Psych Practice Hesi

An adolescent female client is admitted to the Emergency Department because she reports being raped. When the male unlicensed assistive personnel (UAP) enters the room to obtain her vital signs, she begins screaming for her mother and curls up in the corner of the room. What action should the nurse implement?

Reassign an all-female healthcare team to the client until her fear subsides

An adult female who is married and works full-time in a factory has been absent from work for three days at a time on several occasions. Each time she returns to work, she wears dark glasses to cover facial bruising. Her supervisor refers her to the occupational health nurse. What assessment question should the nurse use?

How did this happen to you?

A client on the mental health unit reports concerns about weight gain as a result of taking divalproex (Depakote) and requests assistance to fill out a menu. The nurse should initiate a referral to which healthcare team member?

Dietician.

A woman admitted to the Emergency Department is bleeding profusely from a patch where hair was lost from her scalp. She is accompanied by her husband who tells the nurse that his wife caught her hair on the railing and pulled it out when she fell down the stairs. The husband is solicitous of his wife and quickly answers questions on her behalf. He attempts to comfort his wife by saying to her, "I am right here with you, dear. Nothing can keep us apart." What is the priority nursing intervention?

Require the husband to leave the cubicle while the client is being treated.

During the admission of a male client to the mental health unit, the client tells the nurse that he had a panic attack today and ran out of the physician's office. Which question is most important for the nurse to ask this client?

Have you had any thoughts of hurting yourself?

A client actively involved in substance addiction therapy frequently relapses into benzodiazepines and alcohol use. The client tells the nurse, "I don't think I will ever be able to kick this habit." How should the nurse respond? The goal of the individual is one of growth, health, autonomy, and self-actualization. All people have the right to an equal opportunity for adequate health care. Dependence on an extensive support system is needed to overcome any addiction. The client must participate in making decisions about one's own physical and mental health.

The client must participate in making decisions about one's own physical and mental health. The client has the right to self-determination and the responsibility to make a decision to pursue health or illness, so the client must actively participate, which the nurse should clarify with the client. The other responses are components in addiction recovery, but do not indicate the client's responsibility and primary commitment for decision-making about self care and health.

Which client should the nurse identify as the highest risk for the onset of stress-related problems?

A person whose father died three months ago, who is losing a job due to company downsizing, and states, "Living with loss and the threat of loss makes me feel helpless."

A client who reports feeling depressed tells the nurse on admitted, "I want to feel normal again." How should the nurse respond? How long have you felt this way? We are all here to help you get better. What do you think the hospital can do for you? Tell me more about how things are with you.

"Tell me more about how things are with you." When a client offers psycho-emotional complaints as the reason for admission, open-ended statements that seek clarification and elaboration provide the nurse with information about the client's life experiences that helps the nurse empathize, establish rapport, and support the client while reexamining and expressing feelings. The other responses do not allow the client to vent and is not therapeutic.

An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement? Administer acetylcysteine (Mucocyst). Monitor cardiac rhythm for flat T waves. Check both serum AST and ALT levels. Prepare to administer Syrup of Ipecac.

Administer acetylcysteine (Mucocyst). Tylenol overdose is treated with immediate administration of Mucomyst to prevent hepatic insult. The other actions are not indicated.

At the end of a group therapy session, a client who is hospitalized for psychosis falls to the floor when attempting to stand. What intervention should the nurse implement first?

Ask a group member to seek help.

A client with a history of alcoholism is admitted with a compound fracture of the femur after falling down the previous night. What additional assessment should be the priority focus for the nurse?

Ask the client about the quantity, frequency, and time the last alcohol drink was ingested.

A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth?

Ask the family if they would like to see and hold the infant after birth.

The client with depression asks the nurse, " What are neurotransmitters? My doctor thinks my problem may lie with the neurotransmitters in my brain." What information should the nurse use to support an explanation of neurotransmitters? Chemical messengers that cause brain cells to turn on or off. Areas of the brain that are responsible for controlling emotions. Clumps of cells that alert the other brain cells to receive messages. Web-like structures that provide connections among parts of the brain.

Chemical messengers that cause brain cells to turn on or off. Neurotransmitters are chemicals manufactured in the brain that are responsible for exciting or inhibiting brain cells to produce an action. The other explanations address functions of neural structures and specific areas of the brain.

A client with substance abuse is admitted to the mental health unit. Which action should be implemented by the nurse, and not delegated to a unlicensed assistive personnel (UAP)?

Collect a complete substance abuse history.

The nurse is assessing a client with a history of borderline personality disorder. Which question should the nurse include in the assessment? At what age did you begin to exhibit symptoms? Do you have a family history of borderline disorder? How often do you drink alcoholic beverages? Do you frequently have temper tantrums?

Do you frequently have temper tantrums? A client with borderline personality disorder often has a history of intense outbursts of anger. The other questions may provide worthwhile information, but do not provide specific information about the client's symptomatology of borderline personality disorder.

A nurse is teaching about women's health with a female client who is in a homosexual relationship. Which topic is the most important for the nurse to address? Sexually transmitted diseases. Annual gynecologic examination. Monthly breast self-examination. Domestic violence interventions.

Domestic violence interventions. Since all women, regardless of sexual orientation, are at risk for domestic violence that can be potentially lethal, this is the most important topic for the nurse to address and is a policy that should be included in the nursing interview. The other topics should be included, but determining the presence of domestic violence is a life threatening priority.

The nurse is caring for a client who was admitted for alcohol detoxification 2 days ago. Which finding is most critical for the nurse to report to the healthcare provider? Restlessness, anxiety, and difficulty sleeping. Global confusion and inability to recognize family members. Agitation, vomiting, and visual and auditory hallucinations. Low-grade fever, diaphoresis, hypertension, and tachycardia.

Global confusion and inability to recognize family members. Delirium tremens (DT), or alcohol withdrawal delirium,usually peaks 2 to 3 days (48 to 72 hours or later) after cessation or reduction of intake and lasts 2 to 3 days. The risk of DT carries a 2% to 5% mortality rate, so this critical syndrome of alcohol withdrawal manifested as global confusion and an inability to recognize family members is life-threatening and requires emergency medical intervention. The other signs of withdrawal can occur within hours after cessation or reduction of alcohol intake and may require treatment to minimize risk of progression to DTs.

Which action should the nurse implement during the termination phase of the nurse-client relationship?

Help summarize accomplishments.

The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing problem? Impaired mobility. Ineffective individual coping. Impaired verbal communication. High risk for fluid and electrolyte imbalance.

High risk for fluid and electrolyte imbalance. Maintaining physiological stability by first addressing basic physiological needs is the priority. A client who is in a catatonic or stuporous state is at risk for malnutrition and dehydration. Fluid and electrolyte imbalance is the priority nursing problem for this client at this time. The other problems are not life-threatening.

Which statement made by an adolescent in group therapy should the nurse identify as a priority in planning care?

I have a necktie in my room that I can use to hang myself.

A male client tells the nurse that he plans to kill his spouse and her lover as soon as he is released from the hospital. What action should the nurse implement?

Inform the healthcare provider and document the plan in the record.

A female client who is admitted for treatment of uncontrolled diabetes mellitus is withdrawn and tearful. She complains she has gained excessive weight because she hates her diet, hates taking insulin, and just wants to be normal again. What therapeutic action should the nurse take?

Inquire about emotional factors affecting the client's present condition.

When assessing a client's emotional intelligence, which client capabilities should the nurse focus the interview on with a client diagnosed with a chronic mental illness?

Interpersonal and intrapersonal skills.

A client with panic disorder tells the nurse, "This illness is awful. I'm frightened that I will always be this way and that there's no hope for me." What information should the nurse provide?

Panic disorder is treatable in a number of different ways, including medication.

Which action should the nurse implement first for a client experiencing alcohol withdrawal?

Prepare the environment to prevent self-injury.

A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the nurse to implement? Leave the room without saying a word. Provide information about infection prevention. Allow the client to change the dressing himself. Explain the healthcare provider's prescription.

Provide information about infection prevention. Several factors impact a client who is angry and providing nursing feedback may help lower the client's anger and impact readiness to accept the nurse's interventions in providing care. Since the dressing change is initiated, making the client aware of why the dressing change is necessary to control infection can be therapeutic in forming a nurse-client relationship. The other actions are not indicated and may only escalate the client's anger if the nurse offers no alternatives to addressing the presenting issues during the dressing change.

A female client responds to the nurse with negative comments and antagonistic behavior. The nurse tells the client that she is unconsciously casting the nurse in the role of the client's mother. The nurse's feedback is based on which model of therapy? Medical. Existential. Interpersonal. Psychoanalytical.

Psychoanalytical The psychoanalytical model uses concepts that interpret and focus on working through feelings and behaviors related to previously unresolved conflicts. The other are related to other theoretical frameworks and treatments.

Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? Context. Self-analysis. Counter transference. Therapeutic self-disclosure.

Self-analysis Self-analysis is a tool for the nurse to examine oneself, view one's responses in various mental and emotional moments, and provide a sense of how sensitive care should be provided relative to one's own needs. The nurse's primary tool is self-analysis and use of the therapeutic self to establish therapeutic empathy and achieve authentic, open, and personal communication with a client. The other techniques may occur in a nurse-client relationship, but do not contribute to establishing a therapeutic relationship.

What nursing assessment is the priority focus for a client with major depression?

Suicidal ideation.

A client who abuses alcohol says to the nurse, "I am glad I went in for treatment. Now my problems with alcohol are all behind me." Which response is best for the nurse to provide?

Tell me more about what you mean when you say that your problems with alcohol are now behind you

A female client comes to an outpatient therapy appointment intoxicated. The spouse tells the nurse, "There wasn't anything I could do to stop her drinking this morning." What intervention should the nurse take at this time?

Tell the client that therapy cannot take place while she is intoxicated.

Which client outcome during hospitalization indicates improvement for a client who is admitted with auditory hallucinations?

Tells when voices decrease.

While assessing an older male client, a nurse working in the outpatient clinic notices bruises on the client's chest. The client admits that his daughter, who is his caregiver, becomes frustrated and sometimes hits him. What is the priority outcome for the client who is experience physical abuse at home? The client will verbalize an acceptance of his health status and dependency. The client will report feeling safe with his daughter's care at home. The client will report the frequency of abuse has decreased. The client will describes the potential danger of his situation

The client will report feeling safe with his daughter's care at home. The priority outcome should the client feeling safe and satisfied with his care by his daughter at home. The other statements are not outcomes that are client-centered and measurable.

A female client with severe depression is given information about the risks, benefits, alternatives, and expected outcomes of electroconvulsive therapy (ECT) and signs the informed consent for treatment. After the client's family leaves, the client tells the nurse, "I signed the papers because my husband told me I will be deported if my depression is not cured." What information should the nurse report to the healthcare provider?

The client's consent may have been coerced.

A male client is brought to the emergency department by a police officer, who reports the client was "disturbing the peace" by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment? (Choose all that apply.)

Threats to kill his friend, hears voices telling him to kill himself, reports he has not needed a bath in 4 months and says he has not eaten in 3 days.

A client is pacing in the hall near the nurses' station and swearing loudly. What response is best for the nurse to provide?

You seem pretty upset. Tell me about it.

Which client statement should the nurse identify as most typical of a client with mania?

I manage our finances great because I buy in big quantities.

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? Ready the client for discharge. Notify pastoral care to offer the client a blessing. Ask the client what name she had picked out for the infant. Inquire if the client would like to see what was obtained from her D&C.

Ask the client what name she had picked out for the infant. The client's cues about her preparation for the baby indicate her need to express her feelings of loss, so encouraging further discussion about the infant's name provides an opportunity to offer support. The other actions are not indicated.

A client who is intoxicated is admitted for alcohol and multiple substance detoxification. The nurse determines that the client is becoming increasingly anxious, agitated, and diaphoretic. The client is also experiencing sensory perceptual disturbances and a clouded sensorium. What is the priority nursing intervention for this client at this time? Check on the client every 15 minutes. Begin one-on-one supervision immediately. Keep the room dimly lit and turn on the radio. Push fluids and provide calorie-rich nutritional supplements.

Begin one-on-one supervision immediately. One-on-one supervision ensures the client's physical safety until the client is sedated adequately to reduce feelings of terror and tactile and visual hallucinations. Although the other actions may be indicated, they do not provide immediate assessment of the client's ongoing safety.

The daughter of an older male client tells the nurse that her father is becoming increasingly forgetful. Which finding indicates that the client needs further evaluation of cognitive function?

Cannot mentally retrace objects that were recently misplaced.

The nurse is planning care for a female client with depression who cries when asked to make her menu selections. Which therapy group is likely to be most beneficial for this client?

Coping Skills

A young adult female client with panic disorder arrives in the Emergency Center with a 4-day history of chest pain that began when her boyfriend left her. Initial assessment reveals normal cardiopulmonary findings. Which information is most important for the nurse to obtain?

Drugs taken in last 7 days.

A school-aged girl with severe birth defects and mental retardation is brought to the emergency room because of a possible broken arm. The caregiver reports that the girl sustained the injury when she fell from her wheelchair. Which intervention should the nurse implement?

Evaluate the child for other injuries.

The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

Monitor vital signs.

The nurse completes an emergency admission of a male client with schizophrenia who has not been taking his antipsychotic medications. The client is pacing, is extremely irritable, and has a blood pressure of 146/96. What is the priority nursing action? Encourage the client to stop pacing and sit down. Reevaluate the client's blood pressure in an hour. Direct the client to attend recreational therapy. Review the client's baseline blood pressure.

Reevaluate the client's blood pressure in an hour. The client is irritable and pacing, which can contribute to the elevated BP. A reevaluation of the client's BP in an hour allows time for the excitement and stress of the admission process to abate. The other actions are not indicated at this time.Chemical messengers that cause brain cells to turn on or off. Areas of the brain that are responsible for controlling emotions. Clumps of cells that alert the other brain cells to receive messages. Web-like structures that provide connections among parts of the brain

What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable? Do nothing and remember the client's rights. Express doubt that the goal can be achieved. Tell the client that the goal is unrealistic. Reflect the client's behavior and its consequences.

Reflect the client's behavior and its consequences. A client who is psychotic is unable to visualizing the consequences of proposed goals. The use of reflection about the client's behavior and its consequences is a therapeutic response. The other responses halt therapeutic communication.

A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond? Images indicate the presence of tumors and scars. The scan clearly outlined structures of the brain. Results show activity in various portions of the brain. PET shows biochemical levels of neurotransmitters.

Results show activity in various portions of the brain. The result of a PET scan, which is used to detect cerebral activity in depression, schizophrenia, and Alzheimer's disease, shows brightly colored cerebral areas where an accumulation of a radioactively tagged glucose is used as a tracer to visualize brain activity, blood flow, and glucose metabolism. The other responses do not explain PET scanning.

A client is responding to auditory hallucinations and shakes a fist at a nurse and says, "Back off, witch!" The nurse follows the client to the unit's day room. What action should the nurse implement?

Ensure that there is physical space between the nurse and client.

A female client with bipolar disorder, manic phase, is planning weekend activities with the other clients on the unit. The client interrupts the group, insists that they change their plans to a disco party, and begins to curse loudly when the group refuses to change the plans. Which intervention should the nurse implement?

Escort the client to a quieter place

The nurse is caring for a female client who is admitted for depression with the nursing diagnosis, "Self-esteem, chronic low." Which client response indicates to the nurse that the client has improved self-esteem?

Identifies own strengths

An older client is admitted to a psychiatric hospital with the diagnosis, "Major depression, single episode." Which laboratory value is most important for the nurse to report to the healthcare provider immediately?

Increased thyroid stimulating hormone (TSH).

During an inpatient therapy group session, a client tells the members that he hears voices that say his doctor is going to poison him. He continues, "I look around to see who's talking to me, and I can't see anybody." Another client replies, "I used to hear voices, too. I found out they were my imagination. The voices you hear aren't real either." Which phenomenon, common to groups, is exemplified in this interchange? Catharsis. Ventilation. Universality. Reality testing.

Reality testing Reality testing is a process in which an individual validates one's perception of reality. Group members can provide reality testing by monitoring each member's reactions and behaviors and providing feedback in an open and nonthreatening manner. The other experiences occur during group sessions and not related to validating psychotic phenomena, as in this situation.

Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit? Establish rapport in each phase of the nurse-client relationship. Determine the client's ability to communicate effectively. Reflect on previous psychiatric interviews the nurse has performed. Ensure data is collected and recorded in a systematic sequence.

Establish rapport in each phase of the nurse-client relationship. A client with whom the nurse establishes rapport during the initial interview and in each phase of the nurse-client relationship feels understood by the nurse and is more likely to cooperate and provide feedback during the admission process. The other actions not always needed to establish rapport or maintain the therapeutic self in a therapeutic relationship.

A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?

Explain the rape protocol to the client.

Which nursing intervention should the nurse implement with parents who experience a fetal demise and express the wish not to see the baby? Tell them there is nothing to fear. Insist that they hold infant so they can grieve. Respect their wishes and release the body to the morgue. Keep the body available for a few hours in case they change their minds.

Keep the body available for a few hours in case they change their minds. Grieving parents should be encouraged to hold their infant after death to facilitate closure. If parents are hesitant about seeing or holding their dead infant, the fetus should be available for a few hours in the event they change their mind after the initial shock. The other actions are not indicated.

The nurse is planning care for a client with major depression who is admitted to the unit after a recent suicide attempt. Which intervention has the highest priority for inclusion in this client's plan of care? Search the client's personal belongings. Introduce the client to others on the unit. Ask the client about recent stressful events. Move to a room that allows close observation.

Search the client's personal belongings. To safeguard that the client does not have some means to inflict self harm, a routine search of personal belongings, which is a common safety policy, should be implemented until the client stabilizes and suicidal ideations abate. The other interventions are components of the plan of care that ensure a therapeutic milieu but are not the priority in ensuring safety from self-harm

During a one-to-one interaction, a male client describes the sadness he experienced when his mother died. Suddenly, the nurse begins to think about her grandmother's death. As a result, the nurse asked the client to describe his thoughts when he learned of his own mother's illness. What is the nurse doing? Reflection. Clarification. Self-Awareness. Focusing.

Self-Awareness. Self-awareness describes awareness of the nurse's own feelings while empathizing with the client. The other mechanisms are therapuetic communication skills that the nurse uses to allow a client to open up about experiences and feelings.

The nurse is planning the care for a client based on the psychoanalytical model. Which intervention should the nurse include in the plan of care? Emphasize the client's strengths and assets. Teach the importance of medication compliance. Offer the client psychoeducational materials to read. Focus on the client's positive or negative feelings toward the nurse.

Focus on the client's positive or negative feelings toward the nurse. Interactions and interventions that focus on the client's positive or negative feelings toward the nurse are based on the psychoanalytical model of mental health care. The other interventions are not associated with the psychoanalytical model.

The daughter of a female client with stage-1 Alzheimer's disease (AD) asks the nurse what changes she should expect her mother to demonstrate in this stage. What finding should the nurse tell the daughter is common? Inability to recognize one's location. Personality changes and agitation. Depression and emotional lability. Alterations in communication.

Inability to recognize one's location. Evidence indicates that frequent incidences of confusion, such as being unable to recognize one's location in a familiar environment is associated with the early stages of Alzheimer's Disease. The other manifestations occur with later stages of AD.

The community health nurse facilitates a substance abuse prevention group for a homeless population. Which statement demonstrates that a client has a realistic understanding of the recovery process? I do OK as long as I can get methadone from the clinic regularly. By learning what led to my latest relapse, I know what to do in the future. A 12-step program is the only treatment approach that is proven effective. I know now that I wasn't ready to make a change until I hit rock bottom.

By learning what led to my latest relapse, I know what to do in the future. Recovery is a lifelong process in which clients must constantly learn and apply new behaviors to replace ineffective ones. Long-term recovery improves when a client acquires new coping skills that are successful, so those who learn from their relapses and triggers demonstrate an understanding of the process. The other statements do not necessarily indicate a client who is addicted will maintain recovery.

A male client who is on the liver transplant list is called to the unit for a possible transplant. When learning that the donor organ is no longer available, the client slams doors and shouts vulgarities about his situation. What action should the nurse implement? Encourage him to share his feelings more appropriately. Express concern over his disappointment. Arrange to have a clergy person visit. Administer a PRN prescription for an antianxiety drug.

Express concern over his disappointment. The therapeutic action that is nonjudgmental and supportive should address the client's disappointment and feelings of frustration in a safe environment. The other actions are not supportive of the client's expressions and are not indicated as the first response to frustration and anger.