psy 2

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 who is present at the time should respond by stating which of the following?

"Are you fearful and think that others may want to hurt you?"

A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which of the following would be the therapeutic response by the nurse?

"Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?"

A nursing assistant is assigned to work with a nurse to care for a client who is at risk for suicide. Which of these statements made by the nursing assistant indicates to the nurse that the nursing assistant understands suicide?

"Discussing suicide with a client is not harmful."

During a nursing interview, a client says, "My daughter was murdered in her New York apartment, and her estranged husband called to tell me. I can't stop myself from wondering if he killed her, but the police have ruled him out as a suspect." Which of the following is the therapeutic nursing response?

"Have you shared your concerns with the police?"

A nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you

An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?

"I am concerned about you. Are you now or have you ever been abused?"

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:

"I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."

During a group meeting, a client diagnosed with posttraumatic stress disorder (PTSD) verbalizes difficulty with maintaining realistic behavior. Which of the following responses by the nurse would be therapeutic?

"I can see that you are upset about this. Let's talk about this some more."

A nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse makes which therapeutic response to the client?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

A nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which of the following would be the best response of the nurse at this time?

"I can see that you're upset. I'm willing to listen."

A nurse is providing care to 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?" The appropriate nursing response is which of the following?

"I cannot promise to keep a secret."

A nurse is monitoring a client who is in seclusion. The nurse determines that the client is safe to come out of seclusion when the client states:

"I don't feel like hurting myself anymore."

A psychiatric client diagnosed with schizophrenia approaches the nurses' station and shouts, "Shut up. I told you to be quiet." Looking at the nurse, the client says, "Can't you hear them shouting at me?" The nurse's best response should be which of the following?

"I don't hear the voices, but I can see how upsetting it must be for you."

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." The nurse's best response is:

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"

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 would indicate the client has learned positive coping skills?

"I feel better able to care for my father now that I know where to obtain assistance."

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." The appropriate response by the nurse is:

"I hear what you are saying, but I don't share your belief."

A nurse is preparing a client who was hospitalized for depression for discharge. In evaluating the coping strategies learned during hospitalization, the nurse would recognize which statement by the client as an indication that further teaching is needed?

"I know that I won't become depressed again."

A nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say:

"I no longer feel that I deserve the beatings my husband inflicts on me

A nurse is reviewing the discharge plan with a female teenager with anorexia nervosa and reinforces the importance that the teenager attends a meeting of the local chapter of Anorexia Nervosa and Associated Disorders. Which response by the teenager indicates that she will likely be compliant with this plan?

"I'm going to do whatever it takes to get better."

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attend a meeting of the local chapter of anorexia nervosa and associated disorders. Which response by the teenager indicates that she will likely be compliant with this suggestion?

"I'm going to do whatever it takes to get better."

A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client would best indicate to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which of the following is the therapeutic nursing response?

"It must be hard to accept that she has passed away.

A nurse is caring for an older, depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?

"It seems as if you or your daughter feels regret?"

A 15-year-old client who is pregnant and unwed, says, "My life was unbearable before I met Johnny. My mother beats me up every day and my dad has been sleeping with me since I was ten years old!" Which response is appropriate for the nurse to make?

"It seems that you needed help to separate from your family. Do you feel you are ready to have a baby with Johnny?"

A nurse is caring for an elderly client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse would make which appropriate response?

"It sounds as though you are feeling all alone right now."

A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse makes which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

"It's okay to grieve and be angry with your daughter and anyone else for a time."

A nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." The nurse's best response should be:

"Let me know if you change your mind and I'll get you something to eat."

A nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which of the following?

"Our relationship is a therapeutic and helping one."

A male phobic client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which of the following responses by the nurse would be therapeutic?

"Perhaps you could just enjoy the music without singing."

A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

A 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?

"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."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. The appropriate nursing response is which of the following?

"Tell me more about what causes you to feel like the rape just occurred."

A nurse working in an urgent care center is interviewing a woman with vague somatic complaints. The client states that she was raped a few weeks ago but still feels "as if it just happened to me." The nurse should make which therapeutic response to the client?

"Tell me more about what happened, which causes you to feel like the rape just occurred."

While a nurse is providing care, a client angrily reports to the nurse that the health care provider purposefully provided wrong information about her diagnosis and states, "The doctor lied to me." Which of the following nursing responses would likely be a barrier to further communication with the client?

"The health care provider would never lie to you."

A nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for additional information about this self-help group?

"The leader of this self-help group is a nurse or psychiatrist.

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse appropriately responds by stating:

"What do you and your husband believe is the right thing for your children?"

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be

"What do you find difficult about this situation?"

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" The appropriate initial nursing response is

"What do you mean by that?"

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which of the following comments by the nurse would be therapeutic at this time?

"What is causing you to become agitated?"

A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client?

"What is causing you to become agitated?"

A nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is:

"What leads you to seek help now?"

A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement, if made by the parent, would indicate a characteristic associated with child abuse?

"When I tell my child to do something once, I don't expect to have to repeat it."

A nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask the health care provider to let me have a pass for the weekend?" The appropriate nursing response to assist the client in achieving the goal that has been set for this client is which of the following?

"When the health care provider arrives on the unit, I will let them know that you have a question."

While providing one-to-one supervision, a client who attempted suicide tells the nurse, "I can never do anything right. I'm such a loser. It didn't even work when I tried to kill myself." The appropriate nursing response is:

"You don't think you can ever do anything right?"

A nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which of the following responses by the nurse would be therapeutic?

"You haven't had an appetite at all?"

A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point."

A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which of the following responses by the nurse would be therapeutic?

"You seem very discouraged. Can you think of anything recently that went as you planned?"

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

"You sound very upset. Are you thinking of hurting yourself?"

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it." Which of the following is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." The therapeutic response by the nurse is:

"You're feeling angry that your family continues to hope for you to be 'cured'?"

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse makes which therapeutic response to the client

"You've been feeling like a failure for a while?"

A nurse is caring for a client with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which of the following nursing responses would be therapeutic?

"Your health care provider wants you to continue with this medication because it is helping you. Do you recall needing to be hospitalized because you stopped your medication?"

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Parkinson's disease

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

A nurse is asked to assist in changing the bed assignments on a nursing unit after receiving a call from the admitting department about a client who will require isolation on admission. The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse would avoid choosing which client as a roommate for the client with anorexia nervosa

A client with pneumonia

A nurse employed in a psychiatric unit receives a client assignment for the day. Which of the following clients assigned to the nurse is at the highest risk for committing suicide?

A client with severe depression and cancer

A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

A client was admitted to a medical unit because the client suddenly experienced total deafness. The client undergoes numerous testing to determine the cause of the deafness. All test results are negative, and there seems to be no organic reason why this client cannot hear. On further review of the client's record, the nurse notes that the client became deaf after witnessing a murder. Based on this information and the results of the diagnostic tests, the nurse suspects that the client may be experiencing:

A conversion disorder

Which behavior should the nurse expect a client diagnosed with agoraphobia to describe when discussing the disorder?

A fear of leaving the house

A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image; the client reports an extreme fear of public speaking. The nurse analyzes this information and determines that the client's fear would be considered:

A social phobia

A nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. In the event that tardive dyskinesia occurs, the nurse would likely observe:

Abnormal movements and involuntary movements of the mouth, tongue, and face

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse plans to do which of the following initially with this client?

Accept the client as a person and make the client feel safe.

A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder (OCD). The nurse observes the client for compulsive behavior that denotes repetition in:

Actions

A client is attending a Gamblers Anonymous meeting for the first time. The model used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse understands that the first step in the 12-step program is which of the following?

Admitting to having a problem

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has:

Agoraphobia

The wife of a client who abuses alcohol tells the nurse she cannot "do it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which of the following community groups?

Al-Anon

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which of the following community groups?

Alcoholics Anonymous

A client with a diagnosis of a recurrent major depression who is exhibiting psychotic features is admitted to the mental health unit. In an attempt to create a safe environment for the client, the nurse importantly designs a plan of care that deals specifically with the client's:

Altered thought processes

A client is scheduled to have electroconvulsive therapy (ECT). The nurse tells the client that:

Amnesia of events occurring near the period of the therapy is common.

A nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse determines that:

An informed consent needs to be obtained from the client.

A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action?

Approach the client quietly, take her to her room, and assist her in getting dressed.

A nurse is admitting a client who has a history of bipolar disorder to the hospital, and the health care provider has indicated that the client is currently in the manic phase. When collecting data regarding the client's rest needs, the nurse knows that reliable information may be obtained by:

Asking the significant other about the current sleep patterns

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and plans to:

Assign a staff member to the client who will remain with him or her at all times

A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

A nurse is preparing a client for the termination phase of the nurse-client relationship. Which nursing task would the nurse appropriately plan for this phase?

Assist in making appropriate referrals.

Therapy that involves pairing a stimulus attractive to the client with an unpleasant event is known as which of the following?

Aversion therapy

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Avoid joking or laughing in the presence of the client.

A nurse is assisting in a group therapy session. During this session, the members are identifying tasks and boundaries. The nurse understands that these activities are characteristic of which stage of group development?

Beginning stage

A nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research the disorder?

Body weight well below ideal range

A hospitalized client with a history of alcohol abuse tells a nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action at this time?

Call the nursing supervisor.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. The appropriate nursing action is to:

Call the nursing supervisor.

A nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. The initial nursing action upon admission of the client is to:

Check the wound sites.

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which of the following?

Client involvement in goal setting

A nurse is collecting data from a client who has recently been violently raped. Which data indicates that the client is experiencing rape-trauma syndrome

Client reports nightmares involving being stalked when alone at night.

A nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. The finding that requires the nurse's immediate intervention is the:

Client's inadequate attention to activities of daily living (ADL) and poor nutritional intake

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

Communicate expected behaviors to the client. Assist the client in developing means of setting limits on personal behavior. Follow through about the consequences of behavior in a nonpunitive manner. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?

Constant physical activity and poor oral intake

Which data indicates to the nurse that a client may be experiencing ineffective coping?

Constantly neglects personal grooming

A licensed practical nurse (LPN) enters a client's room, and the client is demanding release from the hospital. The LPN reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder, and that the admission was a voluntary admission. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Contact the health care provider (HCP).

A nurse is preparing a discharge plan for a client who attempted suicide. The nurse understands that the plan of care should focus on which of the following?

Contracts and immediate available crisis resources

A client was admitted to a medical unit with acute blindness. Many tests are performed and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. The nurse suspects that the client may be experiencing a:

Conversion disorder

As the nurse approaches a client who was recently admitted to the inpatient unit of a psychiatric hospital, the client says, "Quit following me. You're with the Federal Crime Scene Investigation Unit; I can tell by the way you are walking." This is an example of which alteration in thinking

Delusion

A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." The nurse interprets this client statement as:

Denial

A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as:

Denial

A nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which of the following is accurate regarding depression and the older client? Select all that apply.

Depression in an older person is likely to have physical manifestations. Some indications of dementia may actually originate as depression. Suicide is a frequent cause of death among the older population.

A nurse working in the long-term care facility understands which of the following concepts related to depression in the older client?

Depression in the older client is often undertreated.

A nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?

Develops a relationship to help reduce the frequency of the delusions

A nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action would the nurse take first to best deal with these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis.

A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and does not speak to the family or visitors. The nurse identifies that this client is using which type of coping mechanism?

Distancing

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." The nurse understands that this medication is:

Disulfiram (Antabuse)

A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client?

Drawing

A nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

Driving under the influence (DUI) conviction resulted in a 1-year suspended license

A 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

Encourage expression of feelings, concerns, and fears. Extend touch and hold the client's or family member's hand if appropriate. Be honest and truthful and let the client and family know that you will not abandon them.

In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following is best

Encourage the client to participate in a structured daily program of activities.

A nurse is assisting in conducting a group therapy session. A female client, who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. The appropriate nursing action is which of the following?

Encourage the client to stay and ask the client what she is feeling.

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to:

Escort the manic client to his or her room.

A nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place first priority on which of the following when planning care for this client?

Establish a trusting nurse-client relationship.

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 a

Evidence of the client's altered and distorted body image

The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to

Examine and treat the wound sites.

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first?

Examine the neck area and assess the airway.

A nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. These behaviors are interpreted by the nurse as:

Expected reactions to a devastating event

When caring for a client who has been raped, which intervention would the nurse implement during the examination?

Explaining procedures to be completed and why the procedures are necessary

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:

Feed, bathe, and dress the client as needed until the client can perform these activities independently.

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which of the following observations, if made by the nurse, are indicative of the clinical manifestations associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea

Following a group therapy session, a client approaches the licensed practical nurse (LPN) and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Get a written prescription from the health care provider (HCP) and obtain an informed consent.

A nurse is preparing a care plan for the client with obsessive-compulsive disorder (OCD). The nurse should focus on which of the following as the primary means to accomplish work with this client?

Goals and objectives

A mental health nurse caring for a client diagnosed with mania selects which activity for this client?

Going for a walk with staff

When admitted to the inpatient mental health unit, a client dramatically states, "I am a member of England's royal family." How does the nurse document this behavior?

Grandiose delusion

The best rationale for using group therapy as an accepted way of treatment of clients in the milieu is because:

Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Have the client open the gift with the nurse present.

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to:

Help the client identify and examine dysfunctional thoughts and beliefs.

A nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse monitors for which of the following?

Hypertension, disorientation, hallucinations

A psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following?

I cannot discuss any client situation with you."

A nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which of the following is the best response by the nurse?

I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this—it's private and personal." Which statement by the nurse indicates a therapeutic response?

I know that some of these questions are difficult for you, but, as a nurse, I must legally respect your confidentiality."

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!" The best nursing action would be to:

Identify recent behaviors or accomplishments that demonstrate skill or ability.

A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, sharing with peers, and makes appropriate suggestions during group discussions. The nurse concludes that this client's behavior is most consistent with:

Improvement

A nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which of the following signs and symptoms associated with opioid withdrawal?

Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by:

Increasing the level of suicide precautions

A client with Alzheimer's disease became very agitated when a group of children came to sing and dance at a long-term care facility and the resident tried to take one of the children to her room. The nurse should use which of the following pieces of information when approaching the client about this behavior?

Individuals with Alzheimer's disease have difficulty tolerating excess stimulation and changes in routine.

A nurse is preparing to admit a client diagnosed with obsessive-compulsive disorder (OCD) to the mental health unit. The nurse observes this client for behavioral characteristic(s) of one who is:

Inflexible and rigid

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, the nurse should:

Inform the client that she is being secluded to help regain control of self

A nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse includes which priority instruction to the victim in the discharge plan?

Information regarding the location of shelters

A nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which of the following nursing interventions is least likely to be helpful to this client at this time?

Initiate confinement measures.

A 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, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

A nurse is caring for a client who was recently admitted for anorexia nervosa. Upon entering the client's room, the nurse finds the client in the middle of a series of sets of rapid sit-ups. Which action should the nurse to take initially?

Interrupt the client and offer to take her for a walk.

A nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The appropriate interpretation of the behavior is that the client

Is displaying typical behaviors that can occur during termination

A mental health nurse on the evening shift is receiving report about a client who was admitted to the nursing unit. The nurse is told that the client was admitted by involuntary status. Based on this type of admission, the nurse would expect that the client:

Is in need of psychiatric treatment

A nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. The best nursing action is to:

Keep the client talking and signal to another staff member to send help to the client.

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing that which of the following is the priority action?

Look for organic causes of the paralysis.

A nurse is caring for a client who verbalizes a need to increase her self-esteem. The nurse plans to assist the client to achieve the goal of gaining self-esteem by encouraging the client to:

Maintain a well-groomed appearance.

A nurse is caring for a client with a diagnosis of agoraphobia. Which of the following behaviors exhibited by the client would support this diagnosis?

Makes excuses for not leaving the house

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen (Tylenol). The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which intervention? Select all that apply

Making nutritious snacks available anytime Providing meals on an isolation tray that contains plastic utensils Assuring that her diet consists of bland, easy-to-digest foods and beverages

A nurse is employed at a drug abusers' residential treatment center. The nurse is preparing for the arrival of a new client and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is which of the following?

Milieu therapy

Which of the following are appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply.

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate.

A client tells a nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

A nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

My friends and I went out to lunch today."

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

My husband always brings me flowers and apologizes after he hits me." "My boyfriend yells and accuses me of having an affair if I am late after work." "I have bruises all over my body. I am frequently clumsy and fall a lot."

A nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs of anxiety and attempts to assist the client back to the client's hospital room. The next appropriate nursing action at this time is which of the following?

Notify the registered nurse (RN).

A nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, the appropriate nursing action would be to

Notify the registered nurse.

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, the priority nursing action is to

Notify the social worker to investigate the situation.

A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise.

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by:

Observing rigid rules and regulations

A client cannot leave the house without checking the stove and the iron many times. The client is often late for appointments and occasionally even misses engagements as a result of this behavior. The nurse interprets that this client's symptoms are compatible with which of the following anxiety disorders?

Obsessive-compulsive disorder

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. The appropriate initial nursing intervention related to this concern is:

Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the health care provider immediately. The appropriate nursing intervention is which of the following?

Offer to assist the client to an examination room until the health care provider is notified.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) 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 HCP immediately. The nurse assisting to care for the client would plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?

One-to-one suicide precautions

A nurse is assigned to care for a client who is experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

A nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is:

Ping-pong

A nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

Places the client on one-to-one suicide precautions

A nurse working in a mental health unit hears that a client has been experiencing "flashbacks." The nurse interprets that this client is exhibiting a sign of:

Posttraumatic stress disorder (PTSD)

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse likely expects that the client:

Presents a harm to self

A nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. After reasoning that the client's symptoms are compatible with a somatization disorder, the nurse recalls that obesity for this client most likely represents:

Protection from the risk of intimacy

A nurse is assigned to care for a client who is suicidal. The appropriate nursing intervention in dealing with this client during this crisis is to:

Provide authority, action, and participation.

A nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that which of the following is the immediate priority of care

Provide safety for both the client and other clients on the unit.

A nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to:

Provide safety for the client and other clients on the unit.

An agoraphobic client has been diagnosed with major depression. The nurse notes that the client is not eating adequately and at times refuses to eat. To meet the client's nutritional needs, the nurse plans to:

Provide small frequent meals.

A client with depression reports to the nurse that she has not been sleeping or eating adequately. The nurse should plan to do which of the following to assist the client in meeting nutritional needs?

Provide small, frequent meals.

A mental health nurse is assigned to care for a client with a diagnosis of schizophrenia, acute phase. The nurse should use which of the following approaches when planning care for this client?

Provides assistance with grooming and nutrition until the client's thinking is cleared

The client diagnosed with paranoid schizophrenia has been exceedingly agitated, is threatening and shouting at everyone, and is refusing to participate in therapy. The nurse takes which initial action?

Provides for safety by recognizing the level of client anxiety and setting limits

A nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is termed

Psychodrama

A nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by:

Psychomotor retardation and side effects of medication

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. The appropriate nursing action is to:

Quietly approach the client, escort her to her room, and assist her in getting dressed.

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:

Re-experiencing recollections of the trauma

A client is admitted to the psychiatric unit following a serious suicidal attempt by a drug overdose. The priority nursing intervention is to:

Remain with the client at all times.

A client comes to the emergency department following an assault and is extremely agitated, trembling, and hyperventilating. The appropriate initial nursing action would be to:

Remain with the client until the anxiety decreases.

A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which of the following actions should the nurse take first?

Remove both clients to a separate, safe location.

A nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which of the following is the priority nursing action?

Removing the client from any immediate danger

A nurse is assessing a newly admitted client recently diagnosed with depression. Which of the following data best supports that the client is at risk for self-harm?

Reported hopelessness

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? Select all that apply.

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother:

Restrict the amount of chocolate and caffeine products in the home.

A nurse is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which of the following would be appropriate for the nurse to suggest including in the plan of care?

Reward the client when a desired behavior is performed.

A client is scheduled to have electroconvulsive therapy (ECT). Which of the following problems would the nurse include in the plan as a priority?

Risk for aspiration

A nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which of the following would be priorities to include? Select all that apply.

Risk for injury Risk for infection Risk for aspiration Impaired verbal communication

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address the client's need for:

Safety and security

A woman comes into the emergency department following an assault. She presents with hyperventilation, pacing, rapid speech, and headache. The nurse correctly determines that the client is experiencing which level of anxiety?

Severe

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment includes ensuring that the client:

Shampoos and dries the hair, freeing it of all hair spray and creams

A nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which of the following actions by the nurse would be most beneficial?

Share the observation with the client and help the client to recognize feelings.

A nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual?

Sibling stating, "I don't feel safe around my brother"

A 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. The appropriate nursing intervention is which of the following?

Sit beside the client in silence and verbalize occasional open-ended questions.

A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action?

Sit beside the client in silence with occasional open-ended questions

A nurse is caring for a client diagnosed as having a psychomotor retarded depression. Based on this condition, the nurse would expect to note which behavior in the client?

Slowed walking and talking

A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencin

Social phobia

A client newly admitted to the mental health unit describes a recent history of emotional turmoil. The client exhibits physical symptoms and has some loss of physical functioning. The nurse determines that this client is exhibiting signs compatible with:

Somatization disorder

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathology after a lengthy workup. In planning care for this client, it is important that the nurse understand that the client is suffering from:

Somatization disorder

A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior?

Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide.

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, would take which immediate action?

Stay with the client at all times.

A nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following?

Suggest that the client stop talking and try listening to others

An adolescent is returning home after an acute psychiatric hospitalization following a suicide attempt. Which of the following would be least effective in preparing the client to return to a safe and effective care environment?

Suggest that the mother's boyfriend move out of the home.

Which data collection finding would indicate the possibility of the sexual abuse of a child?

Swelling of the genitals

After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. The nurse's best response/action is to:

Take the client aside and confront with reality.

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. A nurse assigned to care for the client would first:

Take the client to a quiet room.

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse makes which therapeutic response to the client?

Tell me about your difficulty sleeping."

A nurse is assisting in conducting a group therapy session. During the session a male client threatens to act out physically and states that he will punch another member of the group. Which of the following is the appropriate initial nursing action?

Tell the client that he may talk about his anger but cannot act on it during the group session.

A nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which of the following is the appropriate nursing action?

Tell the client that the health care provider will be contacted regarding discharge.

A nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this fellow employee by:

Telling a friend that this employee hates her or him

A nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings related to loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase

A nurse is collecting data on a client with the diagnosis of anorexia nervosa. The nurse understands that objective findings may indicate:

That the client has extensive knowledge of nutrition

A nurse is monitoring a female client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

A nurse is employed in a mental health clinic that specifically manages somatization disorders. The nurse understands that which of the following is a characteristic of a somatization disorder?

The client experiences disruption in integrative functions of memory, consciousness, or identity.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a prized CD and a cherished autographed picture of the performer.

A nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which of the following data would indicate that the client is a very high risk for suicide?

The client has an immediate plan for a suicide attempt.

A nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse determines that:

The client has the right to demand and obtain release from the hospital.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse interprets the client's behavior as:

The client is at increased risk for suicide.

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which of the following is an appropriate outcome for this client?

The client verbalizes stages of grief and plans to attend a community grief group.

A nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of a nursing diagnosis of Dysfunctional Grieving Related to the Loss of a Spouse. The client progresses well and is approaching discharge. Which of the following is an appropriate outcome for this nursing diagnosis?

The client verbalizes stages of grief and plans to attend a community grief group.

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and instructs the client that:

The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.

A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse would expect which of the following?

The client will participate in the treatment plan.

A nurse is working with a victim of rape in a clinic setting and assists to develop a plan of care for the client. Which of the following is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape traum

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively. Which of the following is the least realistic goal for this client?

The client will stop blaming himself for the lack of insurance.

A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The nurse reviews the data obtained and identifies which of the following as a priority concern?

The client's report of suicidal thoughts

A 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 would determine that this type of crisis could be caused by:

The death of a loved one

A nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which of the following?

The false belief that one is being singled out for harm by others

A nurse is assisting in preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which of the following issues?

The parameters of the relationship

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on:

The physical condition of the client

A client with a history of depression and several suicide attempts is admitted to the mental health unit reporting severe suicidal thoughts. On what does the nurse focus the initial data collection of the client?

The presence of existing suicidal thoughts

A client in the mental health unit engages in repeated handwashing throughout the day. The nurse understands that these repetitive behaviors develop because the client is:

Unconsciously attempting to control unpleasant thoughts or feelings

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. In the planning, the nurse understands that it is important that:

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to

Use a night light and turn off the television.

A nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse develops strategies that will promote adequate nutrition and encourage the client to discuss feelings and plans to:

Use open-ended questions and silence.

A nurse employed in a mental health unit who cares for suicidal clients is reviewing the work schedule. The nurse expects to note in the schedule that additional precautions related to safety to the clients will be provided at which of the following times?

Weekends

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on:

Weight loss

A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which of the following would be the therapeutic response by the nurse?

What aspects of this situation are the most difficult for you?"

A client who is suicidal tells the nurse, "All I want to do is end it all." The appropriate nursing response is which of the following?

What do you mean by that?"

A nurse is collecting data on a client in crisis. Which of the following questions would the nurse ask to determine the client's perception of the precipitating event that led to the crisis?

What leads you to seek help now?"

A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which of the following occurs?

When no acts of aggression are observed within 1 hour after release of two extremity restraints

A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within how much time after cessation or reduction of alcohol intake?

Within a few hours

A nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate initially for this client?

Writing

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which clinical manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea

A nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response by the nurse would be appropriate at this time?

You sound very unhappy. Are you thinking of harming yourself?"

A client with lung cancer says to the nurse, "I'm sick and tired of my family telling me not to worry and that a cure will be discovered before I know it." The therapeutic response by the nurse is:

You're feeling angry that your family is hoping for a cure?"

Which nursing approach to administering an antianxiety agent to a client with acute severe anxiety is most appropriate?

stay with the client until the medication becomes effective.