Psych ATI Modules 1a-5a

A nurse is assessing a client who is experiencing alcohol withdrawal delirium. Which of the following is an expected finding? (select all that apply) ​Severe hypotension ​Visual hallucinations ​Grandiosity ​Paranoid delusions ​Tremors

paranoid delusions tremors visual hallucinations Severe hypotension is incorrect. Elevated blood pressure, rather than hypotension, is an expected finding of alcohol withdrawal delirium. ​Visual hallucinations is correct. Visual hallucinations are an expected finding of alcohol withdrawal delirium. ​​Grandiosity is incorrect. Grandiosity is an expected finding of bipolar disorder rather than alcohol withdrawal delirium.​Paranoid delusions is correct. Paranoid delusions are an expected finding of alcohol withdrawal delirium.​Tremors is correct. Tremors are an expected finding of alcohol withdrawal delirium.

A nurse is providing a staff education session about how to decrease the risk for injury when working with clients who have a history of anger and aggression. Which of the following should the nurse include in the teaching? (select all that apply) ​Avoid wearing necklaces during client care. ​Know the layout of the facility. ​Stand directly in front of the client when talking. ​Bring security with you for all client interactions. ​Provide immediate verbal feedback for escalating behavior.

provide immediate and verbal feedback for escalating behavior avoid wearing necklaces during client care know the layout of the facility Avoid wearing necklaces during client care is correct. Necklaces or any dangling jewelry present a safety hazard when working with angry or aggressive clients. Know the layout of the facility is correct. Knowing the layout of the unit is a safety consideration that can reduce the risk for injury when working with an angry or aggressive client. Stand directly in front of the client when talking is incorrect. Standing directly in front of the client can be interpreted as confrontational by an angry or aggressive client. Bring security with you for all client interactions is incorrect. The presence of security can escalate agitation in an angry or aggressive client; therefore, security should remain in the background and should only be used if needed. Provide immediate verbal feedback for escalating behavior is correct. Providing immediate verbal feedback for escalating behavior is an effective de-escalation technique.

A nurse is caring for a client who has generalized anxiety disorder on the mental health unit. The client received a telephone call that was upsetting and now the client is pacing up and down the corridors of the unit. Which of the following interventions is appropriate for the nurse to take? Instruct the client to sit down and stop pacing. Allow the client to pace alone until physically tired. Escort the client to bed to suggest the client rest. Walk with the client at a gradually slower pace.

Walk with the client at a gradually slower pace. When the client is experiencing increased anxiety, it is important for the nurse to remain with the client and promote a calm atmosphere. By walking with the client at a gradually slowing pace, the nurse provides gross motor activity as an anxiety outlet that helps to calm the client and demonstrates therapeutic offering of self.

A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client? Watching a video in the day room Walking with the nurse in the courtyard Participating in a basketball game in the gym Reading a book in his room

Walking with the nurse in the courtyard. Bipolar disorder is a mood disorder characterized by episodes of mania and severe depression. Gross motor and physical activities will provide the client with an opportunity to expend his excess energy. In addition, walking with the nurse provides an opportunity for therapeutic communication.

A nurse is caring for a client who has been prescribed lithium carbonate (Eskalith) for the treatment of bipolar disorder. Which of the following should the nurse include in her teaching with the client and family regarding this medication? You will need to consume a low-salt diet while on this medication. You will need your blood levels drawn weekly during the first month. You will need to take this medication on an empty stomach. You will need to stop this medication if you experience diarrhea, vomiting, and/or excessive sweating.

You will need to stop this medication if you experience diarrhea, vomiting, and/or excessive sweating These symptoms can lead to dehydration and potentially elevated lithium levels and toxicity.

A nurse in a hospital is caring for a client who has agoraphobia. The nurse should evaluate that the client is making progress when the client is able to attend: a picnic in a local park. daily group therapy sessions. recreational therapy in the day room. lunch in the hospital cafeteria with family.

a picnic in a local park. Agoraphobia is fear of being in places in which help may not be available. This typically manifests as a fear of being outside alone. The client is demonstrating progress by attending a picnic in a local park, which is located outside of the hospital.

A nurse is discussing ageism with a newly licensed nurse. Which of the following statements, by the newly license nurse, indicates understanding? ​"Ageism refers to a higher level of respect that Eastern cultures give to their elders." ​"Ageism refers to the stereotype that older adults are less intelligent than other age groups." ​"Ageism refers to assumptions about an older adult client based on gender and economic status." ​"Ageism refers to the increase in physical care required by older adults."

"Ageism refers to the stereotype that older adults are less intelligent than other age groups."

A nurse is caring for a client who is diagnosed with depression. The client's spouse asks the nurse about possible side effects of electroconvulsive therapy (ECT). After explaining that ECT will not cause brain damage, what additional information should the nurse offer? "The main side effects are temporary, and may include mild confusion, a slight headache, and short-term memory problems." "Most clients have no adverse effects to this treatment, although muscle cramping may result from the induced seizure." "Some clients have been known to have a myocardial infarction, but we will monitor your spouse closely to be certain this does not happen." "The common side effects are related to the use of anesthesia."

"The main side effects are temporary, and may include mild confusion, a slight headache, and short-term memory problems."

A nurse is teaching the family of a client who has a diagnosis of dementia. Which of the following statements is appropriate to include in the teaching? "Dementia is characterized by a sudden onset." ​"An altered level of consciousness is associated with dementia." ​"The signs of dementia are progressive and irreversible." ​"Dementia is often caused by a sudden change in environment."

"The signs of dementia are progressive and irreversible."

A hospitalized client says to the nurse, "My spouse called and told me my boss hired someone to take my place." Which of the following therapeutic responses by the nurse is appropriate? "You should call your boss and ask if you can have your job back." "I don't understand why your spouse would upset you with news like that." "There really isn't much you can do about that until you are discharged." "You must feel very concerned and disappointed by that information."

"You must feel very concerned and disappointed by that information."

A nurse is providing medication teaching for a client who has a new prescription for phenelzine (Nardil) a monoamine oxidase inhibitor (MAOI). Which of the following should the nurse include in the teaching? ​"You should change positions slowly while taking this medication." ​"This medication is prescribed to help overcome alcohol addiction." ​"You should avoid B-vitamins while taking this medication." ​"You should take a hot shower when you experience a headache from this medication."

"You should change positions slowly while taking this medication." ​Clients should change positions slowly while taking an MAOI due to the risk of orthostatic hypotension.

A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately? A client who is taking olanzapine (Zyprexa) and experiences dizziness when first standing up. A client who is taking chlorpromazine (Thorazine) and has excessive daytime sleepiness. A client who is taking thioridazine (Mellaril) and has recurrent constipation. A client who is taking clozapine (Clozaril), and has flu symptoms, fever, and aching joints.

A client who is taking clozapine (Clozaril) and has flu like symptoms, fever, and aching joints. Clozapine is used to treat schizophrenia in clients who have not been helped by or are unable to take other antipsychotic medicines. The client on clozapine will need to have a white blood cell (WBC) count and differential done weekly for at least 6 months to monitor for the development of agranulocytosis, an insufficient number of granulocyte WBCs and a life-threatening condition in which the client is extremely susceptible to infection. A client taking clozapine who has flu manifestations needs immediate blood work to evaluate his WBC count and differential.

A nurse is performing a mental status exam (MSE) on a client who has a new diagnoses of dementia. Which of the following should the nurse include? (select all that apply) ​Grooming ​Long-term memory ​Support systems ​Affect ​Presence of pain

Affect Grooming Long-term memory Grooming is correct. Grooming is included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.​Long-term memory is correct. Long-term memory is included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.​Support systems is incorrect. Support systems are not included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.​Affect is correct. Affect is included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.​Presence of pain is incorrect. The presence of pain is not included in an MSE which consists of appearance, behavior, speech, mood, disorders of the form of thought, perceptual disturbances, cognition, and ideas of harming self or others.

A nurse is performing an admission assessment on a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptoms? ​Affective flattening ​Bizarre behavior ​Illogicality ​Somatic delusions

Affective flattening

A nurse is conducting a staff education session regarding the manifestations of schizophrenia. Which of the following should the nurse identify as negative symptoms? (select all that apply) ​Delusions ​Hallucinations ​Anhedonia ​Poor judgment ​Blunt affect

Blunt affect Anhedonia (inability to feel pleasure) ​Delusions is incorrect. Delusions are an example of a positive symptom of schizophrenia.Hallucinations is incorrect. Hallucinations are an example of a positive symptom of schizophrenia.Anhedonia is correct. Anhedonia is an example of a negative symptom of schizophrenia.Poor judgment is incorrect. Poor judgment is an example of a cognitive symptom of schizophrenia.Blunt affect is correct. Blunt affect is an example of a negative symptom of schizophrenia.

A nurse is caring for a client who receives a new prescription for clozapine (Clozaril). Which of the following is a contraindication to this medication? Bone marrow depression ​Glaucoma ​Hypertension ​Urinary retention

Bone marrow depression

A nurse is caring for a client who has schizophrenia. The client states that he hears voices telling him to do "bad things." The nurse correctly identifies this finding as which of the following? ​Command hallucination ​Gustatory hallucination ​Automatic obedience ​Negativism

Command hallucination

A nurse is caring for a group of clients on a mental health unit. Which of the following actions should the nurse implement? ​Provide sympathy during interaction. ​Focus on the words of client. ​Observe intrapersonal communication. ​Demonstrate honesty when communicating.

Demonstrate honesty when communicating.

A nurse is caring for a client in an urgenct care center who has traumatic injuries following an assault. She sits quietly and calmly in the examination room. The nurse should recognize this behavior as which of the following reactions? ​Denial ​Displacement ​Introjection ​Undoing

Denial ​Denial is a defensive coping mechanism that protects the client from increasing anxiety levels. The client consciously disowns intolerable thoughts and ideas. It is a common response of victims of violent crimes.

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments is the highest priority? ​Determining if the client has Suicidal thoughts. ​Determining if the client has psychotic thinking. ​Asking the client to identify the cause of the crisis. ​Identifying the client's coping skills. ​Identifying the client's support systems.

Determining if the client has suicidal thoughts ​Determining if the client has psychotic thinking. both correct

A nurse is planning discharge teaching for a client who has borderline personality disorder. Which of the following is appropriate for the nurse to include in the teaching? ​Dialectical behavior therapy. ​Behavioral contract ​Bibliotherapy ​Safety plan

Dialectical behavior therapy ​Dialectical behavior therapy is appropriate for the treatment of clients with borderline personality disorder and is often a part of the discharge plan.

A nurse in an ED is assessing a client for suspected cocaine intoxication. The nurse should know that which of the following manifestations is consistent with cocaine intoxication? Nystagmus Dilated pupils Hypersomnia Depression

Dilated pupils Dilated pupils are characteristic of cocaine intoxication due to the stimulation of the sympathetic nervous system.

A nurse is assessing a client who has been receiving treatment for schizophrenia with the typical antipsychotic fluphenazine (Prolixin) for 12 months. The nurse observes that the client has fine, fasciculating tongue movements. The nurse correctly associates this finding with which of the following? ​A drug-food reaction to grapefruit juice. ​The client has missed several doses of medication. ​Early symptoms of neuroleptic malignant syndrome (NMS). ​Early symptoms of tardive dyskinesia (TD).

Early symptoms of tardive dyskinesia (TD)

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following interventions are appropriate? (select all that apply.) ​Avoid eye contact to prevent escalation of anxiety. ​Establish rapport with the client. ​Identify the cause of the anxiety. ​Validate the client's feelings. ​Develop a flexible crisis intervention plan.

Establish rapport with the client Identify the cause of the anxiety Validate the client's feelings ​ Avoid eye contact to prevent escalation of anxiety is incorrect. Avoiding eye contact inhibits the nurse-client relationship and does not assist in establish rapport. ​​Establish rapport with the client is correct. Establishing a rapport with the client is an appropriate crisis intervention.​​Identify the cause of the anxiety is correct. Identifying the cause of the anxiety is an appropriate crisis intervention. Validate the client's feelings is correct. Validating the client's feelings is an appropriate crisis intervention.​Develop a flexible crisis intervention plan is incorrect. Developing a concrete crisis intervention plan, rather than one that is flexible, is an appropriate crisis intervention

A nurse is caring for a client who has bipolar disorder and is hospitalized for a severe depressive episode. The client has been taking citalopram (Celexa) for 2 weeks and reports sleeping better and having an improved appetite, but the client still feels hopeless. Which of the following is an appropriate action? Speak to the provider about increasing the client's dose of citalopram. Explain that antidepressants often take several weeks to be fully effective. Notify the provider so the client can be prescribed a different medication. Recommend a sleep study be done on the client.

Explain that antidepressants often take several weeks to be fully effective. SSRIs are used along with certain anticonvulsant medications in the treatment of bipolar disorder. The lag time for SSRI antidepressants is 3 to 4 weeks before the client will experience significant improvement. Some clients will notice an improvement in the first couple of weeks, but usually the medication must be taken regularly for at least 4 weeks and, in some cases, as many as 8 weeks before the full therapeutic effect occurs.

A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine (Thorazine). Which of the following findings should the nurse recognize as EPS? (select all that apply) ​Muscle contractions of the neck ​Fidgeting behavior ​Fluctuating vital signs ​Impaired gait ​Sexual dysfunction

Impaired gait Muscle contractions of the neck fidgeting behavior Muscle contractions of the neck is correct. Muscle contractions of the neck is an example of EPS associated with conventional antipsychotics.​Fluctuating vital signs is incorrect. Fluctuating vital signs is a sign of anticholinergic toxicity rather than an example of EPSs.​Impaired gait is correct. Impaired gait is an example of EPS associated with conventional antipsychotics.​​Sexual dysfunction is incorrect. Sexual dysfunction is potential side effect of chlorpromazine; however, it is not an EPS.

A client who is newly diagnosed with Alzheimer's disease asks how the symptoms will progress. How should the nurse respond? (Put in order of progression) Inability to remember family members Inability to perform common tasks Difficulty remembering how to swallow Inability to find commonly used items Difficulty with talking or reading

Inability to find commonly used items Inability to perform common tasks Difficulty with talking or reading Inability to remember family members Difficulty remembering how to swallow

A nurse is planning care for a client following a suicide attempt. Which of the following interventions is appropriate when implementing suicide precautions? ​Remove utensils from the client's meal trays. ​Assign the client to a private room. ​Inspect the client's personal belongings. ​Tuck bedcovers over client's hands and arms.

Inspect the client's personal belongings. ​Inspecting the client and his personal belongings is an appropriate intervention to ensure that the client does not have access to potentially harmful objects.

A nurse is caring for a client who has bipolar disorder. Which of the following should be recognized as manic behavior? (Select all that apply.) Talking in rapid, continuous speech Interacting with others in a flirtatious way Spending large sums of money Sleeping for long periods of time Dressing in black or grey clothing

Interacting with others in a flirtatious way Talking in rapid, continuous speech Spending large sums of money

A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding? ​Frequent manic episodes. ​Refusal of medication due to paranoia. ​Constant desire to talk about personal emotions. ​Involuntary loss of a sensory function.

Involuntary loss of a sensory function ​The involuntary loss of a sensory function such as hearing or vision is a finding associated with conversion disorder.

A nurse is admitting a client with a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment? ​Mental status questionnaire ​CAGE questionnaire ​Abnormal Involuntary Movements Scale (AIMS) ​Hamilton Anxiety Scale

Mental Status Questionnaire ​The use of a mental status questionnaire assists in identifying deterioration in mental status and brain damage which are findings associated with cognitive disorders.

A nurse is admitting a client to a substance-abuse program. The client states, "This is all my wife and boss' fault." The client's behavior is an example of which of the following defense mechanisms? ​Reaction-formation ​Compensation ​Projection ​Displacement

Projection ​The client is demonstrating compensation by placing blame on his wife and boss instead of accepting personal responsibility for his behavior.

A nurse at a college campus mental health counseling center is caring for a student who just failed an exam. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as an example of the defense mechanism of: conversion. projection. undoing. idealization.

Projection (pt refuses to acknowledge unacceptable personal characteristics and transfers feelings, thoughts, or traits onto another person)

A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention? ​Promote appropriate behavior during group therapy sessions. ​Encourage client input in the treatment plan. ​Communicate with the client using concrete language. ​Demonstrate assertive behavior.

Promote appropriate behavior during group therapy sessions ​Managing the client's behavior within the group is the priority intervention for the client who has histrionic personality disorder.

A nurse is planning care for a group of clients on a mental health unit. Which of the following indicates understanding of a therapeutic environment? ​Plan to discuss any topic that is presented. ​Focus on client weaknesses to increase adaptation. ​Provide continuity of care by assigning the same staff. ​Allow client to determine the boundaries of the nurse-client relationship.

Provide continuity of care by assigning the same staff.

A nurse in the ED is implementing a plan of care for a client who has delirium tremens. Which of the following actions should the nurse perform first? ​Administer diazepam (Valium). ​Raise the bed side rails. ​Obtain a medical history. ​Start intravenous fluids.

Raise the bed side rails. ​The greatest risk to the client is injury from a fall; therefore, the first action by the nurse is to raise the bed side rails.

A nurse on a mental health unit is caring for clients who have the following depressive disorders. The nurse should identify which of the following diagnoses as presenting the greatest risk for suicide? ​Premenstrual dysphoric disorder ​Seasonal affective disorder ​Recurrent brief depression ​Minor depression

Recurrent brief depression ​A client who has recurrent brief depression experiences periodic major depressive episodes and is at greatest risk for suicide during these times.

A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need to be taken care of." The nurse identifies this behavior as an example of which of the following defense mechanisms? ​Dissociation ​Introjection ​Regression ​Repression

Regression (reverting to childlike or immature behaviors)

A nurse is caring for a young adult client following the death of his wife due to a sudden aneurysm. The client feels paralyzed in his ability to cope with work and family responsibilities. The type of crisis the student is experiencing is: Situational ​Maturational ​Adventitious ​Developmental

Situational

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors? (Select all that apply) ​Substance abuse ​Age greater than 45 years old ​Female gender ​Currently married ​Schizophrenia

Substance Abuse Age greater than 45 years old Schizophrenia Substance abuse is correct. Clients who have a substance abuse disorder are at a higher risk for suicide. Age greater than 45 years old is correct. The rate of suicide increases with age and peaks after the age of 45. Female gender is incorrect. Males are more likely to commit suicide than females. Currently married is incorrect. Clients who are married have a lower risk for suicide than those who are divorced or single. Schizophrenia is correct. Clients who have schizophrenia are at a high risk for suicide.

A physical indicator of possible abuse in a battered woman would be a fracture of the distal bones, such as the skull, face, or extremities. A nurse is discussing factors to include in an abuse assessment with nursing staff. Which of the following should be included in the assessment? (select all that apply) Suicide risk Socioeconomic status Coping patterns Support systems Alcohol use

Suicide risk Coping patterns support systems alcohol use Suicide risk is correct. The risk for suicide should be included in an abuse assessment. Socioeconomic status is incorrect. Abuse can occur in all levels of socioeconomic status; therefore, it is not necessary to include this in an abuse assessment. Coping patterns is correct. Coping patterns should be included in an abuse assessment. Support systems is correct. Support systems should be included in an abuse assessment. Alcohol use is correct. Alcohol and drug use should be included in an abuse assessment.

A nurse on an inpatient mental health unit is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority? ​Home environment ​Support systems ​Suicide risk ​Psychiatric history

Suicide risk ​The greatest risk to the safety of a client who is depressed is self-harm. Therefore, the priority for the nurse to determine is the client's thoughts or plans for suicide.

A nurse is providing teaching for a client who has a new prescription for clozapine (Clozaril). When discussing adverse effects, which of the following should the nurse state is the most common? ​Agranulocytosis ​Dry mouth ​Neck rigidity ​Tachycardia

Tachycardia

A client is admitted with PTSD following a fire. Which of the following should the nurse recognize as an adaptive defense mechanism? The client begins reading a book when he experiences hand tremors in response to loud noise. The client makes a decision to postpone a needed surgery. The client focuses on discussing a daily routine when asked about a tragedy. The client develops stomach pains when fire is seen on television.

The client begins reading a book when he experiences hand tremors in response to loud noise. (temporarily blocking memories and perceptions from conscious thought)

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following signs and symptoms should the nurse expect to find during the assessment? Muscle aches and chills Fatigue and depression Anxiety and diaphoresis Arrhythmia and respiratory depression

anxiety and diaphoresis Alcohol withdrawal symptoms usually occur within hours of the client's last drink, and symptoms intensify over 1 to 3 days after the last drink. Chronic use of alcohol depresses the CNS, and when withdrawal occurs, the CNS stimulates an autonomic nervous system response. Early signs of withdrawal include anxiety, diaphoresis, irritability, mood swings, tremors, dilated pupils, tachycardia, hypertension, anorexia and insomnia. Alcohol withdrawal requires medical attention to safely manage the client and avoid death.

A nurse in the ED is caring for a rape survivor. Which of the following people will provide the most effective support if the client confides in the individual immediately following the incident? Psychologist ​Close friend ​Social worker ​Chaplain

close friend ​Rape survivors who confide in a family member or friend immediately after the incident are more likely to develop fewer somatic manifestations of stress. Family and friends often need support as well, particularly if the individual involved is from a traditional culture or views sexual assault as shameful.

A nurse is teaching a community education course about the physical complications related to substance abuse. Which of the following should the nurse include in the discussion about heroin? ​Pancreatitis ​Dental caries ​Perforation of nasal septum ​Permanent effects on short-term memory loss

dental caries

A nurse is caring for a client who reports acute anxiety. Which of the following is the priority nursing action? ​Remain with the client. ​Provide a diverting activity. ​Encourage verbalization of feelings. ​Establish a nurse-client relationship.

remain with the client. ​The nurse should stay with the client to reduce anxiety and injury to self and others, which is the priority action.

A nurse is leading a family therapy session. Which of the following statements should the nurse recognize as an example of effective communication among family members? "If you keep saying that, I will tell everyone what you did last night." "She is always bossing me around. Should she do that?" "Can you tell me the reason you get upset each time I go to the mall?" "Please do not raise your voice at the children. I am the one who left dishes in the sink."

"Can you tell me the reason you get upset each time I go to the mall?" This is an example of effective or healthy communication. Healthy communication expresses clear, understandable messages between family members. Each family member is encouraged to express their own feelings and thoughts. The family member is asking the member who is perceived to be upset to openly express feelings. The communication is clear, understandable, and direct. This promotes an open exchange of feelings and thoughts.

The mother of an adolescent boy calls the psychiatric health clinic with concerns about her son. Which of the following statements by the mother should indicate to the nurse that the adolescent is at risk for suicide? He gave his guitar to a neighbor, and he loved that guitar." "He wears the same clothes day after day." "He spends most of his time in his room and just opens the door when I bring him a meal." "I hear my son crying for hours at a time."

"He gave his guitar to a neighbor, and he loved that guitar." Warning signs of suicide include giving away possessions the person cherishes, talking about his own death, and describing himself as worthless.

A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates concrete thinking? ​"I am aware that each problem has only one solution." ​"I am a prophet of God." ​"The voices tell me that I must avoid large crowds." ​"I know that you are trying to poison me and you can't convince me otherwise."

"I am aware that each problem has only one solution." ​This statement is an example of concrete thinking which refers to the client's inability to think abstractly.

During a group therapy session, a nurse notes a client using multiple defense mechanisms. Which of the following client statements demonstrates maladaptation? "I wrote a short story about a heroic woman when I was really mad at my boss." "I don't care about work anymore since I was not given a promotion." "I mentally separate myself from distractions around me when I paint on canvas." "I still cannot remember the scene of my husband's car accident."

"I don't care about work anymore since I was not given a promotion." Regression is reverting to an earlier, more primitive and child-like pattern of behavior. If a promotion is lost, maladaptive regression is seen through poor work performance, missing appointments, and being late.

A nurse is caring for a client who has a history of alcohol abuse and has been hospitalized following a drinking binge. The nurse enters the room and finds the client shouting in a terrified voice, "Get these bugs off of me!" Which of the following responses by the nurse is appropriate? "I'm sure that the bugs you see will not harm you." "Tell me more about the bugs that you see in your room." "I don't see any bugs, but you seem very frightened." "I do not see anything. This is part of the withdrawal process."

"I don't see any bugs, but you seem very frightened." This client is experiencing a tactile hallucination, which is a common type of hallucination experienced during alcohol withdrawal. In this response, the nurse presents reality. The response also illustrates the therapeutic communication tool of showing empathy. By saying, "You seem frightened," the nurse acknowledges the client's feelings.

A nurse is counseling a group of clients at an outpatient mental health clinic. Which of the following client statements indicates a problem with role transition? "If my husband had gone to the doctor like I told him to he'd be alive today." "I am so angry with my daughter's attitude. Teenagers think they know everything!" "I want to have an intimate relationship but I end up breaking off relationships as soon as they begin." "I just can't seem to find any energy to take care of my children since my husband divorced me."

"I just can't seem to find any energy to take care of my children since my husband divorced me." This client's statement indicates the client is experiencing a problem with role transition which results from a change in personal, occupational, or social status.

A nurse is caring for a client who is prescribed paroxetine (Paxil). Which of the following statements by the client indicates a need for further teaching? "I may experience a decreased desire to have sex." "I may experience an inability to sleep." "I may experience difficulty concentrating." "I may need to eat more to prevent weight loss."

"I may need to eat more to prevent weight loss."

A nurse attending a group therapy session is listening to clients discuss coping strategies. Which of the following statements by clients indicate adaptive coping? (select all that apply): "I exercise three times a day." "I call a friend who makes me smile and laugh." "I think about being on my favorite beach vacation." "I tense and release my muscles, starting with my feet." "I see the glass as half-full when it starts looking empty."

"I see the glass as half-full when it starts looking empty." "I think about being on my favorite beach vacation." "I call a friend who makes me smile and laugh." "I tense and release my muscles, starting with my feet." "I exercise three times a day" is incorrect. Physical exercise helps the client manage stress levels. However, excessive exercising may be an indication of an obsessive-compulsive disorder and is not effective."I call a friend who makes me smile and laugh" is correct. Humor can be used to turn a stressful situation around. The intensity attached to a stressful thought or situation can be decreased when it is made to appear absurd or comical. Laughter has been shown to increase the release of endorphins, which promote a sense of well-being."I think about being on my favorite beach vacation" is correct. Guided imagery is a process whereby a person is led to envision images that are both calming and health enhancing. Imagery techniques have been used to help improve athletic performance, diminish pain, and reduce cortisol levels in clients who have cancer. Guided imagery CDs and MP3s are available to assist clients."I tense and release my muscles, starting with my feet" is correct. Progressive muscle relaxation (PMR) can be practiced almost anywhere. PMR is accomplished by tensing groups of muscles — beginning with the feet and ending with the face — as tightly as possible for 8 seconds and suddenly releasing them."I see the glass as half-full when it starts looking empty" is correct. Cognitive reframing is correlated with a greater positive affect and higher self-esteem. The goal is to have a negative perception changed to a positive one. For example, a negative statement, such as "I can't pass this course," can be reframed to "If I choose to study more, I will increase my chances of success."

A nurse is teaching a client who has depression about a new prescription for fluoxetine (Prozac). Which of the following statements by the clients indicates understanding of the teaching? ​"I should expect changes within 3 to 4 days." ​"I will increase my water intake up to 8 glasses a day." ​"I should watch my diet to prevent an expected weight gain." ​"I will notice an improvement in my sex drive."

"I should watch my diet to prevent unexpected weight gain." ​Weight gain occurs with Prozac and clients are advised to increase exercise and monitor caloric intake to counter this effect.

A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective? "I journal when I find it difficult to talk." "I pray when I begin to breathe fast." "I watch television when I get anxious." "I exercise when my neck is tense."

"I watch TV when I get anxious." Watching television does not allow the client to directly deal with the stressors in life. Watching television acts more as a distracter or an escape from stress and anxiety. Depending on the program being viewed, television may actually exacerbate the stress and anxiety rather than promote relaxation. This is an ineffective stress management technique.

A nurse is caring for a client who is depressed and refuses to participate in group therapy, or perform ADLs. Which of the following nursing statements by the nurse is appropriate? "I will assist you in getting out of bed and getting dressed." "You can remain in bed until you feel well enough to join the milieu." "The unit rules state that you may not remain in bed." "If you don't participate in your care, you will not get better."

"I will assist you in getting out of bed and getting dressed." Severely depressed persons have problems with self-care and are easily overwhelmed. A nursing approach that focuses on meeting the client's physiologic and basic needs directly is best. The presence of the nurse conveys that the client is worthy of the nurse's attention and will help the client adjust to the hospitalization.

A client calls the crisis hotline and tells the nurse who answers the phone, "I just took an entire bottle of amitriptyline (Elavil)." Which of the following statements by the nurse is appropriate? "I'm glad you called, and I want to send an ambulance to help you." "You must have been feeling pretty depressed to do that." "Do you know how many pills were in the bottle?" "Were you trying to kill yourself by taking an overdose?"

"I'm glad you called, and I want to send an ambulance to help you." Elavil, a tricyclic antidepressant, is used to treat depression. This therapeutic statement shows the nurse's concern for the client's safety and responds to the client's priority need. Maslow's Hierarchy of Needs states that the client's physical and safety needs come first.

The nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse suspects that the client is suffering from PTSD when the client states: "I check any room I enter because the enemy is still after me and could be hiding anywhere." "My child was born with a birth defect I believe is due to an exposure I had overseas." "I killed four enemy soldiers with my bare hands and saved my entire battalion." "In my dreams, all I can see are the wounded reaching out and trying to grab me."

"In my dreams, all I can see are the wounded reaching out and trying to grab me." Many clients who have PTSD repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. This client's statement about haunted dreams is typical of a client who has PTSD. check room- This client is making a paranoid statement, more typical of a client who has persecutory delusions. This statement is not characteristic of a client who has PTSD.

The parents of a 4 year old child who has a serious chronic illness tell the nurse that they have taken their son's name off the list for little league baseball next season. Which of the following is an appropriate nursing response to the parents? ​"It must be frustrating for you to have to cancel an activity your son enjoyed." ​"Baseball can be a dangerous sport for children." ​"You never know. He could be ready for baseball by the spring." ​"I'm so sorry that you felt you had to do that."

"It must be frustrating for you to have to cancel an activity your son enjoyed." ​This response demonstrates the therapeutic communication technique of sharing empathy. It is neutral and nonjudgmental and invites further communication and sharing. im sorry incorrect- ​This response illustrates the nontherapeutic communication technique of offering sympathy. Although it shows compassion, it also demonstrates pity or subjectivity rather than the objectivity that can truly help solve a problem or offer support.

A nurse is caring for a young adult client who says he is experiencing increasing anxiety and the inability to concentrate. Which of the following is an appropriate response by the nurse? "It sounds like you're having a difficult time." "Have you talked to your parents about this yet?" "Why do you think you are so anxious?" "How long has this been going on?"

"It sounds like you're having a difficult time." This therapeutic response is an open-ended empathetic statement that encourages the client to talk.

A nurse is caring for a young adult client who says he is experiencing increasing anxiety and the inability to concentrate. Which of the following is an appropriate response by the nurse? "It sounds like you're having a difficult time." "Have you talked to your parents about this yet?" "Why do you think you are so anxious?" "How long has this been going on?"

"It sounds like you're having a difficult time." This therapeutic response is an open-ended empathetic statement that encourages the client to talk.

A 9 year old boy with a new diagnosis of diabetes mellitus tells the nurse he is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following is an appropriate nursing response to the mother? ​"Tell me more about how you are feeling about your son's activities." ​"You might want to use tutors to home-school him." ​"I agree. His well-being is the most important." ​"You sound overprotective. Let's talk about this some more."

"Tell me more about how you are feeling about your son's activities."

A client who is having burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses by the nurse is appropriate? "Do I cause more pain than the other nurses?" "Tell me more about that." "Let me get you more pain medication." "You have the right to your judgments."

"Tell me more about that."

A provider diagnoses a client with cancer and advises immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following is an appropriate nursing response? ​"Using nontraditional treatments is not a good Idea. I'd rather you avoid that route." ​"A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice." ​"Your doctor is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you." ​"Tell me more about your concerns about taking chemotherapy."

"Tell me more about your concerns about taking chemotherapy."

A nurse is discussing confidentiality with a newly license nurse. Which of the following statements by the newly licensed nurse indicates an understanding? ​"The courts may require me to discuss confidential information." ​"I am required to provide confidential information to insurance companies." ​"If questioned during a police investigation I am required to divulge confidential information." ​"I am legally allowed to discuss confidential information with the client's former therapist."

"The courts may require me to discuss confidential information."

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following client responses is an indication the client is in the denial phase of the grief process? ​"The doctor has been so good to me. I know he has tried everything he can. It is just my time." ​"I can't believe that doctor graduated from medical school; he doesn't know a thing about treating cancer." ​"The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." ​"I can't believe this is happening. Even though I am not hurting right now, I don't feel like I have the energy to get out of bed."

"The doctor says I only have a few months to live, but I know he is exaggerating to to get me to take my medication"

A client states, "I just don't know what to do about my husband's drinking. Every time I see him drinking beer, I start to feel extremely anxious." What would be the most therapeutic response by the nurse? ​"Tell me more about what is going on with your son. Is he still causing problems for you?" "At one time you told me you were drinking with your husband. Are you continuing to do that?" ​"The next time your husband starts drinking, what is something you might do to decrease your anxiety?" ​"I think you should attend an Al-Anon meeting. It is a support group for people who are troubled by another person's drinking."

"The next time your husband starts drinking, what is something you might do to decrease your anxiety?" ​This statement demonstrates the nurse encouraging the client to formulate a plan of action. It allows the client to identify an alternate course of action to a situation she finds troubling. The client is encouraged to continue to explore her feelings and to think about possible options regarding the situation. It also restates and clarifies what the nurse hears the client saying, which would give the client an opportunity to clarify what she has said if needed.

A nurse is providing teaching for a client who has a new prescription for clozapine (Clozaril). Which of the following client statements indicates a need for further teaching? ​"This medication will help prevent seizures." ​"I should keep my medication in a dry place at room temperature." ​"I will report flu symptoms immediately to my doctor." ​"If I miss a dose, I will take the next scheduled dose as prescribed."

"This medication will help prevent seizures." ​Clozapine is prescribed for the treatment of psychotic symptoms and has a potential adverse effect of seizure activity.

A nurse is caring for a client who is receiving chlorpromazine (Thorazine) and is give na pass to attend a family outing on a sunny day. Which of the following is the most important for the nurse to include in the client's teaching about the side effects of Thorazine? "Wear a hat and a long-sleeved shirt." "Suck on hard candies." "Drink plenty of fluids." "Limit alcoholic beverages to one beer only."

"Wear a hat and a long-sleeved shirt." Photophobic skin reactions and damage to the retina of the eye can occur when a client who is taking chlorpromazine is exposed to direct sunlight. Clients should be reminded to wear protective clothing, apply sunscreen, and wear sunglasses when they are outside.

A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements by the nurse is therapeutic? "Antidepressants are not your solution, but this therapy group is." "I notice you keep clenching your fists. This needs to stop." "You need to work hard on resolving conflict with those closest to you." "What do you mean when you say you cannot ever return to work?"

"What do you mean when you say you cannot ever return to work?" This is an example of clarification, which is a therapeutic communication technique. Clarification asks the group member to expand and clarify what he/she means so as to create a better understanding during the group session.

A nurse is caring for a client who just learned that she has invasive breast cancer and must start chemotherapy. She tells the nurse she is worried about the side effects of the treatment. Which of the following is an appropriate nursing response? ​"I will have your doctor discuss the side effects with you." ​"Someone from the American Cancer Society will be here soon." ​"What is it about the side effects that worry you?" ​"I agree. Sometimes the side effects can be worse than the disease."

"What is it about the side effects that worry you?"

A nurse is talking with a client who is discussing important feelings when the time of the session is complete. The next day, when the nurse meets with the client, which of the following statements is appropriate to initiate the interview? ​"Good morning, are you feeling up to our talk today?" ​"Yesterday you were talking about some very important feelings. Let's continue." ​"What would you like to talk about today?" ​"Why do you think you're having the feelings you discussed yesterday?"

"What would you like to talk about today?" ​This statement allows the client to direct the topic of discussion and is an open-ended question. These are both therapeutic communication techniques for initiating an interview.

A male nurse is assigned to care for a female client who was admitted to the hospital following a domestic abuse incident. The client does not want a male nurse as her caregiver. Which of the following responses is appropriate? "I can arrange for a female assistive personnel to do your personal hygiene care." "The nurse assigned to care for you is very capable and has taken care of other women." "Your doctor is a man. Why don't you want a male nurse assigned to your care?" "Would you like me to review the assignment and assign a female nurse to care for you?"

"Would you like me to review the assignment and assign a female nurse to care for you?" In this therapeutic response, the nurse restates and validates the client's concern about having a male nurse assigned to her care and shows the client empathy by endeavoring to meet the client's need for a female caregiver.

A nurse is caring for a client who was admitted to the hospital in critical condition following a cerebrovascular accident. The client's daughter says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses is the most appropriate for the nurse to give the daughter? "Perhaps you could call your children to see how they are doing." "Don't worry. We'll take good care of your parent while you are gone." "You are feeling drawn in two separate directions." "There's nothing you can do here. You should go home to your children."

"You are feeling drawn in two separate directions."

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following statements by the nurse is appropriate? ​"You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." ​"You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable." ​"I'm sure your daughter's diagnosis is very difficult to deal with but everything will be all right once she receives the proper treatment." ​"Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter diagnosis?"

"You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way." ​This statement is an example of clarification and promotes further discussion which is a therapeutic communication techniques.

A nurse is caring for a depressed client who attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." The appropriate nursing response is: "You have a great deal to live for." "It's not unusual for depressed people to feel that way." "Why do you feel you are worthless?" "You've been feeling that your life has no meaning."

"You've been feeling that your life has no meaning." (restating and evaluating the pts feelings)

A nurse is caring for a client who is exhibiting aggressive behavior. Which of the following is an appropriate distance for the nurse to maintain with this client? 6 inches 1 arm's length 3 feet 12 feet or more

3 feet

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client? Disclose some personal information to the client to demonstrate approachability. Wait for the client to initiate interaction. Approach the client frequently throughout the day for brief interactions. Adopt a neutral attitude when providing care.

Adopt a neutral attitude when providing care. To promote a therapeutic relationship, it is best to use a neutral, nonthreatening attitude during care and communication.

A nurse is caring for a client who receives a prescription for a benzodiazepine. Which of the following is a contraindication to this medication? Alcohol abuse ​Drug withdrawal ​Seizure disorder ​Suicide attempts

Alcohol abuse (due to the risk for CNS depression)

A nurse is caring for a group of clients in an acute mental health facility. Which of the following clients has the legal right to refuse treatment? ​A 16-year-old client whose parents have requested treatment. ​An adult client who has delusions and refuses treatment for religious reasons. ​An older adult client who was voluntarily admitted. ​A client who is competent but was involuntarily admitted.

An older adult who was voluntarily admitted.

A nurse is interviewing a female client who is Hispanic. The client's parter answers the questions and states, "She speaks only a little English." Which of the following actions should the nurse take? Arrange to complete the assessment with only the client and a translator present. Ask the client's partner to translate questions and answers for the client. Record the partner's answers to the questions, and complete the assessment. Ask the partner to allow the client to provide her own answers to questions.

Arrange to complete the assessment with only the client and a translator present. This is an example of the nurse's role of client advocacy. It is critical to get accurate assessment information directly from the client. There is no indication that this client cannot speak for herself. An impartial translator may be necessary for that assessment. There is no need to confront the partner. The nurse can simply explain that part of the admission process requires the nurse to speak directly with the client.

A nurse is caring for a client who is a resident in a facility designed for the care of clients with Alzheimers disease. The client has been oriented to name and place and is usually cooperative and able to perform ADLs with minimal supervision. When the client refuses to take medications, the nurse should: notify the provider of the client's increasing confusion. crush the pills, if not contraindicated, and mix them in the client's applesauce. explain to the client the possible implications of missing a dose. ask the client to express the reasons for refusing the morning medications and document the event.

Ask the client to express the reasons for refusing the morning medications and document the event. Before making a judgment about the client's competence, the nurse should complete an assessment of the client. It is important to document the client's reasons in his own words, especially if he is refusing ordered medications and/or treatments.

A nurse is planning care for a client who is being treated for acute PCP intoxication. Which of the following should the nurse include in the plan of care? ​Monitor for autonomic hyperactivity. ​Assess for elevation of vital signs. ​Implement suicide precautions. ​Maintain ready access to naloxone. (Narcan)

Assess for elevation of vital signs ​The client should be monitored for elevation of blood pressure due to the increased risk of hypertensive crisis, elevated temperature due to the risk of hyperthermia, and elevated pulse due to the risk of cardiovascular accident.

A nurse in the ED is preparing to care for a client who has signs of alcohol intoxication. Which if the following should the nurse plan to include in the client's care? (Select all that apply) Contact the laboratory to obtain a blood sample. ​Prepare the client for a CT scan. ​Check the client's pupil reactivity. ​Obtain a urine specimen. ​Perform a developmental screening test.

Contact the laboratory to obtain a blood sample prepare the client for a CT scan Obtain a urine specimen check the client's pupil reactivity Contact the laboratory to obtain a blood sample is correct. A blood sample allows for a blood alcohol level test to be performed. Prepare the client for a CT scan is correct. A CT scan or other neurological tests are performed to rule out brain injury or head trauma. Check the client's pupil reactivity is correct. Checking for pupil reactivity provides information about a client's neurological status. Obtain a urine specimen is correct. A urine specimen is needed to perform a urine toxicology screen. Perform a developmental screening test is incorrect. A developmental screening test is appropriate when needing information about a child or adolescent's maturational or developmental level.

A nurse is interviewing a client who has a personality disorder. The client resists discussion of feelings until 5 mins prior to the end of the session. Which of the following is an appropriate intervention? ​Go over the agreed-upon time, as the client is finally able to discuss important feelings. ​Arrange for another nurse to continue the interview. ​Set an extra meeting time to discuss these feelings. ​End just as agreed, but tell the client he can continue at the next scheduled session.

End just as agreed, but tell the client he can continue at the end of the next scheduled session. ​ Clients who have a personality disorder often use manipulation. Setting limits discourages this behavior and is an appropriate intervention.

A nurse is caring for a client who is prescribed bupropion (Wellbutrin). Which of the following findings in the client indicate effective pharmacotherapy? Loss of interest in hobby Lack of facial expression Decrease in delusional thoughts Decrease in restlessness

Decrease in restlessness Psychomotor retardation is slowed physical movement and slumped posture. Psychomotor agitation includes restlessness, pacing, and finger/toe tapping. Both types can occur during the depressive state. A decrease in anxiety and restlessness indicates therapeutic effect of bupropion. The client's mood will be elevated and energy will be regained when responding to bupropion therapy. delusional incorrect-Bupropion is classified as a norepinephrine dopamine reuptake inhibitor (NDRI) and is used to treat symptoms of depression, such as sleep and appetite disturbance, fatigue, decreased sex drive, poor grooming, psychomotor retardation, mood variations, and impaired concentration. Delusions can occur with major depressive disorder and can be treated with antipsychotic medications.

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following behaviors that may cause lithium toxicity? Fasting Exercising moderately Increasing sodium intake Drinking caffeinated beverages

Fasting Lithium is used to treat the manic stage of bipolar disorder. Toxicity occurs when the level of lithium in the blood becomes too high. Crash dieting or fasting can lead to lithium toxicity because the sodium, electrolyte, and fluid balance are altered, causing the blood levels of lithium to rise.

A nurse on the psychiatric unit is caring fora client who has moderate anxiety disorder. Which of the following measures should the nurse include in the immediate plan of care? ​Circumvent a discussion about concerns. ​Remain near the client. ​Encourage the client to sit for a while. ​Foresee anxiety-provoking circumstances.

Foresee anxiety-provoking circumstances ​The nurse understands the importance of foreseeing anxiety-provoking circumstance to avoid escalation of anxiety.

A nurse is collecting a health history on a client who has a diagnosis of Korsakoff's syndrome. Which of the following is an expected finding? ​Family history of Alzheimer's disease. ​History of chronic alcohol abuse. ​Undergoing current treatment for HIV. ​Current rehabilitation for opiate addiction.

History of chronic alcohol abuse (Korsakoff's is a type of secondary dementia as a result of thiamine deficiency that is commonly associated with chronic alcohol abuse)

A nurse is planning care for a client who has a personality disorder and demonstrates manipulative behavior. Which of the following interventions is appropriate to include in the plan of care? ​Allow manipulation so as to not raise the client's anxiety. ​Create a strict schedule for the client's activities to discourage manipulation. ​Institute consequences for manipulative behavior. ​Bargain with the client to discourage manipulative behavior.

Institute consequences for manipulative behavior. ​The nurse should work with the client to develop a behavior plan that includes specific consequences for manipulative behavior.

A nurse is caring for a client who has delusional behavior and states, "I can't go to group today. I am expecting a high level official to visit today!" The nurse responds, "I understand, but it is time for group and we expect everyone to attend. Let's walk over together." Why is this nurse's response considered therapeutic? ​It clearly articulates what is expected of the client. ​It demonstrates empathy towards the client. ​It sets limits on the client's manipulative behavior. ​It uses reflection when talking with the client.

It clearly articulates what is expected of the client. ​This response is therapeutic because it clearly states what is expected of the client without arguing. The nurse also offers self by offering to walk with the client.

A nurse enters the room of a client who becomes verbally abusive. Which of the following actions is appropriate for the nurse to take? ​Inform the client of consequences. ​Leave the client's room. ​Identify the inappropriate behavior. ​Maintain eye contact until the behavior stops

Leave the client's room. ​Calmly removing herself from the abusive situation is an appropriate action in response to verbal abuse. This indicates that the behavior is not acceptable and does not provide any escalation of the behavior.

A nurse is planning care for a client who has dementia. Which of the following interventions is appropriate to include in the plan of care? ​Provide a cognitively stimulating environment. ​Rotate staff to prevent caregiver role strain. ​Limit the client's choices for daily activities. ​Use confrontation to manage negative behavior.

Limit the client's choices for daily activities. ​Limiting the client's choices is appropriate for a client who has dementia as this intervention decreases the client's level of stress.

A nurse is caring for a client who is hospitalized with bipolar disorder. The client's provider prescribes valproate (Depakote). Which of the following instructions should the nurse give the client about the use of this medication? Thyroid function tests must be performed every 6 months. A pretreatment electroencephalogram (EEG) will be done. Liver function and complete blood cell counts must be monitored. White blood count must be monitored weekly.

Liver function and complete blood cell counts must be monitored. Pancreatitis, hepatic dysfunction, and anemia are adverse effects occasionally associated with valproate. Even though these effects are relatively rare, blood testing should be performed every 3 to 6 months.

A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (select all that apply) Death of a parent at a young age Recent or impending move Low parental expectations Volunteers at a community center after school Sudden decline in school performance

Low parental expectations death of a parent at a young age recent or impending move sudden decline in school performance

A nurse is caring for a client who is withdrawing from opioid addiction. Which of the following medications should be included in client care? Methadone (Dolophine) Disulfiram (Antabuse) Risperidone (Risperdal) Lithium carbonate (Eskalith)

Methadone (Dolophine) Methadone is a synthetic opiate that blocks the craving for and the effects of narcotics. It is widely used to assist with detoxification and maintenance of those who have a dependency to opioids. Methadone reduces withdrawal symptoms, but it does not cause a high. The medication must be taken every day. The client requires close monitoring because methadone is highly addictive. Methadone is approved for the treatment of women who are pregnant and addicted to opioids.

A nurse on an acute mental health unit is caring for a client who has depression. Which of the following is the highest priority nursing intervention? ​Monitor for risk of self-harm. ​Administer prescribed antidepressants. ​Encourage adequate fluid intake. ​Assist with activities of daily living.

Monitor for risk of self-harm. ​Self-harm or suicide presents the greatest risk to the client; therefore, monitoring for risk of self-harm is the highest priority intervention.

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications. Findings include muscle rigidity, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring? ​Tardive dyskinesia ​Neuroleptic malignant syndrome ​Acute dystonia ​Pseudoparkinsonism

Neuroleptic malignant syndrome (NMS)

A nurse is caring for a client who has a serum lithium level of 2.0 mEq/L. Which of the following is the priority action for the nurse to take? Notify the primary provider of this toxic blood level. Continue to monitor this expected maintenance level. Anticipate increasing the medication dose because this value is subtherapeutic. Anticipate decreasing the medication dose because this value is slightly above therapeutic level.

Notify the primary provider of this toxic blood level. A level of 2.0 mEq/L is toxic. The therapeutic range is 0.8-1.4 mEq/L. The margin between the therapeutic and toxic levels of lithium carbonate is very narrow. Early signs of lithium toxicity include gastrointestinal distress, polyuria, muscle weakness, and slurred speech. Late signs of lithium toxicity include mental confusion, poor coordination, and coarse tremors.

A nurse is caring for a client who has obsessive-compulsive behavior (OCD). Which of the following actions should the nurse use to handle the client's ritualistic behaviors? Isolate the client for a period of time. Confront the client about the senseless nature of the ritualistic behaviors. Plan the client's schedule to allow time for rituals. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Plan the client's schedule to allow time for rituals. OCD is an anxiety disorder characterized by obsessions or compulsions. An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. A compulsion is a conscious, recurrent pattern of behavior a client feels driven to perform. This behavior can be a physical action or a mental act that is aimed at neutralizing anxiety or distress. To help the client handle anxiety in the initial phase of treatment, adequate time must be allowed for the client to perform the rituals.

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements indicates an understanding? ​"The legal requirement for client confidentiality does not apply if the client is deceased." ​"Staff members are required to divulge information to attorney's if they call for information." ​"Health care workers can use client confidentiality for their own legal defense." ​"Providers are required to warn individuals if the client threatens harm."

Providers are required to warn individuals if the client threatens harm.

A nurse in a drug and alcohol detoxification center is caring for a client who has a long history of alcohol abuse. Which of the following should be the nurse's primary focus of care during the early phase of alcohol withdrawal? Assessing the client's coping skills Providing for adequate hydration and rest Confronting the use of denial and other defense mechanisms Educating the client about alcohol abuse and treatment

Providing adequate hydration and rest. Providing for the client's physical needs should be the nurse's priority until the client completes the detoxification phase of treatment. Rest is important for two reasons: alcohol use disrupts normal sleep patterns, and alcohol withdrawal or detoxification is often associated with increased restlessness and agitation. Restoring and maintaining fluid and electrolyte balance is another important goal during detoxification to prevent fluid and electrolyte imbalances.

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time? ​Suggest that the client rest in bed. ​Remain with the client in his room. ​Medicate the client with a sedative. ​Have the client join a therapy group.

Remain with the client in his room. ​The nurse should not leave a client who has severe anxiety alone. The nurse's priority is to use the least restrictive intervention, such as staying with the client and calmly encouraging him to express his feelings.

A nurse in an addiction rehabilitation center is planning care for a new client with a long-standing history of alcohol abuse. Which of the following goals is of the highest priority? ​The client will acknowledge alcohol dependence and need for treatment. ​The client will rebuild damaged interpersonal relationships. ​The client will implement alternative strategies for managing anxiety. ​The client's withdrawal from alcohol will be managed without complications.

The client's withdrawal from alcohol will be managed without complications ​The greatest risk to the client is injury and adverse effects of withdrawal therefore this goal is the highest priority.

A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol (Haldol). The nurse should suspect the client may be experiencing tardive dyskinesia as an adverse reaction when the client exhibits which of the following? (Select all that apply) Urinary retention and constipation Tongue thrusting and lip smacking Fine hand tremors and pill rolling Facial grimacing and eye blinking Extreme sedation and lethargy Repetitive involuntary movements

Repetitive involuntary movements Facial grimacing and eye blinking tongue thrusting and lip smacking Urinary retention and constipation is incorrect. Haloperidol can cause cholinergic-type side effects, such as dry mucous membranes, urinary retention, and constipation. However, these are not manifestations of tardive dyskinesia.​ Tongue thrusting and lip smacking is correct. Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as tongue thrusting and lip smacking.​ Fine hand tremors and pill rolling is incorrect. The side effects of haloperidol can include extrapyramidal (parkinsonian) symptoms, such as fine hand tremors and pill rolling. However, these are not manifestations of tardive dyskinesia.​ Facial grimacing and eye blinking is correct. Individuals who have tardive dyskinesia make repetitive and uncontrollable movements such as facial grimacing and eye blinking.​ Repetitive involuntary movements is correct. Long-term use of neuroleptic medications that are used to treat schizophrenia and related psychiatric disorders may cause a side effect known as tardive dyskinesia. Individuals who have tardive dyskinesia make repetitive and involuntary movements.

A nurse is caring for a school-age child who has a history of disruptive behavior. Which of the following actions should the nurse implement? (select all that apply) Introduce some humor during interactions with the child. Explain to the child the need to pick up crayons when thrown on the floor. Shorten a reading activity when the child appears to become frustrated. Place the child in a vest restraint when disruptive behavior occurs. Make an audible tapping sound when the child's disruptive behavior begins.

Shorten a reading activity when the child appears to become frustrated Make an audible tapping sound when the child's disruptive behavior begins. Explain to the child the need to pick up crayons when thrown on the floor Introduce some humor during interactions with the child Introduce some humor during interactions with the child is correct. Using well-timed, appropriate humor acts as a diversion and can help the child save face and relieve feelings of guilt and fear. According to Erikson, the school-age child is in the developmental milestone of industry vs. inferiority and the nurse should promote achievement of this milestone. Humor can be an effective technique to manage disruptive behavior while avoiding feelings of inferiority in the child.Explain to the child the need to pick up crayons when thrown on the floor is correct. This behavior of throwing crayons on the floor is inappropriate and unacceptable. The nurse's role in caring for a child with disruptive behavior is to establish and maintain appropriate behavior. This teaches the child boundaries and helps to differentiate acceptable and unacceptable behavior.Shorten a reading activity when the child appears to become frustrated is correct. Restructuring is changing an activity in a way that will decrease the stimulation or frustration. If a child is reading a book or being read to and suddenly becomes frustrated or begins acting out, the reading activity can be shortened and restructured to decrease frustration or an acting-out behavior. Restructuring is an effective technique to manage disruptive behavior.Place the child in a vest restraint when disruptive behavior occurs is incorrect. A vest restraint is not appropriate for a child who has disruptive behavior. The nurse should implement the least restrictive measures (distractors, communication, and redirecmmediate thtion) prior to physically restraining a client. The criteria for applying a restraint include an ireat to self or others.Make an audible tapping sound when the child's disruptive behavior begins is correct. Redirection is a technique used to engage or re-engage a child in an appropriate activity. A gesture, such as audibly tapping on a table can be used as redirection. The noise provides a distraction, allowing the child to be redirected. Redirection is an acceptable technique for managing disruptive behavior.

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following is an appropriate nursing intervention for helping this client at this time? ​Instruct the client about the importance of eating. ​Weigh the client at the same time every morning. ​Ask provider to arrange a nutritional consultation. ​Sit with the client during meals and snacks.

Sit with the client during meals and snacks. ​A change in appetite is a major symptom of depression. Being present during meals and snacks to support and encourage the client is an appropriate nursing intervention that might actually help the client at this time.

A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care? Encouraging decision-making Giving the client choices of activities Playing a game of chess with the client Spending time with the client

Spending time with the client This option uses the therapeutic communication tool of being silent. Because depressed clients frequently have suicidal tendencies, spending time with the client will provide for safety. Depression also involves diminished self-esteem, and spending time with the client conveys that the client is worth the nurse's time and attention.

A nurse is completing an admission database. Which of the following nonverbal client cues should the nurse recognize as a response to stress? The client says, "I have been sleeping excessively." The client does not maintain eye contact. The client asks the nurse, "Can I have a nerve pill?" The client states, "I am so stressed. I need help."

The client does not maintain eye contact. The nurse collects objective findings related to stress and coping through observation of the appearance and nonverbal behavior of the client. The nurse should observe the client's eye contact, grooming and hygiene, gait, characteristics of the handshake, actions while sitting, quality of speech, and attitude.

A nurse is caring for a 48 year old client who is grieving. The client reports that her husband died seven months ago, that she has lost 30 lb, and that she has difficulty sleeping. Which of the following items of data indicate that the client is experiencing maladaptive grieving? ​The client is 48 years old. ​The client's husband died seven months ago. ​The client has lost 30 lb. ​The client has difficulty sleeping.

The client's husband died seven months ago ​One of the defining factors of maladaptive grieving is grief that lasts 6 months or longer after the loss.

A nurse is caring for a client who has schizophrenia and is receiving treatment with haloperidol (Haldol). The nurse identifies movement disorders as an adverse effect of the medication and should document the findings as which of the following? Extrapyramidal symptoms Autonomic dysreflexia Reflex sympathetic dystrophy Muscular dystrophy

extrapyramidal symptoms

A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission from the nurse before performing activities of daily living. This action indicates that the client ​is ready for discharge. ​may be having a recurrence of delirium tremens. ​is able to function independently. ​is exhibiting dependency.

is exhibiting dependency ​Seeking permission for simple tasks indicates dependent functioning.

A nurse is assessing a parent who lost a 12-year old child in a traffic accident 2 years prior to the visit. The nurse evaluates that the client is is showing manifestations of dysfunctional grieving if the parent: leaves the child's room exactly as it was before the loss. volunteers at a local children's hospital. talks about the child in the past tense. visits the child's grave every week after worship services.

leaves the child's room exactly as it was before the loss.

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize this when the client: displays compulsive and ritualistic behaviors. reminisces about the past. makes up stories when unable to remember actual events. refuses to leave home to see a provider.

makes up stories when unable to remember actual events. Confabulating is filling in gaps in memory by fabrication. A client who has dementia may do this to cover for and decrease anxiety about memory gaps.

A nurse in an ED is caring for a client who has been taking haloperidol (Haldol) for the past 3 months. The client has a temp of 38.9 (102), a blood pressure of 150/110, and is tachycardic. The nurse should know that these manifestations indicate a diagnosis of agranulocytosis. neuroleptic malignant syndrome (NMS). hypertensive crisis. tardive dyskinesia.

neuroleptic malignant syndrome (NMS) NMS is a rare and potentially fatal adverse effect of antipsychotic medications that requires emergency medical intervention. Other manifestations associated with NMS are sudden onset muscle rigidity, tremor, stupor, incontinence, elevated serum enzymes, hyperkalemia (elevated potassium), and renal failure.