psych exam 3 prepu practice

The nurse is providing care for a psychiatric-mental health client who has a diagnosis of anxiety. Which statement by the nurse is likely the most therapeutic intervention?

"Anxiety is a feeling that is experienced by everyone at some point and it can never be completely removed from one's life."

An 11-year-old has been diagnosed with depression. When interviewing the child for the first time, which question would be most appropriate to ask?

"Are you feeling sad?"

A client who is depressed states, "I think my family would be better off without me. They don't need to worry." Which would be the most appropriate response by the nurse?

"Are you planning to commit suicide?"

A client who has a recent diagnosis of bipolar I disorder is scheduled to begin therapy with lithium. Which instruction should the nurse provide to this client?

"Avoid exercise at the hottest times of the day."

The client with mania attempts to hit the nurse. Which of the following is the best response by the nurse?

"Do not swing at me again. If you cannot control yourself, we will help you."

When conducting a social history with a client diagnosed with a borderline personality disorder (BPD), which question would be most important to ask the client related to impulsivity?

"Do you always practice safe sex?"

A nursing instructor is teaching about depressive disorders and identifies a need for further instruction when a student states what?

"Dysthymic disorder is less chronic than major depression."

A nursing instructor is teaching students about borderline personality disorder (BPD) and identifies a need for further instruction when a student makes which statement?

"Family members feel the need to disagree with the client with BPD to help make them resilient."

A client with schizophrenia is prescribed a second-generation antipsychotic. The client's parent asks, "About how long will it take until we see any changes in the symptoms?" Which response by the nurse would be most appropriate?

"Generally, it takes about 1 to 2 weeks to be effective in changing symptoms."

During a therapy session, a client with anorexia tells the nurse, "I measured my thighs today. They are a quarter-inch larger than they were yesterday. I feel like a pig; I'm so fat." Which potential response by the nurse is most therapeutic?

"Has something occurred that caused you to measure your thighs?"

a nurse is assessing a client with borderline personality disorder. Which question would be mostappropriate to assess the client's level of impulsivity?

"Have you ever felt sorry after acting as you did on the spur of the moment?"

A psychiatric nurse is assessing a client with post-traumatic stress disorder (PTSD). During the psychosocial component of the assessment, what assessment question should the nurse include?

"How are your symptoms affecting your day-to-day routines?"

The nurse is preparing to meet with the parents after interviewing the child. Which is the nurse's best opening question to the parents?

"How have things been in your family?"

The nurse is teaching a client with bulimia to use self-monitoring techniques. Which statement by the client would let the nurse know that this has been effective?

"I am learning to recognize events and emotions that trigger my binges and am working on responses other than binging and purging.

At 1 a.m., the client with mania rushes to the nurses' station and demands that the psychiatrist come to the unit now to write an order for a pass to go home. Which response by the nurse would be the most therapeutic?

"I can't call the psychiatrist now, but you and I can talk about your request for a pass."

After teaching a client with schizoaffective disorder about the condition and treatment, the nurse determines that the education was successful when the client states what?

"I need to eat properly so that I can control my weight."

Which statement made by the nurse managing the care of an anorexic teenager demonstrates an understanding of the client's typical, initial reaction to the nurse?

"I realize this must be very difficult for you but try to remember I'm not your enemy."

A client with anorexia weighs less than 85% of the client's normal body weight. The client says, "I'm so fat, I can't even get through this doorway, much less fit into any of my clothes." Which is the nurse's most therapeutic response?

"I understand what you are saying. However, you are under your ideal body weight, and it is causing you to have the medical problems that we have talked about.

A client on an in-patient psychiatric unit has been diagnosed with bulimia nervosa. The client states, "I'm going to the bathroom and will be back in a few minutes." Which response by the nurse is most appropriate?

"I will accompany you to the bathroom."

A nurse is developing a nurse-client relationship with a client diagnosed with borderline personality disorder (BPD). Which statement by the nurse demonstrates that the nurse understands the client's fears of abandonment and intimacy?

"I will be seeing you during the daytime this week."

Which statement by a client would indicate the need for additional education regarding a prescribed lithium treatment regimen?

"I will restrict my intake of processed foods high in sodium."

One approach to establish adequate eating patterns for a client with anorexia is to assume a positive expectation of the client. Which is the best statement by the nurse?

"I will sit here quietly with you while you eat

A client with borderline personality disorder says to the nurse, "I feel so comfortable talking with you. You seem to have a special way about you that really helps me." Which would be the most appropriate response by the nurse?

"I'm here to help you just as all the staff members are."

A client with post-traumatic stress disorder has recently been prescribed prazosin. What statement by the client would most clearly suggest that the medication is having the desired effect?

"I'm sleeping better than I have for many months."

The nurse is sitting with the client at mealtime. The nurse uses cognitive-behavioral approaches to assist the client with bulimia toward recovery. Which statement by the nurse would be consistent with this approach?

"Is there any way you can look at that sandwich as fuel for your body?"

An adolescent diagnosed with anorexia nervosa is insistent on being allowed to take a laxative. Which response by the nurse best demonstrates the management of this client request?

"Laxatives are not a part of your treatment plan."The nurse should avoid sounding parental when teaching about nutrition or why laxative use is harmful.

A 52-year-old client with bipolar disorder tells the nurse, "I read that there are chemicals in my brain that can cause my symptoms." Knowing that the client is referring to neurotransmitters, which would be the best response by the nurse?

"Low levels of the neurotransmitter serotonin are associated with mania."

A nursing student has learned about attachment and how this emotional bond between infant and parent helps create the groundwork for future relationships. What statement made by this student indicates a need for further clarification from the instructor?

"Mother-child separation for 1 week or more within the first 2 years of life has been related to self-reliance on the child's part in later years."

The nurse is working with a client who is suspected of having posttraumatic stress disorder after witnessing a violent crime. What statement by the client's spouse would suggest that the client is experiencing hyperarousal?

"My spouse always seems so irritated now, which isn't like my spouse."

A client tells the nurse that the client has bugs in the client's brain and asks the nurse if the nurse can see them. Which response by the nurse is most therapeutic?

"No, I don't see any bugs. That sounds scary for you."

The nurse has just completed an admission assessment of the client with anorexia. When documenting the mental status exam findings in the chart, the nurse notes poor judgment and insight. Which client statement would support this impression?

"Others are just trying to keep me from looking good."

The nurse is working with a client who has been experiencing nightmares, hyperarousal and negative thoughts following a bomb threat at the client's workplace. The nurse's colleague states, "It turned out to be just a threat, not a bombing, so technically she can't have posttraumatic stress disorder (PTSD)." What is the nurse's best response?

"PTSD is a real possibility, even though the bombing never actually took place."

A nurse is working with the parents of an 8-year-old with attention deficit hyperactivity disorder (ADHD) and teaching the parents about how to manage the child's behavior. During the teaching, the mother asks the nurse, "Sometimes I find our child jumping off the bed onto a chair. What should I do?" The nurse would most likely instruct the mother to say:

"Stop that right now."

The nurse is assisting the client with anorexia nervosa to express feelings more openly. Which response by the nurse would be most likely to encourage expression of feelings?

"Tell me what you are feeling right now."

A client with bipolar I disorder has been prescribed lithium. On a follow-up visit, the client reports a metallic taste in the mouth. Which intervention would the nurse most likely suggest? Select all that apply.

"Try using sugarless candies periodically." "Make sure to brush your teeth frequently."

The advanced practice psychiatric mental health nurse is preparing to begin stress inoculation training with a client who has post-traumatic stress disorder. What should the nurse teach the client about this therapy?

"We're going to work to help you develop a new perspective on your traumatic memories.

A nurse who provides care at an inpatient eating disorder clinic is performing an admission assessment of a young client who has been diagnosed with anorexia nervosa. Which assessment question reflects therapeutic communication?

"What do you think about how much you weigh right now?"

The client with schizophrenia tells the nurse that rats have started to eat the client's brain. Which would be the best response by the nurse?

'Have you discussed this with your health care provider?"

A nurse is interviewing a client and suspects an eating disorder. Which client statement would the nurse interpret as demonstrating a risk for the development of an eating disorder? Select all that apply

."Everything about my school work needs to be perfect." "I want things to be the way I want them to be." "Things being out of order really bothers me."

A client is diagnosed with anorexia nervosa, restricting type. The nurse interprets this as indicating the use of which of the following? Select all that apply

.Dieting Exercising

In a preschool child assessment to clarify the child's body image difficulties, the nurse will use ..

.drawings

a client with borderline personality disorder has difficulty maintaining boundaries of the professionalrelationship. Which of the following would be most effective for the nurse to do? Select all that apply

.• Respond to the client's arrogance in a neutral, nonconfrontational manner. • Discuss the purpose of the limits in the therapeutic relationship. • State the parameters of the limits and boundaries clearly. • Ensure that any established limits are maintained consistently.

A diagnosis of delusional disorder is based on the presence of one or more nonbizarre delusions for at least what period of time?

1 month

Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.2. Hallucinations.3. Disorganized speech (e.g., frequent derailment or incoherence).4. Grossly disorganized or catatonic behavior.5. Negative symptoms (i.e., diminished emotional expression or avolition).

Which lab value is within the range of safety for maintenance or treatment with lithium?

1.2 mEq/L

A nurse is providing care to a client with anorexia who is beginning a refeeding protocol. Based on the nurse's understanding of these protocols, the nurse would expect the client to start with how many calories per day?

1500

A client is being admitted to the in-patient psychiatric unit with a diagnosis of bulimia nervosa. The nurse would expect this client to fall within which age range?

18 to 22 years old

A specific cause for eating disorders is unknown. Many factors are implicated as increasing the tendency toward eating disorders. Which of the following is a family risk factor for bulimia nervosa?

Chaotic family

A 30-year-old client is in therapy for bulimia, depression, and anxiety. The client relates that the client feels unable to cope with the demands of the client's job and that the client's partner recently ended their long-term relationship. The client states that the client frequently binges when stress levels are high. The client denies feeling suicidal but states, "I'm a mess. I'm just not smart enough to figure out how to run my life!" Which nursing diagnosis would best identify the client's problems?

Chronic low self-esteem related to unrealistic self-expectations

A client developed posttraumatic stress disorder (PTSD) after a motor vehicle accident and is scheduled to begin cognitive processing therapy. What outcome should the advanced practice nurse identify when planning this type of therapy?

Client will describe the effects of PTSD on the client's activities of daily living

The difference between clients with anorexia nervosa and bulimia nervosa is which of the following?

Clients who are anorexic are proud of their control over eating, whereas bulimic clients are ashamed of their behavior.

Which of the following is the primary assessment tool in child in adolescent psychiatry?

Clinical interview with child

A client diagnosed with schizophrenia is in anticholinergic crisis. The nurse would expect which finding to be noted upon assessment?

Clinical manifestations of anticholinergic crisis include facial flushing, tachycardia, urinary retention, and hyperthermia (fever).

The psychiatric nurse recognizes that a client's cultural background can contribute to the misdiagnosis of schizophrenia primarily for which reason?

Clinicians diagnose culturally accepted beliefs as psychotic thinking

Which intervention has been found to be most effective reducing the initial symptoms of bulimia?

Cognitive behavior therapy and pharmacologic interventions

A nurse is developing a plan of care for a client newly diagnosed with bulimia nervosa. Which of thefollowing would the nurse expect to implement in conjunction with pharmacologic therapy?

Cognitive behavioral therapy

The nurse is planning the inpatient care of a client who has been admitted with major depression. The client's plan of care includes regular exercise, but the client is reluctant to participate due to a lack of energy and motivation. What is the nurse's best action?

Collaborate with the client to choose a manageable amount of exercise and acknowledge the client's subsequent effort

The nurse is educating a client and family about managing panic attacks after discharge from treatment. The nurse includes which in the discharge teaching? Select all that apply.

Continued development of positive coping skills Continued practice of relaxation techniques Development of a regular exercise program

The nurse documents that the client is in a state of panic anxiety when she is observed doing which of the following?

Crying hysterically and complaining of a shortness of breath prior to a cardiac procedure

A client who otherwise is healthy is admitted for depression and reports feeling "all alone." The client reports recently losing a spouse to divorce. The client admits to drinking at least 12 beers every day. The client has which risk factors for the depression? Select all that apply.

Current substance use or abuseLife and environmental stressorsLack of coping abilities

An adolescent is brought to the emergency department by her parents because they were concerned about their daughter's appearance. The client appears emaciated and pale. The parents tell the nurse that the client has been diagnosed with anorexia nervosa. A history and physical examination and laboratory testing are completed. Which of the following would lead the nurse to suspect that the client will be admitted to the hospital? Select all that apply.

Decreased serum magnesium level Heart rate of 40 beats/min Statements of being hopeless

A nurse is assessing a client diagnosed with delusional disorder. The nurse would expect to find what?

Delusions with a prominent theme

Which term describes feelings of being disconnected from oneself, as seen in a panic attack?

Depersonalization

Which is the most common disorder found in clients diagnosed with bulimia nervosa?

Depression

After teaching a group of nursing students about major depression, the instructor determines that the education was successful when the group identifies which information is accurate?

Depression is twice as common in women than in men

Which assessment finding exhibited by a patient being assessed for posttraumatic stress disorder(PTSD) would be considered a defining behavior and support such a diagnosis?

Describes vivid 'flashbacks' of being attacked

The nurse is conducting an admission assessment of a client who has a history of generalized anxiety disorder. After gauging the client's level of anxiety, what other assessment should the nurse prioritize?

Determining whether there is potential for the client to harm himself or herself or others

The nurse is interviewing a client who has recently been diagnosed with posttraumatic stress disorder (PTSD). What action by the nurse best addresses the client's experience of intrusion?

Dialoguing with the client about the frequency and intensity of the client's nightmares

A nurse is conducting a mental status exam of a client with borderline personality disorder (BPD). The client verbalizes statements that demonstrate a view of things as absolute, with no perception of compromise. The nurse interprets this type of thinking, documenting it as which of the following?

Dichotomous

In the biopsychosocial psychiatric nursing assessment of children, assessment of the psychological domain includes assessing the child's temperament. Which type of temperament is characterized by a negative response to new stimuli and high emotional intensity?

Difficult

A client with a personality disorder is upset and calls the nurse a "stupid cow." Which is an effective initial response to this client's behavior?

Discuss displacement of anger and set limits.

A client with borderline personality was formerly cooperative with the treatment regimen. Suddenly, the client believes the staff is working against the client and is refusing all interaction and participation in treatment. The nurse feels very frustrated by this client's behavior. What is the best action for the nurse to take regarding personal frustration with this client?

Discuss the frustration with a colleague or supervisor in a private setting.

A nurse is assessing a client and determines that the client is experiencing severe anxiety based on which finding?

Distorted sensory awareness

The nurse is assessing a 30-month-old child during a well-baby checkup. Which behaviors by the child would lead the nurse to suspect that the child has autism spectrum disorder? Select all that apply.

Does not like spontaneous play Rarely makes eye contact with others Makes few facial expressions toward others

A nurse is assessing a client with anorexia nervosa. Which would the nurse be most likely to find?

Dry skin

The nurse is assessing a client with an eating disorder. Which personality characteristic would the nurse expect to detect when interacting with the client?

Eager to please

Which statement best describes the theories of the etiology of eating disorders?

Eating disorders involve dysregulation of multiple neurotransmitter systems, whether as a cause or an effect of the eating disorder, and may be influenced by behavioral, cultural, and familial factors.

A nurse is assessing a child diagnosed with autism spectrum disorder. When assessing the child's communication, which of the following would the nurse expect to find? Select all that apply.

Echolalia delayed language skills

Which aspect of managing a child with attention deficit hyperactivity disorder (ADHD) may often be overlooked in the treatment plan?

Effects on siblings

A client with a diagnosis of bipolar disorder is described by a family member as "flip-flopping between being happy and loving to irritable and hostile." Which characteristic symptoms of this disorder is the family member referring to?

Emotional lability

The nurse is teaching the family of a client who has bulimia about nutritional needs. Which dietary pattern would be most helpful to assist the client in recovering from bulimia?

Encourage the entire family to engage in a balanced and regular dietary pattern.

A nurse is assessing a preschooler and uses play to develop rapport with the child. The nurse uses play based on the understanding that it helps in which area?

Encourages verbalizations.

A client diagnosed with bipolar disorder is admitted to an inpatient psychiatric facility with acute mania and threats of attacking others in the household. Which would be the priority?

Ensuring safety

The nurse is planning to explain the purpose of the behavioral therapy technique of self-monitoring to aclient with bulimia nervosa. The nurse would emphasize keeping a diary to record which of thefollowing?

Environmental stimuli

A client has been diagnosed with anorexia nervosa. Which of the following is a dental complication associated with purging?

Erosion of dental enamel

A client diagnosed with anorexia nervosa is being treated in an outpatient setting in the community. Which activity would be the priority?

Establishing a therapeutic relationship

Nursing interventions for physical stress related illness should include what?

Establishing daily routines of meals and sleeping

A client with a history of bipolar disorder is at home with family. The family calls the mental health clinic because they suspect that the client may be experiencing a relapse of mania. Which would support the family's suspicions?

Excessive energy levels

The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional assessment finding would suggest that the woman has an eating disorder?

Excessive exercise

A client with posttraumatic stress disorder (PTSD) has been unable to have restful sleep since being the victim of a robbery and assault. What should the nurse recommend?

Exercising regularly, but not close to bedtime

A client has been diagnosed with posttraumatic stress disorder (PTSD) after a house fire. Which nursing intervention is most appropriate?

Facilitate the client's introduction to a support group of other people recovering from PTSD

Posttraumatic stress disorder (PTSD) has been diagnosed in a sexually assaulted female client. Which of the following manifestations is the most consistent with PTSD?

Flashbacks

The nurse is assessing a client with posttraumatic stress disorder (PTSD). Which of the following would the nurse categorize as reflecting intrusion? Select all that apply.

Flashbacks & Short-term memory deficits

A client asks how the client's prescribed alprazolam helps the client's anxiety disorder. The nurse explains while teaching the client about medications that antianxiety medications such as alprazolam affect the function of which neurotransmitter that is believed to be dysfunctional in anxiety disorders?

Gamma-aminobutyric acid (GABA)

Which meal would the nurse provide to best meet the nutritional needs of a client who is manic?

Ham sandwich, cheese slices, milk

The nurse is assessing for negative symptoms of schizophrenia in a newly admitted client. The nurse would note which behavior as indicative of a negative symptom?

Hesitant to answer the nurse's questions during the assessment interview

A client with delusional disorder is hospitalized. When reviewing the client's medical record, the nurse identifies which reason as most likely for the hospitalization?

Hospitalization rarely occurs and is usually initiated by legal or social violations. The hospital environment protects the client from further legal intervention

A nurse is reviewing the laboratory test results of a client with anorexia nervosa. Which result would alert the nurse to a possible problem?

Hypercholesterolemia

A nurse is talking to a 7-year-old. The child describes in detail a family pet who recently died. Which response by the nurse is appropriate?

I am sad for your loss.

The nurse is assessing a client who is diagnosed with borderline personality disorder. Which clientstatement indicates the client is at risk for self-injurious behavior?

I have felt so down lately. I don't enjoy doing anything anymore.

While caring for a client with anorexia nervosa, the nurse anticipates that the client would havedifficulty making which of the following comments?

I'm mad at you because you won't let me go on a pass unless I gain weight!

A nurse is performing an admission assessment for an adolescent girl with an eating disorder who isbeing admitted to the psychiatric unit. Which statement would the nurse interpret as most likelysupporting the client's diagnosis?

I've never really liked myself.

Catatonia as seen in clients with schizophrenia is unique in the existence of which feature?

Immobility like being in a trance

When documenting observations of the behaviors exhibited by a client diagnosed with borderline personality disorder, the nurse can correctly use which terms?

Impulsive, self-destructive, unstable

A client with bulimia nervosa is scheduled for a visit to the clinic. When assessing this client, which ofthe following would the nurse expect to find?

Impulsivity

Which is one characteristic that differentiates generalized anxiety disorder (GAD) and panic disorder?

In GAD, the person usually does not experience eruptions of acute anxiety.

Which could be incorporated into the plan of care for a client receiving an antidepressant who is experiencing orthostatic hypotension?

Increase hydration

A nurse is caring for a client with generalized anxiety disorder. When the client starts trembling and perspiring, the nurse becomes uncomfortable and anxious; develops cold, clammy hands; and has a racing pulse. When the nurse responds in this way during an interaction, what will the client most likely develop?

Increased anxiety

A child with attention deficit hyperactivity disorder is taking methylphenidate in divided doses. If the child takes the first dose at 8 a.m., which behavior might the school nurse expect to see at noon?

Increased impulsivity or hyperactive behavior

A nurse is preparing a presentation for a group of mental health nurses on the staff. The nurse is planning to address the topic of the effect of psychoeducation on schizoaffective disorder. Which of the following would the nurse include as an effect? Select all that apply.

Increased social functionIncreased medication complianceDecreased family tension

A psychiatric-mental health nurse who works with a large number of female clients experiencing posttraumatic stress disorder (PTSD) is reading a research article about sexual revictimization and PTSD. Which area would the nurse identify as being a major cause for concern in this group?

Increased substance use across all age groups

A client with post-traumatic stress disorder (PTSD) tells the nurse, "Every morning I wake up with a vicious hangover and swear I'll never drink like that again. Yet, every night I some how end up at the bar." The nurse should consider the possibility of what nursing diagnosis?

Ineffective impulse control

A nursing instructor is preparing a class discussion on personality disorders and characteristics. Which term would the instructor include to differentiate personality disorders from normal personality? Select all that apply.

Inflexible, pervasive, unstable over time & distressing

A nurse is conducting a presentation about autism spectrum disorder for a group of parents. When describing this condition, the nurse would identify that approximately 50% of those with this condition also experience which of the following?

Intellectual disability

A nursing instructor is developing a class lecture that compares and contrasts schizoaffective disorder with schizophrenia. When describing one of the differences between these two diagnoses, what would the instructor include as reflecting schizoaffective disorder?

It is episodic in nature

After educating a group of students on attention deficit hyperactivity disorder (ADHD), the instructor determines that additional education is required when the group identifies which as a typical characteristic?

Language difficulty

A client is prescribed lithium to treat mania. The client also has a history of hypertension for which the client takes lisinopril and hydrocholorothiazide. When monitoring this client, the nurse would be especially alert for signs and symptoms of which condition?

Lithium toxicity

Which of the following personality characteristics is most likely to predispose an individual to medication abuse?

Low self-esteem

A nurse is conducting an assessment of a child. Which technique would be most effective for the nurse to use to establish rapport with family members? Select all that apply.

Maintaining eye contact. Speaking slowly. Showing acceptance.

A client with a history of intimate partner violence has been diagnosed with posttraumatic stress disorder. The client is wholly unwilling to discuss any aspects of personal history or current mental status with the nurse. What is the nurse's best initial action?

Make efforts to demonstrate empathy to the client

The family member of a client who is experiencing delusions asks the nurse if the client will also experience memory problems. Which information would the nurse integrate into the response?

Memory generally remains unaffected and intact

Which medication classification is considered first-line drug therapy for bipolar disorder?

Mood stabilizers

A client with borderline personality disorder (BPD) usually is treated with multiple medications. They can include which of the following types? Select all that apply.

Mood stabilizersAntidepressantsAnxiolytics

When a client is experiencing panic, which is the priority intervention?

Move the client to a quiet environment.

The nurse observes a client sitting alone at a table, looking sad and preoccupied. The nurse sits down and says, "I saw you sitting alone and thought I might keep you company." The client turns away from the nurse. Which would be the most therapeutic nursing intervention?

Move to a chair a little further away and say, "We can just sit together quietly."

A client with posttraumatic stress disorder (PTSD) has been prescribed sertraline. While educating this client about possible side effects, the nurse should stress that the client needs to call their health care provider if they experience which of the following signs/symptoms? Select all that apply.

Muscle twitching Tachycardia (racing heart)

Which of the following is an adverse effect of lithium?

Nausea and diarrhea

Both valproate and carbamazepine may be lethal if high doses are ingested. Toxic symptoms appear in 1 to 3 hours and include what?

Neuromuscular disturbances

The nurse is teaching a class to a group of individuals diagnosed with anxiety disorders. When describing the underlying cause of these disorders, which information would the nurse most likely include?

Neurotransmitter involvement

after teaching a group of students about medications used to treat ADHD, the instructor determines that the education was successful when the group identifies atomoxetine as which of the following?

Noradrenergic reuptake inhibitor

The nurse is assessing a client who has borderline personality disorder. Which of the following would be a priority?

Nutrition patterns

After teaching a class of nursing students about the different types of delusions, the instructor determines that the education was successful when the class identifies which type as most common?

Of the different types of delusions, persecutory delusions are the most common.

Which nursing intervention would be most likely to help the client with anorexia to establish healthy eating patterns?

Offer liquid protein supplements if the client is unable to complete a meal.

A nurse provides care to a client with schizoaffective disorder during hospitalization for acute psychosis. Nursing interventions to help the client to establish trust with the health care team is best accomplished by what?

Offering reassurance in a soft, nonthreatening voice

A depressed older adult client is being treated with a tricyclic antidepressant (TCA). For which clinical manifestations should the nurse monitor the client?

Orthostatic hypotension and urinary retention

A client with mania is in the dining room at lunchtime and is observed taking food from other clients' trays. The nurse's intervention should be based on which rationale?

Other clients need to be protected from the intrusive behavior.

The nurse explains to the client that therapy will be a long process. Which is a realistic outcome for the care of a person with a personality disorder?

Outcomes that focus on change in behavior

Which is a typical characteristic of parents of clients diagnosed with anorexia nervosa?

Overprotective of their children

Individuals with anorexia nervosa often experience comorbid conditions. Which of the following would be most common? Select all that apply.

Panic disorder Obsessive compulsive disorder Depression

Given that the child's primary environment is most often with the parent, the assessment of the child and parent interaction commences when ...

Parent and child are in the waiting area, noting behaviors expressed toward each other

A nurse is observing a client diagnosed with borderline personality disorder on the inpatient unit. Which of the following would the nurse most likely note?

Participating in relationships in which the client has control

A nurse who works primarily with clients who have bipolar disorder identifies which group of clients as not being candidates to take lithium as treatment?

Patients who take ACE inhibitors

A nurse is preparing to assess a school-aged child. Which method would be most effective for the nurse to use to establish rapport with this child?

Playing cards

At the prompting of friends, a 16-year-old client has agreed to meet with the school nurse who suspects that the client may have an eating disorder. During the nurse's assessment, the nurse has asked the client to describe the client's family. Which family process and characteristic is thought to contribute to eating disorders?

Poor communication and enmeshed family dynamics

A client with major depression and a suicide attempt is admitted to the inpatient facility. The client is started on antidepressant therapy. The next day, the client demonstrates significantly higher energy and says, "I'll feel much better." The nurse would interpret this behavior as suggesting what?

Possible decision to complete a suicide attempt

A visitor comes to see a client who is suicidal. Upon entering the unit, the nurse notices that the visitor has brought the client a can of the client's favorite soda. Which action should the nurse take at his time?

Pour the soda into a plastic cup.

A client was admitted to the psychiatric unit after being picked up by police officers who found the client frantically running back and forth across the freeway. The client's spouse reports that the client stayed up all night, ate very little, and talked incessantly. Additional assessment findings that indicate a manic episode include what?

Pressured speech, combative behavior, and impaired judgment

A nurse is preparing a presentation for a group of mental health nurses on the staff. The nurse is planning to address the topic of the effect of psychoeducation on schizoaffective disorder. Which of the following would the nurse include as an effect? Select all that apply.

Psychoeducation results in increased knowledge of the illness and treatment, increased medication compliance, fewer relapses and hospitalizations, briefer inpatient stays, increased social function, decreased family tension, and lighter family burdens

A nurse is teaching a client with borderline personality disorder to reshape thinking patterns. Which is an example of a cognitive restructuring technique that would be helpful for this client?

Recognize negative thoughts and replace them with positive ones.

The nurse is teaching about postoperative wound care. As the wound is uncovered, the client begins mumbling, breathing rapidly, and trying to get out of bed, and the client does not respond when the nurse calls his name. The nurse determines that the client is experiencing anxiety. Which of the following should be the nurse's first action?

Replace the dressing on the wound

A client with bulimia nervosa is being treated at an outpatient clinic and is prescribed a selectiveserotonin reuptake inhibitor (SSRI). Which of the following would the nurse include when teaching theclient about the prescribed medication?

Report any weight changes that occur during the first few weeks this medication is taken.

The immediate goal of nursing interventions in the care of a client with anorexia nervosa is which of the following?

Restoring nutritional status to normal

When developing a plan of care for a client diagnosed with panic disorder, which nursing diagnosis would be considered the priority?

Risk for Self-Directed Violence

A client arrives on the psychiatric unit exhibiting restlessness, disorientation, incoherent speech, agitation, purposeless physical activity, and suicidal ideations. Which of the following is the priority nursing diagnosis for this client?

Risk for injury

The client with bulimia reports feeling helpless and says, "What's the use?" As the nurse plans the client's care, the priority diagnosis is which?

Risk for self-directed violence

Assessment of a child with autism spectrum disorder reveals stereotypic behavior. Which behavior would the nurse most likely document being demonstrated by the child? Select all that apply.

Rocking Hand flapping Head banging

Which type of antidepressants are rarely fatal in overdose

SSRIs

After educating a group of nursing students on comorbidities associated with borderline personality disorder, the instructor determines a need for additional education when the students identify which of the following as a common comorbid condition?

Schizophrenia

A nurse is providing care to a client with social anxiety disorder. Based on the nurse's understanding of pharmacotherapy, which medication would the nurse anticipate being used as part of the treatment plan?

Selective serotonin reuptake inhibitors (SSRIs)

Identity diffusion occurs in clients diagnosed with borderline personality disorder. Which description would the nurse most commonly associate with identity diffusion in these clients? Select all that apply

Self-image instability Feelings of emptiness Inconsistency

As part of a client's treatment plan for borderline personality disorder, the client is engaged indialectical behavior therapy. As part of the therapy, the client is learning how to control and changebehavior in response to events. The nurse identifies the client as learning which type of skills?

Self-management skills

A client has been diagnosed with bulimia. Which cognitive behavioral technique would be useful for the client?

Self-monitoring

An adolescent client has been diagnosed with anorexia nervosa. Which intervention should be included in the client's plan of care?

Set up a strict eating plan for the client

The nurse is preparing to discharge a client who has been hospitalized with anorexia nervosa. Which ofthe following would the nurse include in the teaching plan?

Setting realistic goals

A group of nursing students is reviewing possible risk factors for development of borderline personalitydisorder. The students demonstrate understanding of the information when they identify which of thefollowing as a risk factor? Select all that apply.

Sexual abuse & parental lost

When planning the discharge for a client who has schizophrenia, the nurse anticipates barriers to the client's ability to adhere to the medication regimen.Which characteristics improves the likelihood that the client will follow the prescribed medication regimen? Select all that apply.

Short-term memory intactReceives monthly disability checksStates location of pharmacy nearest the client's residence

Ground rules for nurses to follow when establishing rapport with children include what?

Showing acceptance and giving clear directions about unacceptable behavior

The nurse asking to speak to the child alone can provide reassurance to the child by ...

Showing the child that the waiting area is close by, where the parents will wait for the child

When performing a spiritual assessment on a child, the nurse and child discuss church attendance and practices that are most important to the child. Which domain is the nurse addressing when doing this assessment?

Social

A woman with borderline personality disorder has been admitted to the inpatient unit because she hasbeen engaging in wrist cutting. The client's sister is visiting, and the sister asks the nurse to explain whyher sister sometimes does this to herself. Which response by the nurse would be most appropriate?

Sometimes the self-injurious behavior is undertaken to relieve stress.

A nurse assessing for suicide and violent thoughts of children should ask ...

Straightforward questions about suicide and violence

the nurse knows that which statement is true about stress and anxiety?

Stress is the wear and tear that life causes on the body.

A client with depression appears lethargic and apathetic but agrees to participate in a leisure activity group. Which nursing intervention is most likely to help the client successfully participate?

Structuring the activity to facilitate completion of one specific task

A nurse is preparing a presentation about suicide for a local community group. What would the nurse most likely include?

Suffocation is a common means of suicide among children.

Although a psychotic episode can be brief, the client impact can last a long time. For this reason, the nurse is aware of what?

Supervision may be required to protect the person

A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called what?

Systematic desensitization

A client with post-traumatic stress disorder has just been prescribed sertraline. When teaching the client about this medication, which information would the nurse most likely stress?

Taking the medication once per day

A concerned family member tells the nurse, "I am concerned about my sibling. My sibling has been acting very different lately." Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the sibling has bipolar disorder?

Taking unnecessary risks

A school nurse is conducting a workshop that has the goal of promoting children's resilience. Which activity would be most important for the nurse to include to promote resilience? Select all that apply.

Teach the children that each of them possesses inherent self-worth Give the children exercises that allow them to exercise their autonomy Provide the children with activities that will promote their self-concept

A group of nursing students are reviewing signs and symptoms of anxiety. The students demonstrate a need for additional review when they identify what?

Tearfulness

A client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5' 8" tall and weighs only 90 lb. When considering the client's unrealistic body image, which intervention should be included in the care plan?

Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy

A 14-year-old survived a house fire in which a younger sibling died. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)?

The adolescent expresses intense guilt for the inability to save the sibling

The nurse's assessment of a child from a dysfunctional family background suggests that the child lacks resilience. What outcome should the nurse identify after performing appropriate interventions?

The child demonstrates that the child is empowered to solve life problems

A police officer was diagnosed with posttraumatic stress disorder after attending to a violent crime scene. What aspect of the client's current health status would most likely warrant inpatient treatment?

The client alluded to "ending this misery" in a conversation with a colleague

The nurse is interviewing a client who witnessed a fatal accident at the workplace and was unable to save a colleague. What assessment findings would support a diagnosis of posttraumatic stress disorder (PTSD)? Select all that apply.

The client has nightmares about the accident The client says the client is "unable to face that place again" The client says the client's family describes the client now as "edgy" and "irritable"

A nurse assesses a client and determines that the client is experiencing mild anxiety based on what?

The client is aware and alert

A client with major depression is scheduled to receive electroconvulsive therapy. The nurse understands that this treatment is typically used in which situation?

The client is experiencing catatonia.

The nurse is interviewing a client who has been diagnosed with posttraumatic stress disorder (PTSD) after being randomly attacked with a gun. The client describes a recent event where the client panicked and jumped for cover when a car backfired on the street. How should the nurse best interpret this event?

The client is experiencing hyperarousal

A nurse is reviewing the medical records of several clients being treated for eating disorders at the community mental health center. Which behavior would the nurse identify as differentiating a client who is believed to have bulimia nervosa from one who has anorexia nervosa?

The client is of normal body weight.

The nurse can document correctly that a client diagnosed with an anxiety disorder is experiencing moderate anxiety when the nurse observes the client doing what?

The client keeps getting distracted but can be brought back to focus on the current conversation.

The psychiatric mental health nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) after the death of the client's child from a medical error. What assessment finding would most warrant interventions aimed at addressing the client's dissociation?

The client reports large gaps in memory of the traumatic event

After complaining of weakness and confusion while at school, a 16-year-old client was admitted to the hospital where admission assessments revealed hypokalemia. The client has normal body weight. In planning the client's nursing care and treatment, which outcome should be prioritized?

The client will be free of self-induced vomiting.

The nursing student understands correctly when identifying which objective is appropriate for all clients with anxiety disorders?

The client will experience reduced anxiety and develop alternative responses to anxiety-provoking situations.

A client with schizophrenia is admitted to the inpatient unit. The client does not speak when spoken to but has been observed talking to the self on occasion. What would be the priority objective at this time?

The client will increase reality orientation

A mental health nurse has identified a nursing diagnosis of hopelessness related to poor self-concept for a client with depression. Which outcome would be most appropriate for this nursing diagnosis?

The client will reframe negative thoughts in a more positive way.

The nurse is assessing a client who has been diagnosed with post-traumatic stress disorder (PTSD). During the interview, the nurse learns that the client is wealthy and is under no significant pressure to return to work. How should the nurse best interpret the client's statement?

The client's financial resources are a potential strength that can be utilized in recovery

During an assessment of a client with schizophrenia, the client states, "The end of the world is coming. I just know it." The nurse interprets this as which type of delusion?

The client's statement reflects a nihilistic delusion, in which the client believes that one is dead or a calamity is impending

The nurse is assessing a client who was diagnosed with posttraumatic stress disorder (PTSD) several months ago. During a comprehensive follow-up assessment, what areas should the nurse assess? Select all that apply.

The client's use of alcohol or other drugs The effect of the client's PTSD on the family Characteristics of the client's sleep

A nurse assessing a client with schizoaffective disorder should obtain a detailed history with a description of the full range and duration for which of the following reasons?

The history should contain a description of the full range and duration of symptoms the client has experienced and those observed by the family; this information is important for predicting outcomes.

A client with post-traumatic stress disorder (PTSD) has just been prescribed sertraline by her primary care provider. What topic should the nurse include during health education?

The importance of avoiding alcohol use during treatment

Which of the following is accurate regarding the completion of a mental health assessment of a child? Select all that apply.

The nurse should corroborate information offered by the child with other sources The nurse should use simple phrasing with children Children have a less specific sense of time than adults

A nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a client believed to be exhibiting characteristics of a personality disorder?

This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened.

A client states, "I will just die if I don't get this job." The nurse then asks the client, "What will be the worst that will happen if you don't get the job?" Why does the nurse ask this question?

To help the client appraise their situation more realistically

Why must nurses understand why anxiety occurs and how anxiety behaviors work? Select all that apply.

To provide better care for the client To help understand the role anxiety plays in performing nursing responsibilities To help nurses to function at a high level

A client with schizophrenia has returned to the clinic because of an increase in symptoms. The client reports the client stopped taking the medication because the client did not like the side effects. The nurse educates the client about managing uncomfortable side effects. Which is included in the teaching plan? Select all that apply.

Use stool softeners as neededMaintain a balanced calorie-controlled dietSuck on hard candy as desired

A client is admitted to the psychiatric hospital with a diagnosis of schizophrenia. During the physical examination, the client's arm remains outstretched after the nurse obtains the pulse and blood pressure, and the nurse must reposition the arm. The nurse interprets this as what?

Waxy flexibility, the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia

All of the following would be included as interventions for eating disorders to establish nutritional eating patterns except ...

Weighing the client twice daily

Which is most often the criterion for determining the effectiveness of treatment in the client diagnosed with anorexia nervosa?

Weight gain

A client with borderline personality disorder tells the nurse, I'm afraid to get on a train because we'llprobably get into a wreck. Which response by the nurse would be most appropriate?

What are the chances of that actually happening?

A client has experienced a first episode of major depression and has received medication and treatment, which has led to a complete remission of the symptoms. The client asks the nurse, "How much longer will I need to take the medication?" Which response by the nurse would be most appropriate?"

You'll need to continue the medication for about 6 to 12 months to see how things go.

Which is considered the etiology of personality disorders?

a combination of psychosocial and biologic variable

A nurse teaching a client about prescribed antipsychotic medication informs the client to contact a health care provider immediately if the client notices:

a dramatic change in temp

A client has been diagnosed with major depressive disorder. The clinical symptom that would be included when the clinician makes this diagnosis is what?

a significant decrease in appetite

A psychiatric-mental health nurse is teaching the family members of a client about strategies for engaging with their family member who has recently been diagnosed with posttraumatic stress disorder (PTSD). The nurse should encourage the client's family to:

anticipate that the client is likely to be irritable and withdrawn at times.

A client diagnosed with anorexia nervosa is newly admitted to an in-patient psychiatric unit. Which nursing intervention takes priority?

assessment and monitoring of vital signs and lab values to recognize and anticipate medical problems

Genetics can play a role in the development of a childhood psychiatric disorder. When assessing a child, which disorder would the nurse identify as having a genetic component?

attention-deficit hyperactivity disorder

A client with schizoaffective disorder is prescribed medication therapy. Which type of medications would be most likely be ordered?

atypical antipsychotics

When a nurse is interviewing a parent and a child in a psychiatric setting, the nurse recognizes that parents generally provide better information about the child's ...

behavior disturbances.

A psychiatric-mental health nurse is conducting a refresher class for a group of psychiatric-mental health nurses returning to the field. After teaching about depressive disorders, the nurse determines a need for additional teaching when the class identifies which physical or psychological symptom as being associated with depression?

catatonia

A client with schizoaffective disorder is engaging in an extremely long conversation about a current affairs in the world. The client goes on to provide the nurse with minute details. The nurse interprets this as suggesting what?

circumstantility

A variety of areas are assessed during the mental status examination. Which are sections of the mental status examination? Select all that apply.

cognition, intellectual functioning, gross and fine motor movement

When working with the client with bulimia, the nurse should be aware that the nurse's own feelings and needs may affect care. Feelings that may be aroused in the nurse may include what?

control

When working with the family of a client with anorexia nervosa, which issue must be addressed?

control

An elderly client is admitted to the hospital with fatigue and weight loss of 20 pounds in 1 month. Upon further assessment, the client is diagnosed with depression. What other thing should the nurse assess this client for based on the weight loss?

dehydration

The nurse is caring for several hospitalized clients with anorexia nervosa. The nurse would beespecially alert for which of the following if noted in the clients' histories?

depression

A nurse taking an admission history from a client suspects that the physician will diagnose major depression. For the physician to make this diagnosis, the client will have to demonstrate specific symptoms. What are some of these symptoms? Select all that apply.

disruption in sleep,disruption in appetite,disruption in concentration,excessive guilt

Which nursing diagnosis would be most difficult to successfully resolve in a client who had anorexia nervosa?

disturbed body image

Which is an example of egocentrism by an adolescent?

does not talk much because they think they are being watched by others

Which temperament can serve as a protective factor against the development of psychopathology?

easy

A nurse is working with a client that has been diagnosed with delusional thoughts. Which is an initial short-term outcome appropriate for this client?

engage in reality oriented conversation

What behavior is likely a result of an adolescent's attempt to manage the effects of over-productive parenting?

engaging in severe dieting

A client with posttraumatic stress disorder (PTSD) tells the nurse that the client's recent cognitive behavioral therapy has been difficult. The client states that the client's therapist has the client visualize the sights and sounds from the time that the client was assaulted. This client is likely receiving:

exposure therapy.

Which medication has been found to be worthy of a trial in clients with bulimia nervosa who have obsessive-compulsive traits?

fluoxetine

When reviewing the documented history of an adult client with anorexia nervosa, what is the nurse most likely to find? (Select all that apply.)

food restriction began at age 15 depression at age 16 lasting one month reported believing that friends were "jealous" of her body

A psychiatric-mental health nurse is reviewing a journal article about schizophrenia and disorders related to it. The nurse demonstrates understanding of the article by identifying which information as a major factor associated with increasing a person's risk for schizophrenia?

genetics

A nurse is working with a patient who is experiencing large amounts of stress due to relational, financial, and physiologic factors. The nurse can best enhance this patient's resilience by:

helping the patient to think about herself in a positive way.

A client with schizophrenia is prescribed clozapine. The nurse would monitor the client closely for specific signs of:

infection

Encephalopathic syndrome has occurred in a few clients when haloperidol is taken with which medication?

lithium

After teaching a client about possible side effects of benzodiazepines, the nurse determines that additional teaching is needed when the client identifies which of the following as a possible side effect of the drug?

metallic taste

During which type of anxiety does a person's perceptual field actually increase?

mild

Cognitive psychotherapy is most likely to be appropriate in the care of a client who has been diagnosed with what?

moderate depression

All are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client?

observe for signs of fear or aggitation

A nurse is reading a journal article about anorexia nervosa and comorbidities. The article describes a strong association between anorexia and obsessive-compulsive disorder. The nurse demonstrates understanding of this information by identifiying which aspect as common to both of these disorders?

perfectionism

To establish rapport with a 10-year-old child who is hospitalized in a psychiatric setting, the nurse should ...

play a competitive board game.

A nurse is providing care to a client with recurrent major depression. The nurse would most likely expect a combination of medications and which treatment to be used to achieve maximum effectiveness?

psychotherapy

The nurse is preparing to interview a 6-year-old child and her mother in an outpatient psychiatric setting. To establish a treatment alliance with the child, the nurse should ...

recognize the child's individuality.

A client begins to exhibit hallucinations and delusions along with disorganized speech after forgetting to take antipsychotic medication. The nurse suspects that the client is at which point in the clinical course of the disorder?

relapse

All are nursing diagnoses identified for a client with schizophrenia. The student nurse correctly anticipates that which diagnosis will resolve when the client's negative symptoms improve?

social isolation

After a client has been prescribed on fluoxetine (Prozac) for a diagnosis of anxiety disorder, which of the following information should the nurse be sure to include in the client teaching?

sometimes in the first week of treatment, the client may experience heightened feelings of anxiety, but these will pass when you become accustomed to the new medication.

A client with borderline personality disorder (BPD) who evaluates experiences, people, and objects in terms of mutually exclusive categories (e.g., good or bad, success or failure) is demonstrating which type of thinking?

splitting

A client is diagnosed with schizoaffective disorder. The interdisciplinary plan of care includes key family members. The nurse understands that a major reason for doing so involves which of the following?

strengthening the clients recovery

A nurse planning interventions for the psychological domain for a client with a delusional disorder in the outpatient setting is providing ...

supportive therapy

The nurse is working with a child with a mental health problem and the family must be included in the care. Which is one of the best ways the nurse can advocate for the child?

teach the parents age-appropriate expectations of the child.

Which of the following is a cognitive intervention for clients diagnosed with depression?

thought stopping

A client who experienced serious and repeated traumas has been diagnosed with dissociative identity disorder after being rescued from an abuser. Before caring for this client, the nurse should be prepared for:

wide variations in the personality that the client exhibits.

A nurse is engaged in role-playing with a client with borderline personality disorder to assist the clientin learning how to communicate effectively. Which of the following would the nurse encourage the client to use? Select all that apply.

• Validating perceptions with others • Paraphrasing before responding • Compromising

A patient with bipolar I disorder being treated with lithium is brought to the emergency department. Assessment reveals moderate ataxia, slurred speech, asymmetric deep tendon reflexes, muscle twitching and increased muscle tone. The nurse suspects moderate lithium toxicity. Which lithium blood level would support the nurse's suspicion?

2.2 mEq/L

The onset of major depressive disorder is most common among people who are in their

20s

The nurse recognizes that which client is most likely experiencing generalized anxiety disorder (GAD)?

40-year-old who has reported numerous absences from work, muscle aches, and difficulty falling asleep for the last 8 months

The nurse is assessing a child's fine motor skills. By which age should a child be able to dress himself with minimal assistance?

5

A client who is a bus driver was involved in an accident in which two of her passengers died. The client blames herself for their death even though she was exonerated in the follow-up investigation. To help the client see the event more realistically, the nurse should?

:facilitate a referral for cognitive restructuring therapy.

Which client best exhibits the characteristics that are typical of the prodromal period of schizophrenia?

A 20-year-old man who is exhibiting a gradual decrease in his ability to concentrate and function in daily activities

The medical-surgical nurse has worked with numerous clients who have had difficult and stressful courses of treatment. What client likely faces the greatest risk for developing post-traumatic stress disorder?

A child who has endured repeated treatments for cancer over multiple admissions

Which individual is exhibiting signs or symptoms that are characteristic of posttraumatic stress disorder (PTSD)? Select all that apply.

A client who has quit the client's job so that the client no longer has to go to the client's old office where the client was attacked and robbedA client who is unable to relax without first barricading the client's home after a violent home invasion and assaultA client who has frequent nightmares about the time a fellow soldier died from an improvised explosive deviceA police officer who experiences panic attacks when thinking about the time the police officer was forced to shoot a violent suspect

A 46-year-old client has been diagnosed with major depressive disorder. The client is seeing a nurse practitioner who is deciding on an appropriate treatment regimen. The nurse practitioner knows that which will be the most effective treatment for this client's depressive disorder?

A combination of psychotherapy and medication

A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client?

Ability to concentrate and process the information

A client with mania is demonstrating hypersexual behavior by blowing kisses to other clients, making suggestive remarks, and removing some articles of clothing. Which nursing intervention would be most appropriate at this time?

Accompany the client to his or her room to get dressed.

A nurse's colleague expresses sympathy for a client who is traumatized following a terrorist attack 1 week earlier. The colleague states, "I'm certain that the client has posttraumatic stress disorder (PTSD)." What is the nurse's best response?"

Acute stress disorder is a possibility, which might develop into PTSD."

A client approaches the nurse on an inpatient psychiatric hospital unit crying, trembling, and feeling nauseous. The client states, "I've tried everything, I still feel so anxious." Which action by the nurse would be most appropriate?

Administer the prescribed PRN anxiolytic medication.

Which age group is dependent on the rapport established by the nurse?

Adolescent

A client taking an antidepressant has experienced a 12-pound weight gain in 1 month as a side effect of the medication. Which of the following are nursing interventions to help this patient with this problem? Select all that apply.

Advocate with the physician to consider changing the medication.Recommend a nutritionally balanced diet.Recommend daily exercise.

Which of the following primary characteristics of borderline personality disorder is evidenced by erratic emotional responses to situations with intense sensitivity to criticism

Affective instability

While shopping in a grocery store, a client with borderline personality disorder (BPD) greets the sibling of a neighbor with a great big hug. Then about 5 minutes later, the client walks past the sibling and ignores the sibling. The client is demonstrating what?

Affective instability

The advanced practice psychiatric mental health registered nurse is leading a support group for adolescents who have recently experienced disruptions in their life. What participant most warrants further assessment for posttraumatic stress disorder?

An adolescent who has committed uncharacteristic acts of violence since the death of the adolescent's mother

What does the nurse recognize as the most likely explanation for the self-mutilating behaviors that occur with borderline personality disorder?

An expression of intense anger or helplessness in order to block emotional pain

A client is being seen in the health clinic. During the nursing assessment, the client states that she has amenorrhea for the last 6 months. She weighs 80 pounds and is 5'2" tall. She states that she usually eats salads so that she does not gain weight. The nurse suspects that the client most likely has ...

Anorexia nervosa

A client is 5 feet 6 inches tall, weighs 105 pounds, exercises 4 hours per day, and does not engage in any binging or purging behaviors. The client believes that he or she is becoming obese and states, "I'm shocked that you think I'm underweight. You don't understand me." The most likely diagnosis for this client is what?

Anorexia nervosa, restricting type

Panic disorder is treated with cognitive-behavioral techniques, deep breathing, and relaxation, in addition to what?

Antidepressants

A psychiatric-mental health nurse is working at a community mental health center that serves a large pediatric population. When assessing children for depression, which information would be most important for the nurse to keep in mind?

Anxiety symptoms are more commonly noted in children who are depressed.

A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?

Approximately 2 weeks after starting antidepressant medication

Family-based theories of causality propose that eating disorders develop how?

As a way for the child to feel a sense of control in response to controlling parents

The nurse is caring for a client diagnosed with bulimia. Which would be important for the nurse to do first?

Ask the client directly about thoughts of suicide or self-harm

A nurse working on a unit for children with mental health issues understands the importance of assessing self-concept, even in young children. Some ways to do this when working with young children are which of the following? Select all that apply.

Asking them what they would wish for Getting them to draw Asking them what they want to do when they grow up

An inappropriately dressed client has not slept for 3 days and has been making excessive long-distance phone calls. When the client can be heard singing loudly in the examining room, the nurse makes initial plans to focus on what?

Assessing needs for food, liquids, and rest

A nurse is providing care to a client with borderline personality disorder. When providing for the client's biopsychosocial needs, the nurse would address which in the biologic domain?

Assisting with sleep measures

A child is diagnosed with attention deficit hyperactivity disorder and is to receive pharmacologic therapy. Which of the following would the nurse expect to be prescribed as a first line agent?

Atomoxetine

The child psychiatric assessment differs from that of adults in which of the following ways?

Attention to developmental milestones

To promote sleep hygiene, a nurse should encourage a client with posttraumatic stress disorder (PTSD) to incorporate which of the following strategies into his routine? Select all that apply.

Avoid drinking alcohol before bedtime. Go to bed at a regular time nightly.

Which statement is true about delusional disorder?

Behavior is relatively normal except when focused on the delusion.

A client is seeking counseling due to difficulty coping with being a victim of a violent attack 16 months ago. The initial medical diagnosis is to rule out posttraumatic stress disorder (PTSD). Which would the nurse assess for when determining the major elements of PTSD? Select all that apply.

Being on guard, irritable, or experiencing hyperarousal Showing emotional numbing such as feeling detached from others Reexperiencing the trauma through dreams or recurrent and intrusive thoughts

A client is admitted to the unit in an acute manic episode. The client has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which disorders would reflect the client's symptom profile?

Bipolar I

When teaching a client who is recently diagnosed bipolar I disorder, the nurse correctly tells the client that the difference between bipolar I disorder and bipolar II disorder is what?

Bipolar I disorder is often more disruptive than bipolar II disorder.

A client with schizophrenia is being treated with olanzapine 10 mg daily. The client asks the nurse how this medicine works. The nurse explains that the mechanism by which the olanzapine controls the client's psychotic symptoms is believed to be what?

Blocking dopamine receptors in the brain.

A nurse is caring for a client receiving a tricyclic antidepressant and is monitoring for anticholinergic side effects. Anticholinergic effects include which of the following?

Blurred vision

A nurse is preparing a presentation for a local middle school health class about eating disorders as ameans for prevention and early detection. Which of the following would the nurse incorporate into the presentation as being common to both anorexia nervosa and bulimia nervosa? Select all that apply.

Body dissatisfaction Obsessiveness Cognitive distortions

A 15-year-old is admitted for treatment of anorexia nervosa. Which is characteristic of anorexia nervosa?

Body weight less than normal for age, height, and overall physical health

The nurse is counseling a 35-year-old client with a personality disorder. The client states that the client's problems are not the client's fault and that the client is a victim of circumstances and "fate." When experiencing stress, the client has impulsively called friends and family and stating, "It's my last day on earth." This client presentation is best described by which disorder?

Borderline personality disorder

A client is suspected of having anorexia nervosa and meets the diagnostic criteria for the disorder. When conducting the physical examination, which would be a probable finding from the assessment?

Bradycardia

A client has an eating disorder characterized by consuming an amount of food much larger than a person would normally eat. Afterward, the client often purges the food or exercises excessively. Between binges, the client often eats low-calorie foods or fasts. What is the client's most likely diagnosis?

Bulimia nervosa

while a nurse talks to the mother of a 15-year-old client, the mother expresses concern over the client's eating and exercise habits. The mother says that as soon as the client comes home from school, the client exercises for 2 to 3 hours every day. She says the client eats very little at dinner, but in the morning she notices that large amounts of food are missing from the kitchen. The client was complaining of tooth pain, and when the mother took the client to the dentist, the client had over 10 cavities. Which disorder is the client most likely suffering from?

Bulimia nervosa