbal de-escalation techniques have not been tried first. Standing in the doorway and saying, "I'll have to put you in restraints if you don't stop that," is threatening to punish the client rather than helping the client gain control of their behaviors.

A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the client's attention, the nurse should encourage the client to: A. Fold towels and pillowcases. B. Participate in a game of charades. C. Play cards with another client. D. Perform an aerobic exercise.

A. Fold towels and pillowcases. Rationale: Folding towels and pillowcases is a simple activity that redirects the client's attention. Also, because this activity is familiar, the client is likely to perform it successfully. Cards, charades, and aerobic exercise are too complicated for a confused client.

The nurse is collecting data to determine whether a client is experiencing dementia or depression. Which findings indicate dementia? Select all that apply. A. The progression of symptoms is slow. B. The client answers questions with, "I don't know." C. The client acts apathetic and pessimistic. D. The family cannot identify when symptoms first appeared. E. The client's basic personality has changed. F. The client has great difficulty paying attention to others.

A. The progression of symptoms is slow. D. The family cannot identify when symptoms first appeared. E. The client's basic personality has changed. F. The client has great difficulty paying attention to others. Rationale: Common characteristics of dementia include slow onset of symptoms, difficulty identifying when symptoms first occurred, noticeable changes in the client's personality, and impaired ability to pay attention to others. Options 2 and 3 are symptoms of depression, not dementia.

The nurse at the mental health center is working with an adolescent with depression. The client has begun to display social withdrawal and oppositional behavior. What would this change indicate to the nurse? A. Worsening of the adolescent's depression. B. A transition to more adult signs of depression. C. Dependency on drugs. D. Obsession with body image.

A. Worsening of the adolescent's depression. Rationale: For adolescents, depression typically manifests as social withdrawal and oppositional behavior. Drug use may lead to stealing and truancy, not signs of worsening depression. Adolescents quite commonly display obsession with body image which is not be a sign of worsening depression. Adult signs of depression include worsening mood and suicidal thoughts.

While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response? A. "It might be best if you discuss this with the client directly." B. "I'm sorry, I can't disclose client information." C. "You should probably try to call your friend for an update." D. "I can only say your friend is stable and seems to be doing well."

B. "I'm sorry, I can't disclose client information." Rationale: The nurse is bound by the rules of confidentiality and can't reveal any information about a client or treatment, and should state this fact to the neighbor. Suggesting that the neighbor call the client is inappropriate because the nurse is inadvertently disclosing information and acknowledging the client's presence at the clinic. Saying that the client is stable and doing well is a blatant violation of the client's right to absolute confidentiality.

The nurse is instructing a client on a tyramine-free diet. Which dietary selection by the client requires further discussion? A. Fruit, yellow vegetables, and steak. B. Aged cheese, Chianti wine, and garlic bread. C. Eggs, bread, and peaches. D. Green, leafy vegetables, mashed potatoes, and beef patty.

B. Aged cheese, Chianti wine, and garlic bread. Rationale: Tyramine is an amino acid and when it is consumed in the presence of an MAO inhibitor will cause a rise in blood pressure leading to hypertensive crisis. Aged cheese and Chianti wine contain high concentrations of tyramine. The other diets have either low or little levels of tyramine and pose no harm to the client.

The guardian of a client diagnosed with schizophrenia indicates to the nurse a concern that the client is at risk for suicide. Which question to the client would the nurse utilize to determine the seriousness of the suicidal idealization? A. "Do you have a gun at home?" B. "Do you have access to poisonous chemicals at home?" C. "Are you planning on hurting yourself?" D. "Are you taking your psychiatric medications?"

C. "Are you planning on hurting yourself?" Rationale: Asking the client directly about thoughts of self-harm is the best way to know whether the client is at risk for suicide. Having a gun at home does not put the client at an increased risk for suicide; however, a sudden interest in firearms is a strong indicator of impending suicide. The client may be experiencing uncomfortable side effects, disturbed thoughts, or disturbed sensory perceptions that would cause the failure to follow the treatment plan. Refusing to take medication is an indication of the symptoms of schizophrenia rather than a consideration of suicide. Access to poisonous substances is also not a risk factor for suicide idealization.

The nurse cares for a client who is breathing rapidly, pacing back and forth across the room, has lips tightly closed, and with arms crossed tightly across his chest. What action should the nurse do first? A. Place the client in an isolation room. B. Administer PRN buspirone. C. Assist client to a safe, calm environment. D. Ask the client why he or she is so anxious.

C. Assist client to a safe, calm environment. Rationale: The nurse should first ensure the safety of the severely anxious client in a safe, quiet, environment. The nurse should not leave the client alone. Asking the client "why" is not therapeutic. Buspirone is a maintenance medication that will not help relieve anxiety immediately.

A client's nursing care plan includes the following prescription: "Assess for auditory hallucinations." What behavior would suggest to the nurse the client may be experiencing auditory hallucinations? A. Elevated mood, hyperactivity, distractibility. B. Performing rituals, avoiding open places. C. Poor eye contact, tilted head, mumbling to self. D. Distrust, fear, suspicion.

C. Poor eye contact, tilted head, mumbling to self. Rationale: Cues that the client is experiencing auditory hallucinations include eyes looking around the room as though looking for a speaker, tilting the head to one side as though listening, and mumbling or talking aloud as though responding to someone. Performing rituals and avoiding open places is associated with anxiety and compulsive behaviors. Elevated mood and hyperactivity are features of a manic episode. Distrust and suspicion are prevalent in paranoia.

A 40-year-old executive who was unexpectedly laid off from work 2 days earlier complains of fatigue and an inability to cope. The client admits drinking excessively over the previous 48 hours. This behavior is an example of: A. A manic episode. B. Depression. C. Situational crisis. D. Alcoholism.

C. Situational crisis. Rationale: A situational crisis results from a specific event in the life of a person who is overwhelmed by the situation and reacts emotionally. Fatigue, insomnia, and inability to make decisions are common signs and symptoms. The situational crisis may precipitate behavior that causes a crisis (alcohol or drug abuse). There isn't enough information to label this client an alcoholic. A manic episode is characterized by euphoria and labile affect. Symptoms of depression are usually present for 2 or more weeks.

A client, age 87, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find: A. Permanent long-term memory loss and hypomania. B. Transitory short-term memory loss and permanent long-term memory loss. C. Transitory short- and long-term memory loss and confusion. D. Permanent short-term memory loss and hypertension.

C. Transitory short- and long-term memory loss and confusion. Rationale: ECT commonly causes transitory short- and long-term memory loss and confusion, especially in elderly clients. It rarely results in permanent short- and long-term memory loss. ECT may lead to hypotension or hypertension. ECT rarely causes hypomania.

A 67-year-old client will be discharged to home with imipramine. Which information would be most important for the nurse to include when instructing the client and spouse about the medication? A. Urinate as soon as the urge is felt. B. Wear sunglasses outdoors. C. Eat a high-fiber diet. D. Avoid alcohol.

D. Avoid alcohol. Rationale: Alcohol potentiates the central nervous system depression that can occur with imipramine, leading to increased sedation, confusion, and disorientation and consequently placing the client at risk for injury. Therefore, instructing the client and spouse about avoiding alcohol is most important.It is not necessary to eat a high-fiber diet while taking imipramine.Imipramine does not cause photosensitivity or changes in urinary patterns.

In a predischarge program to educate clients with bipolar disorder and their family members, the nurse emphasizes that which symptom is the most significant indicator for the onset of relapse? A. A sense of pleasure and motivation for new endeavors. B. Self-concern about increase in energy. C. Leaving a good job to start a new business. D. Decreased need for sleep and racing thoughts.

D. Decreased need for sleep and racing thoughts Rationale: Decreased need for sleep and racing thoughts are the most prominent hallmarks of mania. Feelings of pleasure, motivation, and increased energy, within reason, are desired experiences. Also leaving a job to start a new business is not, in itself, a sign of impending illness.

A nurse is assessing a client who has just been admitted to the emergency department. Which signs suggest an overdose of an antianxiety agent? A. Slurred speech, dyspnea, and impaired coordination. B. Suspiciousness, dilated pupils, and increased blood pressure. C. Combativeness, sweating, and confusion. D. Agitation, hyperactivity, and grandiose ideation.

A. Slurred speech, dyspnea, and impaired coordination Rationale: Signs of antianxiety agent overdose include slurred speech, dyspnea, and impaired circulation. Phencyclidine (PCP) overdose can cause combativeness, sweating, and confusion. Amphetamine overdose can result in agitation, hyperactivity, and grandiose ideation. Hallucinogen overdose can produce suspiciousness, dilated pupils, and increased blood pressure.

A client experienced the loss of home and beloved family dog in flood waters 4 months ago. The client states that since the loss, the client finds it hard to "feel anything." The client says they can't concentrate on simple tasks, thinks about the flood incessantly, and fears losing control. The client reports becoming extremely anxious whenever the flood is mentioned and must leave the room if people talk about it. The admitting nurse suspects the client has post-traumatic stress disorder (PTSD). Which nursing goal would be most appropriate for this client? A. The client will demonstrate progress in dealing with the grief of losing their home and dog. B. The client will acclimate to the psychiatric unit. C. The client will avoid disturbing thoughts or feelings associated with the trauma. D. The client will be able to sleep 8 hours per night.

A. The client will demonstrate progress in dealing with the grief of losing their home and dog. Rationale: Survivors of trauma, disasters, and events outside of the usual ranges of human experiences may experience PTSD. The client is displaying dysfunctional grieving, which is common in PTSD. The priority for the nurse is to help the client gain adaptive coping strategies. Although sleep loss is an issue with PTSD, assisting the client with the grief would have the most impact on the client's behavior. Acclimation to the unit should not be an issue to the client with PTSD. The client will have difficulty avoiding thoughts of the trauma due to the persistent nature of PTSD.

A nurse is caring for a client receiving a dopamine receptor agonist for treatment of extrapyramidal symptoms caused by antipsychotic medications. What evaluation would indicate a therapeutic response to this drug? A. Client exhibits akathisia only while sitting. B. Client experiences a decrease in dystonia. C. Client exhibits bradyphrenia during the nursing assessment. D. Client exhibits a shuffling gait with stooped posture.

B. Client experiences a decrease in dystonia. Rationale: Extrapyramidal effects and antipsychotic-induced muscle rigidity are caused by a low level of dopamine. Dopamine receptor agonists reduce extrapyramidal symptoms such as bradyphrenia or slowed thought processes, akathisia or meaningless movements such as marching in place, or dystonia or abnormal muscle rigidity or movements.

Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills? A. Determining if the client was trying to self-harm. B. Determining if the client's physical condition is life-threatening. C. Determining if the client has a support system. D. Determining if the client has a history of suicide attempts.

B. Determining if the client's physical condition is life-threatening Rationale: If the client's physical condition is life-threatening, the priority is to treat the medical condition. Any compromise to the client's airway, breathing, or circulation must be addressed immediately. It's also imperative to determine the time of ingestion because this may determine treatment. The psychiatric evaluation, which includes intent to harm oneself, adequate support system, and history, can be performed after the client is medically stable.

A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because "voices on television are talking about me." What should the nurse do first? A. Remind the client that hearing voices is a symptom of her illness that she can cope with. B. Obtain information about the client's medication compliance. C. Arrange for the client to be admitted to a psychiatric hospital for a short stay. D. Check with the client's employer about her work performance.

B. Obtain information about the client's medication compliance. Rationale: Symptom exacerbation is most often related to noncompliance with the prescribed medication regimen. Therefore, obtaining information about the client's compliance is the first priority. Helping the client recognize the symptoms and her ability to manage them is appropriate, but this is not the first priority. Checking with her employer is not appropriate and does not help the client with management of her illness. Hospitalization is not indicated because the client is still working and can talk about the symptoms.

The client with bipolar disorder, manic phase, states to the nurse, "You're looking good. I'm taking you out to dinner." What reply by the nurse is most therapeutic? A. "I don't want to go out to dinner." B. "I can't go out to dinner with you." C. "I'm Chris, a nurse working on this unit." D. "It doesn't matter how I look; the answer is no."

C. "I'm Chris, a nurse working on this unit." Rationale: The nurse should state her first name and purpose on the unit to clarify her identity and to counteract other beliefs the client may have. Stating that the nurse does not want to or cannot go out to dinner is not therapeutic because it fails to clarify the client's misperceptions or erroneous beliefs, as is the statement "It doesn't matter how I look; the answer is no."

A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which change in her husband's behavior may confirm her fears? A. Increase in social interactions. B. Increased decisiveness. C. Disturbance in his sleep patterns. D. Problem-focused coping style.

C. Disturbance in his sleep patterns Rationale: Depression can be a mixture of affective responses (feelings of worthlessness, hopelessness, sadness), behavioral responses (appetite changes, withdrawal, sleep disturbances, lethargy), and cognitive responses (decreased ability to concentrate, indecisiveness, suicidal ideation). Increased decisiveness, problem-solving ability, and increased social interactions are reflective of adaptive coping.

A client experiencing a schizophrenic episode is hospitalized. The client is attempting to hit and bite the staff. When the nurse phones the primary care provider for orders to help calm the client, the nurse anticipates what medication is likely to be ordered? A. Chlorpromazine. B. Amitriptyline hydrochloride. C. Haloperidol. D. Lithium carbonate.

C. Haloperidol. Rationale: Haloperidol administered I.M. or I.V. is the drug of choice for acute aggressive psychotic behavior. Chlorpromazine is also an antipsychotic drug; however, it causes more pronounced sedation than haloperidol. Lithium carbonate is useful in bipolar disorder, and amitriptyline is used for depression.

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. What complication of antipsychotic therapy does the nurse suspect? A. Agranulocytosis. B. Extrapyramidal effects. C. Neuroleptic malignant syndrome. D. Anticholinergic effects.

C. Neuroleptic malignant syndrome. Rationale: Neuroleptic malignant syndrome is a rare but potentially fatal effect of antipsychotic medication. This condition generally begins with an elevated temperature and severe extrapyramidal effects. Agranulocytosis is a blood disorder. Symptoms of extrapyramidal effects include tremors, restlessness, muscle spasms, and pseudoparkinsonism. Anticholinergic effects include blurred vision, drowsiness, and dry mouth.

A client is in the geriatric psychiatry inpatient unit. The client has bilateral electroconvulsive therapy (ECT) scheduled for tomorrow. Which intervention would be most important for the nurse to implement for this client? A. Encourage fluids 6 to 8 hours before the treatment. B. Encourage caffeine intake the day before treatment. C. Provide frequent, supportive reorientation after the treatment. D. Encourage the family to accompany the client to the treatment.

C. Provide frequent, supportive reorientation after the treatment. Rationale: Common side effects of bilateral ECT treatments are confusion, disorientation, and short-term memory loss. The nurse should plan frequent, brief, and succinct reorientation statements. The client is frequently NPO after midnight prior to ECT therapy. Caffeine augmentation to ECT therapy would occur immediately prior to the procedure via intravenous administration. Family would be helpful for the client postprocedure but would not necessarily be part of the plan of care for the procedure.

A nurse is caring for a client in an acute manic state. What is the most effective nursing action that can be taken on behalf of this client? A. Assigning the client to group activities. B. Helping the client express feelings. C. Reducing stimuli for the client. D. Assisting the client with self-care.

C. Reducing stimuli for the client. Rationale: Reducing stimuli helps to reduce hyperactivity during a manic state. Group activities would provide too much stimulation. Trying to assist the client with self-care could cause increased agitation. When in a manic state, clients aren't able to express their inner feelings in a productive, introspective manner. The focus of treatment for a client in the manic state is behavior control.

A client and her partner come to the clinic stating they have been unable to have sexual intercourse. The female client states she has pain and her "vagina is too tight." The client was raped at age 15 years of age. Which nursing problem is most appropriate for this client? A. Dysfunctional grieving related to loss of self- esteem because of lack of sexual intimacy. B. Vaginismus related to vaginal constriction. C. Sexual dysfunction related to sexual trauma. D. Risk for trauma related to fear of vaginal penetration.

C. Sexual dysfunction related to sexual trauma. Rationale: Sexual dysfunction is the problem that is the most appropriate. Dysfunctional grieving because of lack of intimacy is not correct as the couple may have emotional intimacy. The trauma occurred when the female client was 15 years of age thus is not an acute problem. Vaginismus is a medical diagnosis.

A client with major depression states, "Life is not worth living anymore. Nothing matters." Which response by the nurse is best? A. "Things will get better, you know." B. "Why do you think that way?" C. "You should not feel that way." D. "Are you thinking about killing yourself?"

D. "Are you thinking about killing yourself?" Rationale: When the client verbalizes that life is not worth living anymore, the nurse needs to ask the client directly about suicide by saying, "Are you thinking about killing yourself?" Asking directly does not provoke suicide but conveys concern, understanding, and the worth of the client. Commonly, the client experiences a sense of relief that someone finally hears him. It also helps the nurse plan responsible care by identifying the client who is at risk for suicide. The nurse should then evaluate the seriousness of the suicidal ideation by inquiring about the intent and plan. Stating, "Things will get better," offers hope too soon without first evaluating the intent of the suicidal ideation. Asking, "Why do you think that way?" implies a lack of understanding and knowledge on the part of the nurse. Major depression usually is endogenous and biochemically based. Therefore, the client may not know why he does not want to live. Saying, "You should not feel that way," admonishes the client, decreases self-worth, and conveys a lack of understanding.

Which statement made by an adolescent who has just begun taking an antidepressant would indicate the need for further teaching? A. "After a week of taking my antidepressant, I can sleep a little better—6 hours or so each night." B. "Now that I've had a week of my antidepressant, it's a little easier to get up in the morning." C. "A week ago when I started my antidepressant, I didn't care about eating, but now I want to eat a bit more." D. "Now that I've been taking my antidepressant for a week, I'm going to feel better about myself."

D. "Now that I've been taking my antidepressant for a week, I'm going to feel better about myself." Rationale: In the first week or so of taking an antidepressant, the vegetative symptoms of depression (poor sleep, appetite, and energy level) improve. However, it takes 3 to 4 weeks for improvement in self-concept/self-esteem to take place.

The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which factor? A. Lack of desire for involvement in milieu activities. B. Boredom suggesting the need for something to do. C. Enjoyment of bothering the staff. D. Fears of abandonment and attention seeking.

D. Fears of abandonment and attention seeking. Rationale: Clients with borderline personality disorder have fears of abandonment and seek attention. Clients are dependent and fear being alone; this stems from disapproval, feelings of being abandoned, and not having needs met earlier in their life. The nurse intervenes by reducing attention-seeking behaviors and abandonment fears to help with intense feelings and emotions.

A nurse is caring for a client who is on close observation for suicide. When accompanying this client to the bathroom, the nurse should: A. Give the client privacy in the bathroom. B. Open the window and allow the client to get some fresh air. C. Allow the client to shave. D. Observe the client.

D. Observe the client. Rationale: The nurse has a responsibility to continuously observe the acutely suicidal client. The need for observation precludes the patient's right to privacy. The nurse should watch for clues, such as communicating suicidal thoughts, threats, and messages; hoarding medications; and talking about death. By accompanying the client to the bathroom, the nurse prevents hanging or other injury. The nurse should remove potentially dangerous objects, such as belts, razors, suspenders, glass, and knives. The nurse should also check the client's area and correct dangerous conditions, such as exposed pipes and windows without safety glass.

A client is brought to the hospital by the spouse, who states that the client has refused all meals for the past week and accused the spouse of trying to poison the client. During the initial interview, the client's speech, only partly comprehensible, reveals that the client's thoughts are controlled by delusions that the client is possessed by the devil. A health care provider diagnoses paranoid schizophrenia. Paranoid schizophrenia is best described as a disorder characterized by: A. Multiple personalities, one of which is more destructive than the others. B. Olfactory and tactile hallucinations. C. Severe mood swings and periods of low and high activity. D. Preoccupation with persecutory delusions, anxiety, anger, and potential for violence.

D. Preoccupation with persecutory delusions, anxiety, anger, and potential for violence. Rationale: Schizophrenia is best described as one of a group of psychotic reactions characterized by disturbed relationships with others and an inability to communicate and think clearly. Schizophrenic thoughts, feelings, and behavior are commonly evidenced by withdrawal, fluctuating moods, disordered thinking, and regressive tendencies. While some clients with schizophrenia may be at risk for violent behavior, people with schizophrenia generally are not prone to violence. Severe mood swings and periods of low and high activity are typical of bipolar disorder. Multiple personality, sometimes confused with schizophrenia, is a dissociative personality disorder, not a psychotic illness. Many schizophrenic clients have auditory hallucinations; olfactory and tactile hallucinations are much less common with schizophrenia and tend to be associated with other disorders.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take? A. Advise the client to discuss the MI with the physician. B. Administer the medication as ordered. C. Discontinue the medication. D. Question the physician about the order.

D. Question the physician about the order. Rationale: Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

The nurse attempts to interact with a client who barely responds with yes or no. The client states, "Don't bother me. I want to die." What action should the nurse take? A. Send another staff member to interact with the client. B. Leave the client alone. C. Turn on the television for the client. D. Sit with the client.

D. Sit with the client. Rationale: The nurse sits in silence with the client who is severely depressed. The nurse's presence conveys concern for and acceptance of the client, provides security, increases self-worth, and gives some structure to the client's day. Leaving the client alone ignores the client's needs and does nothing to foster trust in the nurse. Sending another staff member to interact with the client does not help the client gain trust and may be interpreted as the nurse not wanting to be "bothered." Turning on the television for the client completely blocks communication and diverts attention away from the client's needs.