Psych Exam 2 notecards

Which statement made by an unlicensed assistive personnel (UAP) indicates to the registered nurse that the UAP understands the concepts related to suicide? 1. "Discussing suicide with a client is not harmful." 2. "Those clients who talk about suicide never do it." 3. "Depressed clients are the only persons who commit suicide." 4. "When a person talks about making suicide threats, the only thing the person wants is attention from family and friends."

1. "Discussing suicide with a client is not harmful."

Which client is most at risk for committing suicide? 1. A 75-year-old client with metastatic cancer 2. A 71-year-old client with a cardiac disorder 3. A 24-year-old client who just had an argument with her roommate 4. A 30-year-old newly divorced client who states she has custody of the children

1. A 75-year-old client with metastatic cancer

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 and 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. What action should the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the health care provider (HCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.

1. Call the nursing supervisor.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings does the nurse expect to note? Select all that apply. 1. Dental decay 2. Moist oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range

1. Dental decay 3. Loss of tooth enamel 4. Electrolyte imbalances

The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explaining the importance of leaving the violent situation

1. Information regarding shelters

The nurse has been observing a client closely who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least helpful to this client at this time? 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client.

1. Initiate confinement measures.

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

1. Monitor vital signs. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 6. Provide reality orientation as appropriate.

The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately

1. One-to-one suicide precautions

The nurse obtains an ECG rhythm strip for an adult client who is anxious about the result. The ECG shows that the heart rate is 90 beats/minute. What should the nurse tell the client to relieve anxiety? 1. The rate is normal 2. There is no need to worry 3. A slower heart rate is preferred 4. Medication specific to the problem will be prescribed

1. The rate is normal

The nurse is performing an assessment on a client with dementia. Which data gathered during the assessment indicates a manifestation associated with dementia? 1. Uses confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care

1. Uses confabulation

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times."

2. "I keep reliving the robbery." 3. "I see his face everywhere I go." 5. "I might have died over a few dollars in my pocket."

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." What is the most helpful response by the nurse? 1. "Why don't you tell your wife about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation."

2. "What do you find difficult about this situation?

A client says to the nurse, "I don't do anything right. I'm such a loser." Which therapeutic statement should the nurse make to the client? 1. "Everything will get better" 2. "You don't do anything right?" 3. "You do things right all the time" 4. "You are not a loser, you are sick"

2. "You don't do anything right?"

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care? 1. Ask the client why he started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long he thought that he could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

2. Ask the client about the amount of drug use and its effect.

What should the nurse instruct the staff to do when formulating the plan of care for a client with paranoia? 1. Have the client sign a release of information form 2. Avoid laughing or whispering in front of the client 3. Increase the socialization of the client with unit peers 4. Begin educating the client about available social supports

2. Avoid laughing or whispering in front of the client

The nurse develops a plan of care for a 1-month-old infant hospitalized for intussusception. Which nursing measure would be most effective to provide psychosocial support for the parent--child relationship? 1. Provide educational materials 2. Encourage the parents to room-in with their infant 3. Initiate home nutritional support as early as possible 4. Encourage the parents to go home and get some sleep

2. Encourage the parents to room-in with their infant

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes were much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge

2. Evidence of the client's disturbed body image

The police arrive at the emergency department with a client who has lacerated both wrists. What is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.

2. Examine and treat the wound sites.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continued contact with a crisis counselor 4. Eliminating all anxiety from daily situations

2. Identifying anxiety-producing situations

The nurse in the emergency department is 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. How should the nurse interpret these behaviors? 1. Signs of depression 2. Normal reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

2. Normal reactions to a devastating event

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis could be caused by which event? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client

2. The death of a loved one

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client? 1. Chess 2. Writing 3. Ping pong 4. Basketball

2. Writing

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. What is the most appropriate nursing response? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel like the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"

3. "Tell me more about the incident that causes you to feel like the rape just occurred."

A preschool child is placed in traction for treatment of a femur fracture. The child has started bedwetting, even though he has been toilet trained for a year. The mother is very upset about the situation. The nurse explains to the mother that this behavior should be recognized as which psychosocial adaptation? 1. A body image disturbance 2. Attention-seeking behavior 3. Regressing to earlier developmental behavior 4. A result of an undiagnosed urinary tract infection

3. Regressing to earlier developmental behavior

The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, "There sure are a lot of wires around here. I sure hope we don't get hit by lightening." Which is the appropriate nursing response? 1. "Your family can stay tonight if they wish." 2. "Would you like a mild sedative to help your relax?" 3. "Oh, don't worry, the weather is supposed to be sunny and clear today." 4. "Did someone explain to you what the cardiac monitor is for?"

4. "Did someone explain to you what the cardiac monitor is for?"

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations." 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

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

A manic client is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention should the nurse include in her plan of care before seclusion? 1. Ask the client if she understands why the seclusion is necessary 2. Remain silent because verbal interaction would be too stimulating 3. Tell the client that she will be allowed to come out when she can behave 4. Inform the client that she is being secluded to help her regain her self-control

4. Inform the client that she is being secluded to help her regain her self-control

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1. Incessant talking and sexual innuendoes 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake

4. Nonstop physical activity and poor nutritional intake

The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is complaining of insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse recognizes these complaints to be indications of which disorder? 1. Phobia 2. Dissociative disorder 3. OCD 4. PTSD

4. PTSD

The community health nurse is conducting an awareness workshop on adolescent suicide. What should the nurse discuss as risk factors? Select all that apply 1. Family violence 2. Use of alcohol or drugs 3. Strong peer relationships 4. Family history of depression 5. Adequate school performance

1, 2, 4 1. Family violence 2. Use of alcohol or drugs 4. Family history of depression

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective coping mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client

1. An expected coping mechanism

The nurse is assessing a client who was just admitted to the psychiatric unit. The client says, "You won't have to worry about me much longer." How should the nurse interpret this statement? 1. An intention of suicide 2. An expression of depression 3. An intention of self-mutilation 4. An expression of hopelessness

1. An intention of suicide

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1. Provide authority, action, and participation. 2. Display an attitude of detachment, confrontation, and efficiency. 3. Demonstrate confidence in the client's ability to deal with stressors. 4. Provide hope and reassurance that the problems will resolve themselves.

1. Provide authority, action, and participation.

A client with angina pectoris is extremely anxious after being hospitalized. What should the nurse do to minimize the client's anxiety? 1. Provide care choices to the client 2. Keep the door open and the hallway lights on at night 3. Encourage the client to limit visitors to as few as possible 4. Admit the client to a room as far as possible from the nurses station

1. Provide care choices to the client

A community health nurse visits a recently widowed retired military man. When the nurse visits, the ordinarily immaculate house is in chaos, the client is disheveled and has an alcohol type of odor on his breath. Which therapeutic statement should the nurse make to the client? 1. "I can see this isn't a good time to visit" 2. "You seem to be having a very troubling time" 3. "Do you think your wife would want you to behave like this?" 4. "What are you doing? How much are you drinking and for how long?"

2. "You seem to be having a very troubling time"

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime

2. A client undergoing diagnostic tests

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? 1. Increase socialization of the client with peers. 2. Avoid laughing or whispering in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.

2. Avoid laughing or whispering in front of the client.

The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise rigorously.

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

An older client is brought to the emergency room by a family member with whom she lives. The nurse notes that the client has poor hygiene, contractures, and pressure ulcers on the sacrum, the scapula, and the heels. The client is suspected of which form of victimization? 1. Sexual abuse 2. Physical abuse 3. Emotional abuse 4. Psychological abuse

2. Physical abuse-includes neglect

A 9-year-old is hospitalized for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development? 1. Providing a portable media player (MP3) 2. Tutoring to keep the child up with schoolwork 3. Providing a phone for calling family and friends 4. Placing computer games, a television, and videos at the bedside

2. Tutoring to keep the child up with schoolwork

The nurse is preparing a plan of care for a client diagnosed with mania. Which interventions should be included in the plan of care? Select all that apply. 1. Place the client in seclusion 2. Ignore any client complaints 3. Use a firm and calm approach 4. Use short and concise explanations and statements 5. Remain neutral and avoid power struggles and value judgments 6. Firmly redirect energy into more appropriate and constructive channels

3, 4, 5, 6 3. Use a firm and calm approach 4. Use short and concise explanations and statements 5. Remain neutral and avoid power struggles and value judgments 6. Firmly redirect energy into more appropriate and constructive channels

A 16 year old client is hospitalized. Which statement by the client would alert the nurse to a potential developmental problem? 1. "I'd like my hair washed before my friends get here" 2. "Is it okay if I have a couple of friends in to visit me this evening?" 3. "Please tell my friends not to visit, since I'll see them back at school next week." 4. "When my friends get here, I would like to play some computer games with them."

3. "Please tell my friends not to visit, since I'll see them back at school next week."

The nurse is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, what is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?"

The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."

3. "You seem restless; tell me what is happening."

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action? 1. Requesting that a peer remain with the client at all times 2. Removing the client's clothing and placing the client in a hospital gown 3. Assigning a staff member to the client who will remain with the client at all times 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed

3. Assigning a staff member to the client who will remain with the client at all times

The nurse is leading a crisis intervention group comprised of high school students who have experienced the recent death of a classmate who committed suicide. The students are experiencing disbelief as they review the details of finding the classmate dead in the bathroom. What should be the initial step by the nurse? 1. Ask how the students recovered from a death event in the past 2. Reinforce the students' ability to work through this death event 3. Inquire about the students' perceptions of their classmate's suicide 4. Reinforce the students' sense of growth through this death experience

3. Inquire about the students' perceptions of their classmate's suicide

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision

3. Observing rigid rules and regulations

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques. 2. Encourage the client to discuss the assault. 3. Remain with the client until the anxiety decreases. 4. Place the client in a quiet room alone to decrease stimulation.

3. Remain with the client until the anxiety decreases.

The nurse is developing a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.

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

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations

4. Hypertension, changes in level of consciousness, hallucinations

The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care? 1. Disrupted appearance because of weight 2. Inability to feed self because of weakness 3. Pain because of an inflamed gastric mucosa 4. Nutritional imbalance because of lack of intake

4. Nutritional imbalance because of lack of intake

The nurse manager is discussing seclusion procedures with the nursing staff for clients with a mental health disorder. Under which circumstances is seclusion contraindicated? Select all that apply. 1. The client has severe dementia 2. The client requests to be secluded 3. The client experienced a severe drug overdose 4. The client presents a clear and present danger to self or others 5. The client has been legally detained for involuntary treatment and is thought to pose an escape risk 6. The client has an unstable mental health disorder and nursing staff needs to attend a monthly staff meeting

1, 3, 6 1. The client has severe dementia 3. The client experienced a severe drug overdose 6. The client has an unstable mental health disorder and nursing staff needs to attend a monthly staff meeting

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse-reporting laws 2. Notifying the case worker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member

3. Removing the client from any immediate danger

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the day before ECT includes ensuring that the client follows which guideline? 1. Does not smoke at all 2. Receives no visitors and participates in limited unit activities 3. Reports to the clinic for blood draws and an electrocardiogram (ECG) 4. Is placed on nothing by mouth (NPO) status for 16 to 24 hours before the ECT

3. Reports to the clinic for blood draws and an electrocardiogram (ECG)

A client diagnosed with catatonic posturing demonstrates severe withdrawal by lying on the bed with his body pulled into a fetal position. Which intervention should the nurse take to increase interpersonal communication? 1. Ask the client direct questions to encourage talking 2. Leave the client alone and intermittently check on him 3. Sit beside the client in silence and occasionally ask open-ended questions 4. Take the client into the dayroom with the other clients so that they can help watch him

3. Sit beside the client in silence and occasionally ask open-ended questions

The nurse in the mental health unit is performing an assessment in a client who has a history of multiple somatic complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder? 1. Depression 2. Schizophrenia 3. Somatization disorder 4. Obsessive-compulsive disorder

3. Somatization disorder

A hospitalized client has participated in substance abuse therapy group sessions. The nurse is monitoring the client's response to these sessions. Which statement by the client would best indicate that the client has assimilated session topics, understood coping response styles, and processed information effectively for self-use? 1. "I'll keep all my appointments and I'll do everything I'm supposed to. I just know nothing will go wrong that way." 2. "I know I'm ready to be discharged. I feel like I'll have no problem saying no and leaving a group of friends if they are drinking." 3. "This group has really helped a lot. I know it will be different when I go home. But I'm sure that my family and friends will all help me, like the people in this group have. They'll all help me, I know they will. They won't let me go back to my old ways." 4. "I'm looking forward to leaving here, but 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 all have been. I know it isn't going to be easy, but I'm going to try as hard as I can."

4. "I'm looking forward to leaving here, but 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 all have been. I know it isn't going to be easy, but I'm going to try as hard as I can."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics."

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

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent gives away a DVD and a cherished autographed picture of a performer. 2. The adolescent runs out of the therapy group, swearing at the group leader, and runs to her room. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

1. The adolescent gives away a DVD and a cherished autographed picture of a performer.

A nursing instructor teaches a group of nursing students about violence in the family. Which statement by a student indicates a need for further teaching? 1. "Abusers use fear and intimidation." 2. "Abusers usually have poor self-esteem." 3. "Abusers often are jealous or self-centered." 4. "Abuse occurs more often in low-income families."

4. "Abuse occurs more often in low-income families."

The nurse is performing an assessment on a 16 year old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further assessment? 1. "I check my weight every day without fail." 2. "I exercise 3 to 4 hours every day to keep my slim figure." 3. "I've been told that I am 10% below my ideal body weight." 4. "My best friend was in the hospital with this disorder a year ago."

2. "I exercise 3 to 4 hours every day to keep my slim figure."

A client is admitted to the inpatient mental health unit. When asked her name, she responds, "I am Elizabeth, the Queen of England." What should the nurse recognize this client statement as indicating? 1. Visual illusion 2. Loose association 3. Grandiose delusion 4. Auditory hallucination

3. Grandiose delusion

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." How should the nurse plan on responding to the client's statement? 1. Reassure the client that things will get better. 2. Tell the client that this is not true and that we all have a purpose in life. 3. Identify recent behaviors or accomplishments that demonstrate the client's skills. 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

3. Identify recent behaviors or accomplishments that demonstrate the client's skills.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed

3. Increasing the level of suicide precautions