PSYCH NURSING PRE TEST 2
The nurse should know that the normal therapeutic level of lithium is: .6 to 1.2 meq/L .6 to .12 cc3/L .6 to .12 cc/ml 6 to 12 meq/L
.6 to 1.2 meq/L
A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine, but he can control his use if he chooses. Which coping mechanism is he using? Logical thinking Withdrawal Repression Denial
Denial
In group therapy, a client who has used I.V. heroin every day for the past 14 years says, "I don't have a drug problem. I can quit whenever I want. I've done it before." Which defense mechanism is the client using? Rationalization Compensation Denial Obsession
Denial
As a care provider, the nurse should do first: a. Early recognition of the client's needs. b. Participate with the team in performing nursing intervention c. Provide direct nursing care. d. Therapeutic use of self.
a. Early recognition of the client's needs.
The most effective treatment modality for persons if anti-social PD is: behavior therapy hypnotherapy gestalt therapy crisis intervention
behavior therapy
Which of the following etiologic factors predispose a client to Tourette syndrome? a. No known etiology b. Environmental factors and birth-related trauma c. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics d. Abnormalities in the structure and function of the ventricles
c. Abnormalities in brain neurotransmitters, structural changes in basal ganglia and caudate nucleus, and genetics
When you find yourself in disagreement with some of the client's expressed sexual values or beliefs, which approach would be best on your part? nonjudgmental educational self-disclosing confrontational
nonjudgmental
A female client undergoes yearly mammography. This is a type of what level of prevention? primary tertiary nota secondary
secondary
A 60-year-old post CVA patient is taking TPA for his disease, the nurse understands that this is an example of what level of prevention? primary tertiary secondary nota
tertiary
The primary focus of therapeutic communication with any client is: the nurse's needs. the nursing diagnosis the client's needs the medical diagnosis
the client's needs
The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include: dilated pupils and slurred speech. euphoria and constricted pupils. rapid speech and agitation. dilated pupils and agitation.
.euphoria and constricted pupils.
A client is admitted to the hospital. Twelve hours later the nurse observes hand tremors, hyperexcitability, tachycardia, diaphoresis and hypertension. The nurse suspects alcohol withdrawal. The nurse should ask the client: Do you drink beer or hard liquor? Why didn't you tell us you're a drinker? How long have you been drinking? At what time was your last drink taken?
At what time was your last drink taken?
Which of the following drugs needs a WBC level checked regularly? Clozaril Tofranil Diazepam Lithane
Clozaril
An elderly client describes being recently frightened by a snake and then suddenly having increased energy in preparation for running away. The nurse realizes that this client is describing which of the following stages identified in Selye's general adaptation syndrome? stabilizing response alarm resistance
alarm
The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft? a. Zoloft causes postural hypotension b. It may take 3-4 weeks before client will start feeling better. c. Zoloft causes erectile dysfunction in men. d. Zoloft increases appetite and weight gain
c. Zoloft causes erectile dysfunction in men.
When first implementing treatment with a child with ADHD, which of the following would be the best initial goal of treatment? no incidences of interrupting others increase total work completed complete an assignment correctly get all homework in on time
complete an assignment correctly
A client is brought to the emergency department after being beaten by her husband, a prominent attorney. The nurse caring for this client understands that: a. violent behavior is a genetic trait passed from one generation to the next. b. open boundaries are common in violent families. c. violence usually results from a power struggle. d. domestic violence and abuse span all socioeconomic classes.
d. domestic violence and abuse span all socioeconomic classes.
The client is taking TOFRANIL. The nurse should closely monitor the patient for: increase intraocular pressure hypertension increase intra-cranial pressure hypothermia
increase intraocular pressure
A 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include: violence on television. passive parents a single-parent family an internal locus of control.
violence on television.
A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurse's teaching about this medication? "I can take over-the-counter sleeping medication if I have trouble sleeping." "I can drink alcohol with this medication." I need to call my doctor in 2 weeks for a checkup." "I need to keep my appointment here at the hospital this week for a blood test."
"I need to keep my appointment here at the hospital this week for a blood test."
You enter the room of your depressed client and find him crying. What is your best response? "I'm sorry, I will come back later when you are not so upset." "Don't worry, everything will be much better tomorrow." "I'm sorry you are upset. I will stay with you awhile." "You should not be crying. Things could be so much worse."
"I'm sorry you are upset. I will stay with you awhile."
When working with a young adult and planning a teaching session about bipolar disorder and its treatment, the nurse will include the client in the planning. Which of the following questions is most important for the nurse to ask the client? "Who is your significant other at this time?" "When can your family come to a session?" "May I have permission to invite your parents?" "Who do you want involved in the treatment?"
"Who do you want involved in the treatment?"
A client recently admitted to the ICU after a car accident says to you, "Am I going to die?" Your best response would be: "Don't worry, the doctors and nurses are all trying to help you." "You must be very frightened right now." "Many people survive car accidents like the one you had." "Why do you think you are dying?"
"You must be very frightened right now."
A client with a history of substance abuse has been attending Alcoholics Anonymous meetings regularly in the psychiatric unit. One afternoon, the client tells the nurse, "I'm not going to those meetings anymore. I'm not like the rest of those people. I'm not a drunk. "What is the most appropriate response? "You seem upset about the meetings." "It's your decision. If you don't want to go, you don't have to." "If you aren't an alcoholic, why do you keep drinking and ending up in the hospital?" "You have to go to the meetings. It's part of your treatment plan."
"You seem upset about the meetings."
The nurse would teach the client taking tranylcypromine sulfate (Parnate) to avoid which food because of its high tyramine content? Reconstituted milk Aged cheese Nuts Grain cereals
Aged cheese
After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. Of the following extrapyramidal adverse reactions, the client is showing signs of: Tardive dyskinesia Dystonia Akathisia Parkinsonism
Akathisia
After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows that this value indicates which of the following? A laboratory error. A toxic level. An anticipated therapeutic blood level of the drug. An atypical client response to the drug.
An anticipated therapeutic blood level of the drug.
When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following? Hypersalivation Hypertensive episodes. Oversedation. Extrapyramidal symptoms.
Extrapyramidal symptoms.
A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurse's highest priority in assessing the client on admission would be to ask him: How he feels about himself. About recent stresses. If he is thinking about hurting himself. How he sleeps at night.
If he is thinking about hurting himself.
Which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder? A history of schizophrenia in the family Rejection by peers An overbearing mother Low socioeconomic status
Rejection by peers
A client has been taking lithium carbonate (Lithane) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of: Iodine Calcium Iron Sodium
Sodium
Which ANA standard of care is addressed when the nurse reviews the client's progress toward goal achievement? Standard II Planning Standard V Evaluation Standard I Assessment Standard III Outcome Identification
Standard V Evaluation
Which of the following is an example of objective data? The family states the client has not been herself. The client is pacing the floor. The client states she is anxious The client complains of dizziness.
The client is pacing the floor.
As a manager, the nurse should: Plans nursing care with the patient. Work together with the team. Initiates nursing action with co-workers. Speaks in behalf of the patient.
Work together with the team.
Which of the following questions is an example of a closed-ended question? Tell me more about yourself. How can I help you? Would you like help? Why would you like to play that game?
Would you like help?
Which nursing action is best when trying to diffuse a client's impending violent behavior? a. Helping the client identify and express feelings of anxiety and anger b. Placing the client in seclusion c. Involving the client in a quiet activity to divert attention d. Leaving the client alone until the client can talk about feelings
a. Helping the client identify and express feelings of anxiety and anger
A client with a history of schizophrenia has been admitted for suicidal ideation. The client states "God is telling me to kill myself right now." The nurse's best response is: a. I understand that god's voice are real to you, But I don't hear anything. I will stay with you. b. The voices are all in your imagination, think of something else and it'll go away c. The voices are part of your illness, it will stop if you take medication d. Don't think of anything right now, just go and relax.
a. I understand that god's voice are real to you, But I don't hear anything. I will stay with you.
In planning nursing care for a client with body dysmorphic disorder, the plan would reflect an understanding that body image is: a. one's physical perception, sense of identity, strengths, and limitations b. unchanging as the individual matures c. always an accurate perception of oneself and one's ability d. not a significant issue for adolescent boys and girls
a. one's physical perception, sense of identity, strengths, and limitations
A client is admitted to the emergency department after being found unconscious. Her blood pressure is 82/50 mm Hg. She is 5′ 4" (1.6 m) tall, weighs 79 lb (35.8 kg), and appears dehydrated and emaciated. After regaining consciousness, she reports that she has had trouble eating lately and can't remember what she ate in the last 24 hours. She also states that she has had amenorrhea for the past year. She is convinced she is fat and refuses food. The nurse suspects that she has: bulimia nervosa. schizophrenia. depression. anorexia nervosa.
anorexia nervosa.
A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority? a. Checking the client's medical records for health history information b. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output c. Attempting to contact the client's family to obtain more information about the client d. Restricting fluids and leaving the client alone to "sleep off" the episode
b. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output
A 15-year-old girl with anorexia has been admitted to a mental health unit. She refuses to eat. Which of the following statements is the best response from the nurse? a. "Why do you think you're fat? You're underweight. Here — look in the mirror." b. "You don't have to eat. It's your choice." c. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable." d. "You really look terrible at this weight. I hope you'll eat."
c. "I hope you'll eat your food by mouth. Tube feedings and I.V. lines can be uncomfortable."
In a toddler, which of the following injuries is most likely the result of child abuse? a. A hematoma on the occipital region of the head b. A 1-inch forehead laceration c. Several small, dime-sized circular burns on the child's back d. A small, isolated bruise on the right lower extremity
c. Several small, dime-sized circular burns on the child's back
The school nurse is teaching psychosocial interventions to parents and teachers working with children who have attention-deficit hyperactivity disorder (ADHD). The nurse will most likely teach the parents and teachers to do which of the following things? a. be firm and stop even the smallest deviation from expected behaviors b. have the child write down all the things they are not to do and all the consequences c. ignore mildly inappropriate behavior and praise positive behaviors d. put all consequences for bad behavior in writing and post it where the child can see it
c. ignore mildly inappropriate behavior and praise positive behaviors
Which intervention would have the highest priority when caring for a client with severe anxiety? a. offering medications to reduce anxiety b. setting limits on the client's behavior c. providing for the client's safety d. offering the client a warm cup of milk
c. providing for the client's safety
Which of the following client statements about clozapine (Clozaril) indicates that the client needs additional teaching? a. "The sleepiness I feel will decrease as my body adjusts to clozapine." b. "I need to have my blood checked once every several months while I'm taking this drug." c. "I need to sit on the side of the bed for a while when I wake up in the morning." d. "I need to call my doctor whenever I notice that I have a fever or sore throat."
d. "I need to call my doctor whenever I notice that I have a fever or sore throat."
As a client's anxiety increases, the nurse should anticipate that the client's perceptual field will: remain the same decrease become unpredictable increase
decrease
The nurse shows a patient advocate role when: intercedes in behalf of the patient. work with significant others refer patient for other services she needs defend the patients' right
defend the patients' right
The nurse needs to be aware that clients often perceive nurses' attention to their physical complaints to be: helpful and soothing unnecessary and unnatural a trigger for dissociation uncomfortable
helpful and soothing
Which of the ff: is not a characteristic of PD? fails to conform to social norms loss of cognitive functioning not capable of experiencing guild or remorse for their behaviour disregard rights of others
loss of cognitive functioning
A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to: perform activities of daily living hold a job relate to his peers behave in an outwardly normal
perform activities of daily living
A client who was wandering aimlessly around the streets acting inappropriately and appeared disheveled and unkempt was admitted to a psychiatric unit and is experiencing auditory and visual hallucinations. The nurse would develop a plan of care based on: anxiety disorder depression schizophrenia borderline personality disorder
schizophrenia
A nurse is having a one-to-one interaction with a newly assigned client. The nurse's goals include learning more about the client's relationship with his family. Which of the following statements by the nurse would be best in this situation? "Are your parents alive?" "Do you get along with your family?" "Tell me a little about your family." "Where does your family live?"
"Tell me a little about your family."
When assessing a client with bipolar disease, the nurse discovers that the client's older brother, who is dead, had a diagnosis of bipolar disorder. The nurse most importantly needs to say which of the following things to the client? "Tell me about your brother's symptoms." "Who else in your family has bipolar disorder?" "Tell me about his death." "What was your brother like?"
"Tell me about his death."
A client with paranoid schizophrenia has persecutory delusions and auditory hallucinations and is extremely agitated. He has been given a PRN dose of Thorazine IM. Which of the following would indicate to the nurse that the medication is having the desired effect? Stops pacing and sits with the nurse Exhibits increase activity and speech State he feels restless in his body Complains of dry mouth
Stops pacing and sits with the nurse
Which of the following signs should the nurse expect in a client with known amphetamine overdose? Constricted pupils Hot, dry skin Tachycardia Hypotension
Tachycardia
You are interviewing the family members of the client who was recently admitted. Which question is appropriate for family members? a. "What is your understanding of the reason(s) for the client's admission to the hospital?" b. "What problems are your family experiencing that might have caused the client to get ill?" c. "Why did you wait so long to bring her to the hospital?" d. "Why did you bring your family member to the hospital?"
a. "What is your understanding of the reason(s) for the client's admission to the hospital?"
The client tells you that he is upset because he has no one to talk with except you, and you are going on vacation. Which of the following approaches is best? a. Ask the client if they have any ideas on how to deal with this problem. b. Give the client some advice on which people to try to talk with in your absence. c. Arrange to have someone talk with the client in your absence. d. Tell the client not to be upset, that you will work it out somehow.
a. Ask the client if they have any ideas on how to deal with this problem.
In assessing a client's suicide potential, which statement by the client would give the nurse the HIGHEST cause for concern? a. I've thought about taking pills and alcohol till I pass out b. I'd like to go to sleep and not wake up c. I'd like to be free from all these worries d. My thoughts of hurting myself are scary to me
a. I've thought about taking pills and alcohol till I pass out
When psychiatric nurses closely assess older adults who are poor, whose relatives have a history of mental illness, who are unemployed, and clients from families that have disintegrated, the nurses have identified that these clients need this in-depth assessment because they: need help in getting more public assistance are less likely to seek help have little self-care agency are in high-risk groups for mental illness
are in high-risk groups for mental illness
On discharge after treatment for alcoholism, a client plans to take disulfiram (Antabuse) as prescribed. When teaching the client about this drug, the nurse emphasizes the need to: return for monthly blood drug level monitoring. avoid all products containing alcohol. limit alcohol consumption to a moderate level. adhere to concomitant vitamin B therapy.
avoid all products containing alcohol.
You are assigned to work with a client with a dissociative disorder that presents with a number of somatic complaints. Which of the following will be your top priority? a. determines which medications the client is taking b. assesses the client's physical status c. get a history of any psychiatric treatment d. finds out about the dissociative symptoms
b. assesses the client's physical status
A 16-year-old child is hospitalized, according to Erik Erikson, what is an appropriate intervention? a. encourage patient to help child learn lessons missed b. tell the friends to visit the child c. call the priest to intervene d. tell the child's girlfriend to visit the child.
b. tell the friends to visit the child
During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on the forearms. What is the nurse's best response? a. "That's it! You're on suicide precautions." b. "I'm going to tell your physician. Do you want to tell me why you did that?" c. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first." d. "Tell me what type of instrument you used. I'm concerned about infection."
c. "The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."
Which is the priority of care with a client whose lithium level is 1.5? a. Give the next dose and take the client's vital signs. b. Hold the next dose and offer the client orange juice. c. Give the next dose and notify the physician. d. Hold the next dose and contact the physician.
d. Hold the next dose and contact the physician.
Which of the following is not an example of alteration of perception? hallucination illusion ideas of reference flight of ideas
flight of ideas
When working with clients with the diagnosis of bipolar disorder, your effective management of the milieu will require three essential elements. They are safety, stabilization, and which one of the following? activities gentleness limit setting increased praise
limit setting
The nurse caring for a client with hypochondriasis would assess that which of the following defense mechanisms is characteristic of this disorder? reaction formation and rationalization projection and rationalization rationalization and sublimation regression and repression
regression and repression
You are working with a group of clients who ask you to explain what is meant by mental health. You would explain that there are many definitions, but the broadest agreement is that a key component is the ability to: get one's needs met without delay amass material property be optimistic in all situations respond to stress effectively
respond to stress effectively
A student nurse asks her instructor, "What is the difference between mood and affect?" The best response by the instructor would be: a. "A mood is a person's sustained emotional state that depicts her perception of the world, while affect is emotional responsiveness demonstrated in body language." b. "A person's mood is observable but her affect is not." c. "There is really no difference between the two." d. "Nurses assess the mood of children and adolescents, but they assess the affect of adults and elderly clients."
a. "A mood is a person's sustained emotional state that depicts her perception of the world, while affect is emotional responsiveness demonstrated in body language."
Which of the following is important when restraining a violent client? a. Have an organized, efficient team approach after the decision is made to restrain the client. b. Have three staff members present, one for each side of the body and one for the head. c. Secure restraints to the gurney with knots to prevent escape. d. Always tie restraints to side rails.
a. Have an organized, efficient team approach after the decision is made to restrain the client.
The patient complaint of vomiting, diarrhea and restlessness after taking lithane. The nurse's initial intervention is : a. Recognize that this is a sign of toxicity and withhold the next medication. b. Check V/S to validate patient's concerns. c. Notify the physician. d. Recognize that this is a normal side effects of lithium and still continue the drug.
a. Recognize that this is a sign of toxicity and withhold the next medication.
You are assigned to a client diagnosed with a somatization disorder. Your initial approach should be to: a. ask the client to describe the physical problems which caused this admission b. assure the client that you have cared for many other clients with similar problems discuss c. discuss the client's relationship with family and friends in order to assess the client's support system d. explain to the client that there is no physiologic basis to the problems
a. ask the client to describe the physical problems which caused this admission
When working with clients who have lost a loved one, you could minimize the discomfort associated with unmet spiritual needs of the client by taking which of the following approaches to assessing the client's spiritual needs? a. asking the client directly about any interest or preference she may have for spiritual support b. praying over the client and assess her reaction to prayer c. asking family members if the client needs spiritual help d. asking a chaplain to stop by to see the client to provide beginning spiritual support
a. asking the client directly about any interest or preference she may have for spiritual support
When working with a client whose spouse had died 3 weeks earlier, the nurse finds that the client is focused primarily on the loss and the memories of the spouse. The client describes emotional pain, loneliness, crying spells, and loss of appetite. Which of the following actions would be best on the part of the nurse? a. assure the client that what they are experiencing is part of the normal grieving process b. encourage the client to immediately return to work or find an absorbing hobby c. tell the client to start planning for the future and to get new friends d. discourage the client from focusing on memories of the spouse
a. assure the client that what they are experiencing is part of the normal grieving process
Which of the following actions by psychiatric nurses is an example of an initial move to incorporate a primary prevention measure into practice? a. identifying persons at risk for mental illness b. comparing a client's symptoms with the diagnostic manual c. teaching clients with mental illness about medications d. assessing for side effects of psychotropic medications
a. identifying persons at risk for mental illness
Which of the following actions on your part would most enhance your understanding of the grief reaction and personal spiritual beliefs of the client? a. understanding the meaning of your own personal spiritual beliefs and grief reactions b. reading a variety of books written by several authors on different types of grief work c. having the client journal about her grief reaction and personal spiritual beliefs d. talking with the client at least twice a week about their grief reaction and beliefs
a. understanding the meaning of your own personal spiritual beliefs and grief reactions
When assessing an elderly client, the nurse should understand that which of the following is the most common psychiatric disorder in the elderly? personality disorders anxiety disorders schizophrenia depression
anxiety disorders
When working with clients with somatization disorders, the nurse needs to use which of the following approaches? a. empathetic, quiet listener, and helper b. caring, nonjudgmental, and a firm manner c. promoter of self-care but otherwise unavailable d. gentle, kind, and attentive to all of the client's needs
b. caring, nonjudgmental, and a firm manner
A nursing intervention for a client experiencing panic attacks would include encouraging the client to: a. have her husband seek mental health services because he probably is the cause of her problems b. identify anxiety-provoking situations and thoughts that arise from them c. avoid family and friends to reduce episodes of anxiety d. apply for a new job in order to refocus on less stressful situations in her life
b. identify anxiety-provoking situations and thoughts that arise from them
Which of the following activities by psychiatric nurses is the best example of secondary prevention? a. teaching teenagers about the problems of alcohol abuse b. implementing measures that reduce symptoms of mental illness c. working with a terminally ill client in the hospice program d. giving immunizations at a clinic for 2-year-olds
b. implementing measures that reduce symptoms of mental illness
You are working with a 6-year-old child who is diagnosed with attention-deficit hyperactivity disorder (ADHD) who tends to do things like climbing to great heights and running away from caregivers in the store. Which of the following nursing diagnoses would most likely be the top priority for this child? a. alteration in attention process, etiology unknown b. potential for injury related to impulsivity c. alteration in motor activity, overactive, etiology unknown d. potential for alterations in nutrition, less than body requirements related to excess motor activity
b. potential for injury related to impulsivity
The goals of treatment when working with a client who has a diagnosis of attention-deficit hyperactivity disorder are: a. medication compliance in the 95% to 100% range b. reduction of disruptive symptoms and improvement in relationships c. cessation of hyperactivity and increased attention span to a normal level d. insight into the causes and treatment of attention-deficit hyperactivity disorder
b. reduction of disruptive symptoms and improvement in relationships
While talking with a client about his family relationships, the client suddenly asks the nurse if she is married. The best response of the nurse is to: a. say "yes" whether married or not to discourage client fantasies b. refocus the client saying something like "Let's focus on you for now." c. tell the client this question is inappropriate and not answer it d. answer the question and then ask the client another question
b. refocus the client saying something like "Let's focus on you for now."
You are helping a client in the manic phase to select an activity. Toward which of the following activities would you guide the client? a. a volleyball game of clients against the staff b. shooting baskets one-on-one with a staff member c. playing chess with another client d. working a 1500-piece puzzle with a group
b. shooting baskets one-on-one with a staff member
A client is brought to the hospital's emergency room by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms? a. Eye irritation, tinnitus, and irritation of nasal and oral mucosa. b. Tremulousness, impaired coordination, increased blood pressure, and ruddy complexion. c. Decreased respirations, constricted pupils, and pallor. d. Increased heart rate, dilated pupils, and fever.
c. Decreased respirations, constricted pupils, and pallor.
A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5′ 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? a. Addressing the client's low self-esteem b. Regularly monitoring vital signs and weight c. Initiating caloric and nutritional therapy as ordered d. Instituting behavioral modification therapy as ordered
c. Initiating caloric and nutritional therapy as ordered
An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. She says she has quit her last five jobs because her coworkers didn't like her and didn't train her adequately. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which nursing observations support this diagnosis? a. Suspiciousness, hypervigilance, and emotional coldness b. Flat affect, social withdrawal, and unusual dress c. Lack of self-esteem, strong dependency needs, and impulsive behavior d. Insensitivity to others, sexual acting out, and violence
c. Lack of self-esteem, strong dependency needs, and impulsive behavior
The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse: a. Asks the physician to order benztropine (Cogentin) for the side effects. b. Questions the dosage ordered. c. Questions the physician about the order. d. Gives the medication as ordered.
c. Questions the physician about the order.
A person's ability to adapt to crisis begins effectively at which of the following times? a. when entering school and dealing with peers of varying ages b. when asserting independence around 2 years of age c. adolescence d. birth
d. birth
Community mental health centers have provided three levels of preventative care. Which of the following types of activities best exemplify the secondary level of preventative care? a. drop-in program for discharged inpatients b. day care program for persons with problems in mobility c. educational pamphlets on how to stay mentally healthy d. community screening day for depression
d. community screening day for depression
You are working with a client who writes for a living. The client has a conversion disorder with an inability to utilize the hand used for writing. Which of the following goals would the client likely benefit from the most? a. demonstrates the ability to use the computer within 2 days b. verbalizes a lack of stressors within 1 week c. demonstrates the ability to write at least three pages within 1 week d. describes five ways to effectively deal with stress within 2 days
d. describes five ways to effectively deal with stress within 2 days
Which of the following is the most appropriate during the orientation phase? a. exploration of inadequate coping skills b. identification of more effective ways of coping c. patients' perception on the reason of her hospitalization d. establishment of regular meeting of schedules
d. establishment of regular meeting of schedules
While assessing the sexual history of a couple, you learn that the wife has a difficult time initiating sexual activity and the husband wants her to. You find yourself identifying with the wife's position as this is similar to your own current experience. Which of the following courses of action would be best? a. enlist the help of your husband and conquer your own problem through him b. read a sex manual and design some exercises for the wife to try with her husband c. let the wife know you understand how she feels as this is similar to your experience d. talk to a psychiatric nurse specialist or sexologist and discuss your issues
d. talk to a psychiatric nurse specialist or sexologist and discuss your issues
You are caring for a client diagnosed with bipolar disorder. The client is to begin taking lithium carbonate. As her nurse you are aware that before administering lithium carbonate to a client for the first time, you must assess the client for which of the following? restlessness depression akathisia dehydration
dehydration
When a couple is having difficulties with the sexual aspect of their lives, the nurse will most often find that the problem is: boredom with the same partner failure to communicate too many stressors narcissistic behavior
failure to communicate
Angelo, an 18-year-old out of school youth was caught shoplifting in a department store. He has history of being quarrelsome and involving physical fight with his friends. He has been out of jail for the past two years. Initially, the nurse identifies which of the ff: Nursing diagnosis: impaired social interaction self-centered disturbance altered thought process sensory perceptual alteration
impaired social interaction
A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse plans to write a behavioral contract. To best promote compliance, the contract should be written: jointly by the physician and nurse by the client alone abstractly jointly by the client and nurse
jointly by the client and nurse
The type of anxiety that leads to personality disorganization is: panic severe mild moderate
panic
You are visiting a client after she has been discharged from the mental health hospital. During your interview, the client constantly turns to the television to see what is happening on the soap opera. This would be an example of: delusion obsession preoccupation illusion
preoccupation
When working with children and adolescents who have a diagnosis of attention-deficit hyperactivity disorder (ADHD) and their parents, which of the following interventions would be most helpful to the clients? Insight-oriented groups psychoeducation groups individual psychotherapy family therapy
psychoeducation groups
