Psych Prep U Exam 3

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."

Which statement is typical of the first stage of grieving described by Engel?

"No, not me."

A nurse suggests that the client explores new ideas about a particular problem and considers other possibilities to reflect:

A cognitive intervention.

Which assessment findings can most accurately be described as complicated grieving?

A person is unable to return to work after a sister's death 18 months ago Correct response:

Which likely takes place in the fourth stage of Kubler-Ross's stages of grieving?

Depression

The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which would be the priority assessment at this time?

Asking whether the client often feels cold

A group of nursing students is reviewing information about grief and bereavement. The students demonstrate understanding of the information when they state:

Bereavement is the process of mourning and grief is the emotional reaction.

According to Mardi Horowitz (2001), life begins to feel "normal" again in which stage?

Completion

During the assessment of a client who has a pattern of eating-disordered behavior, the nurse asks, "What would you change about your body, if you could?" The nurse is assessing which component of the psychosocial assessment?

self-concept

The client expresses grief about not being able to fulfill the wish to pursue doctoral studies. Which type of loss does this indicate?

Loss related to self-actualization

Which statement, made by a nurse who experienced sexual abuse as as a child, demonstrates being best prepared to work with sexual abuse and trauma survivors?

"I've been supported by health care professionals and now I want to support other survivors."

A client is attending anger management class and wants to know how the class will help. What is the nurse's best response?

"It will help you to learn how to control the arousal of anger."

During assessment of a client with schizophrenia, the nurse notes the client has ideas of reference. Which statement of the client would have led the nurse to conclude this?

"The news of the terrorist attack is directed to me. The terrorists are trying to warn me."

The nurse is caring for a hospitalized client who is suspicious and guarded. The client tells the nurse that the client does not want anyone to tell the family about the client's condition. What is the nurse's best response when the family calls the hospital unit to inquire about the client's condition?

"You are welcome to share any information that you think would be helpful." Correct response:

A nurse is caring for a client in the hospital who was admitted for injuries sustained from an abusive spouse. The client says she's scared to leave her husband for fear he will hurt her. Which actions should the nurse plan to include in the plan of care for this client? Select all that apply.

-Consult social services. -Plan an interdisciplinary team meeting regarding this situation. -educate the client on resources available to her

Which is a cognitive response to grief?

Attempting to keep the lost one present

Which term is used to describe an activity used to release anger?

Catharsis

A female client states that she has been receiving numerous text and phone messages from a co-worker. Which type of harrassment should be documented in the nurse's notes?

Cyberstalking

How should the nurse describe the mood and affect of a client who has a mask-like facial expression but states, "I'm really happy"?

Incongruent

A client with aggressive behavior shows no psychotic symptoms. Which medication should the nurse expect to be ordered for this client?

Lorazepam

Which type of rapist derives erotic gratification from the victim's suffering?

Sadistic rapist

Which is not a risk factor for child sexual abuse?

The child is aged 10 years or younger.

A client is crying uncontrollably after having experienced an assault by a family member. The nurse is aware that the client is experiencing which type of crisis?

traumatic

A female client tells the nurse she has had low appetite and motivation since the recent breakup of a long-term relationship. The client states, "I just can't stand not having her around. I need her back." The client is experiencing which of Bowlby's phases of grieving?

yearning

The nurse begins an assessment of an older adult client who was brought to the hospital by her son. The client states, "I don't want your kind of help." What is the nurse's best response?

"Have you had a bad experience in the hospital before?"

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

"He tells me that he is sorry and that he will never hit me again."

The client is scheduled to undergo an amputation of the lower right limb. The client is experiencing grief over the pending procedure. Which question should the nurse ask while assessing the client's perception of loss?

"How do you feel about the news?"

Which statement by the client best demonstrates a healthy relationship with family?

"I feel better after I visit with my Mom."

A nurse is working in a mental health clinic. Which client statement should the nurse recognize as describing a type A personality?

"I work harder than anybody else in my job. I am not satisfied until I achieve each goal I set for myself."

A nurse is assessing a 7-year-old child in a school. The nurse suspects that the child has an insecure relationship with the parents. Which statement said by the child would have led the nurse to this conclusion?

"Please don't tell my mom anything we've talked about."

A psychiatric-mental health nurse is assessing a client. Which statement by a client would the nurse recognize as evidence of an absence of insight?

"Sometimes I feel like the world would be better off if I were dead."

A nurse is working with a client who has lost unit privileges due to inappropriate behavior. Which statement by the nurse demonstrates appropriate offering of choices?

"Would you rather go to the cafeteria or have dinner in the dayroom?"

The nurse is performing a psychosocial assessment of a client. Which questions should the nurse ask to assess the client's self-concept? Select all that apply.

-"How do you think you look today?" -"What do you do when you have a problem?"

The nurse is performing a psychosocial assessment of a client with a mental illness. What information should the nurse gather from the client while taking the history? Select all that apply.

-Chronological age -Cultural considerations -Spiritual beliefs

A client with schizophrenia has been brought to the hospital in an agitated state. In order for the nurse to perform the initial assessment, which approaches should the nurse use to manage the situation? Select all that apply.

-Monitor facial expressions -Monitor emotional responses -Ensure availability of assistance

After a series of admissions to the emergency department over the past several months, an 80-year-old client's malnutrition, vague history, and pattern of physical injuries lead the nurse to suspect elder abuse. Which aspect of the client's situation may contribute to elder abuse? Select all that apply.

-The client is physically dependent on the client's son since losing mobility. -The client has no income or savings of the client's own. -The client's son describes the client as "needy, helpless, and pathetic."

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 -Characteristics of the client's sleep -The effect of the client's PTSD on the family

When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home? (Select all that apply.)

-has a family history of alcohol abuse must go straight -home after school each day the client's father -monitors contact with friends

Which client is most at risk for experiencing anticipatory grief?

61-year-old spouse of a client experiencing symptomology of moderate-stage Alzheimer

A nursing student learning about intimate partner violence (IPV) correctly identifies the percentage of deaths attributed to IPV to be what?

70% women and 30% men

During an admission assessment, the nurse asks a client the meaning of the proverb, "People in glass houses should not throw stones." Which clinical feature is the nurse assessing?

Abstract reasoning

If the client provides a literal explanation of a proverb and cannot interpret its meaning, which thought process is lacking?

Abstract thinking

A client diagnosed with terminal cancer is making plans to take flying lessons because that has always been the client's personal goal and it will allow the client to visit the client's elderly parents. What stage of death and dying according to Kübler-Ross is best illustrated in this description?

Acceptance

In which ways can anticipatory grief be helpful for the client and family?

Acceptance of impending death

A client is arranging a funeral ceremony for the client's child. According to the Worden's tasks of grieving, which task is being accomplished?

Acceptance of the reality of the loss

When communicating with a client in the triggering phase of the aggression cycle, which intervention should the nurse include?

Allow the client to take a "time out" in a quiet area

Seclusion and restraint are nursing interventions to be used for an individual in which situation?

As a last resort

The nurse has been asked to assess a 54-year-old client's memory. Which technique would allow the nurse to evaluate recent memory?

Ask the client to recall events that have occurred over the past few weeks.

The family members of a military veteran are distraught that he has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action?

Assess the client for signs and symptoms associated with post-traumatic stress disorder

The psychiatric mental health nurse is working with a client who has been diagnosed with posttraumatic stress disorder (PTSD). Assessment reveals that the client is experiencing frequent episodes of intrusion. The nurse should consequently prioritize what assessment?

Assessing the quantity and quality of the client's sleep

Nurses at an urban emergency department seek to develop a plan to help women involved in abusive relationships. Which component is critical to the success of the plan?

Access to community resources for referral

While conducting an interview with a psychiatric-mental health client, the nurse is observing the client's facial expressions and nonverbal cues. What are these physical manifestations known as?

Affect

What assessment data, related to a 77 year old client, would be considered the highest risk for possible elder abuse?

Diagnosed with mild dementia

When attempting to preserve evidence from a possible rape with no report of oral sex, the female victim should be instructed that which self-care activities are permitted?

Brushing her teeth

The nurse is legally obligated to report suspected child abuse to local authorities. Which information is essential?

Child's name, location, age, and suspected perpetrator

When noted in an assessment of a child, the nurse should suspect child abuse if which common physical findings signaling abuse are present?

Bruises, burns, lacerations, missing teeth, and skeletal injuries

The nurse is assessing a client with psychiatric disorder. The nurse finds that when asked a question, the client gives excessive and unnecessary details followed by the answer. This is indicative of which impairment of thought content?

Circumstantial thinking

The nurse performs an assessment of a client who presents with symptoms of mental illness for the first time. Which is the nurse's priority?

Collect comprehensive data

A 27-year-old has been brought to the emergency department by emergency medical services following a violent sexual assault that took place in the parking garage of the client's building. Which task would fall most clearly within the scope of practice of a forensic nurse?

Collecting specimens from the client for use as evidence

A client has lost emotional and physical control. The client is shouting, screaming, hitting others, and throwing objects. Which phase of the aggression cycle is this client expressing?

Crisis

In which phase of the aggression cycle can techniques of seclusion or restraint be used to deal with the aggression quickly?

Crisis

A nurse is beginning the process of providing therapy to a client with anger management problems. When implementing this therapy, which should occur first to promote optimal effectiveness?

Development of a therapeutic relationship

A client's children have downplayed their grief following the death of their mother's partner, claiming that their mother and her partner were only together for a few months and that "he was no good for her anyways." The client is at risk of experiencing which type of grief?

Disenfranchised grief

A 20-year-old client who has a diagnosis of schizophrenia frequently experiences delusions of persecution. At the prompting of the client's mother, the nurse attempts to determine the character and severity of these delusions on a particular day. In doing so, the nurse is conducting what type of assessment?

Focused

A client is exhibiting a behavioral response to grief. When obtaining a health history, the nurse would expect which assessment finding to be noted?

Hostility

Which term is used to describe an emotion expressed through verbal abuse and violation of rules or norms?

Hostility

When caring for a client who is experiencing the symptomology of acute stress disorder, the nurse recognizes the importance of minimizing the client's risk for developing which condition?

Posttraumatic stress disorder

A client is diagnosed with intermittent explosive disorder. The nurse understands that this disorder is associated with which neurotransmitter?

Serotonin

A college student who was the victim of an attempted sexual assault has sought care due to anxiety that is affecting every aspect of the client's life. Which characteristic of the client's situation and the client's anxiety would suggest a diagnosis of posttraumatic stress disorder (PTSD) rather than acute stress disorder?

The attack took place several months ago, and the client's anxiety has been continuous.

During a mental status exam, what conclusion should the nurse draw when the client is able to complete fewer than half of tasks accurately?

The client's cognitive deficit is significant

The nurse is assessing an older adult client with lower back pain. In the course of assessment, the nurse learns that the client lost a spouse 10 weeks ago. The client laughs inappropriately and states, "My spouse just up and left me!" Which is the nurse's best response?

The nurse should recognize the incongruity between content and behavior and find ways of exploring further.

Which is an inaccurate picture of the cycle of abuse that occurs over time?

Violent episodes are less frequent

A nurse is working in a mental health clinic and cares for various clients. Which client should the nurse recognize as having the greatest risk for the development of drug dependence?

a 12 year old girl who was raped by a family friend

A client has been diagnosed with posttraumatic stress disorder (PTSD) after witnessing an explosion at the client's industrial worksite. The client will soon begin exposure therapy, so the nurse should prepare the client for:

a visit with the therapist to the place where the explosion occurred.

The family members of a client with posttraumatic stress disorder (PTSD) state that they are "constantly walking on eggshells" because the client reacts so strongly to stressors that seem inconsequential to them. What is the nurse's best response?

Educate the family about the client's hyperarousal

Which personality trait is associated with aggressive behavior?

Impulsivity

Which term describes the process by which a person experiences grief?

Bereavement

The nurse is assessing a client who is recently divorced. The client tells the nurse that the memories of the client's former spouse are interfering with an ability to concentrate at work. According to Horowitz's stages of loss and adaptation, this is indicative of which stage?

Denial and intrusion

While working in a psychiatric-mental health facility, the nurse notices a client pacing back and forth and becoming increasingly agitated. Which is a critical step in communicating with the client to prevent the escalation of aggressive behavior?

Discover the source of the distress.

Which must the nurse consider a priority in the assessment of mental status?

Safety

The nurse is looking to assess the client's ability to concentrate. Which task should the nurse ask the client to perform?

Spell "America" backward.

A client comes to the clinic for a prenatal visit. While the client is in the examining room, her estranged husband appears and insists on seeing the client. The client tells the nurse that they are in the process of getting a divorce and she does not want to be around him. "He's been following me to work and at my home everyday." What should the nurse suspect?

Stalking

The psychiatric nurse correctly identifies the client's form of communication as circumstantiality when the client does what?

Provides long, irrelevant explanations when asked why the client abuses alcohol.

During which phase of the aggression cycle does the staff usually have a debriefing session?

Recovery

When asking a client to "tell me how having schizophrenia has affected your life," the nurse is assessing the client's capacity for what?

Reflective insight

Which provides the most acceptable example of neglect according to the definition of the term?

Rejecting a 3-year-old who is crying and seeking affection after the child stumbles and falls

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

When conducting a psycho-social assessment, the nurse inquires about the client's social supports. In order to effectively do this, which does the nurse need to explore?

The length and quality of relationships

A nurse is giving a talk about child abuse to a local community group. When discussing risk factors for child abusers, which would the nurse identify as the most likely profile of the perpetrator of fatal child abuse?

Unemployed young woman who dropped out of high school

Which drug has been effective in treating aggressive clients diagnosed with bipolar disorders?

Lithium

The nurse has been working on anger management with the client. The client yells during dinner, "Give me that salt shaker!" What is the best nursing intervention at this time?

Remind the client about communication skills discussed earlier

The nurse asks the client to explain the meaning of the proverb "a stitch in time saves nine." Which explanation given by the client indicates concrete thinking?

You should not forget to sew up holes in your clothes.

A nurse is counseling a client with depression on what to do in case the client has suicidal thoughts. Which option may provide the most immediate help for the client?

a telephone hotline

A client who has recently lost his same-sex partner in a motor vehicle accident tells the nurse, "My family doesn't speak to me because of my lifestyle. I feel like I have no one to talk to about my loss." The client is experiencing:

disenfranchised grief.

A client is assessed for recurring episodes of fainting and blurred vision. A diagnostic scan reveals the client has an ominous mass in the brain. When the client is told this news, the client appears stoic and does not cry. According to Horowitz's stages of loss and adaptation, this client is in which stage?

outcry

A client tells the nurse the client been dating someone for three months after finalizing divorce one year ago. According to Rando (1984), the client is engaging in which grieving task?

re-investing

The nurse is caring for a client who has recently lost a sibling due to suicide. Which type of grief does the nurse anticipate the client is experiencing?

traumatic grief

A client is admitted to the hospital with posttraumatic stress disorder (PTSD). When approaching the client for the first time, the nurse speaks softly and gently, in a nonthreatening manner. What is the most appropriate reason for this behavior of the nurse?

To prevent the risk of triggering fears in the client

A client with dissociative disorder is referred for psychotherapy. What would be the main focus of therapy for this client?

To reassociate with conciousness

The nurse is working with a client who has experienced the death of a spouse. The nurse is aware that the client is in the acute mourning stage of grief with which client statement?

"I just want to be left alone by my family and friends."

A female client with post-traumatic stress disorder (PTSD) has just completed a session of eye movement, desensitization, and reprocessing (EMDR) therapy and exposure therapy. The client states that she is exhausted because she has been:

imagining the details of the traumatic event with the therapist.

The nurse is performing a physical assessment on a 3-year-old client. During the assessment, the child starts screaming and kicking. The nurse suspects this child:

is acting out.

A nurse is working with a client who is a survivor of rape. The client asks the nurse, "It's been 6 months since it happened. Why can't I get back into doing the things I did before?" What is the nurse's best response?

"It can take at least a year or more to get back to where you were before."

When considering where to conduct a psychosocial assessment, the nurse can effectively interview which client in the unit's conference room?

the anxious client

Which child has the greatest risk for being the target of bullying at school?

the child who wears hearing aids

The nurse states "I know this must be frightening for you" to a client who is angry and has a potential for violence. Which communication technique is the nurse utilizing with this statement?

validation

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.

What question should nurses ask themselves to determine if the care they provide to the grieving client has been both therapeutic and client focused?

"Do I have the strength to be present and to facilitate the client who is grieving?"

The nurse is assessing a client who is grieving the loss of a spouse. According to Kubler-Ross's stages of grieving, which statement indicates that the client is in the depression stage?

"My spouse is gone. I am having a really hard time finding a reason to keep going."

What are some types of behavior that the nurse would recognize as qualifying as psychological abuse? Select all that apply.

-Criticizing -Ridiculing -Threatening a victim's dog

The nurse is preparing to perform a psychosocial assessment of the client. Which describes the most effective approach taken by the nurse? Select all that apply.

-Objective -Accepting

The nurse is aware that fewer than half of rapes and sexual assaults are reported. Which are some of the reasons people do not report being sexually assaulted? Select all that apply.

-The client is embarrassed of the assault. -They have a fear of being blamed for the incident. -The perpetrator may use coercion or threats to control the victim.

A nurse is meeting an older adult client for the first time. What may hinder the nurse's ability to effectively carry out the psychiatric assessment? (Select all that apply.)

-The client is not wearing a hearing aid. -The nurse and the client speak different primary languages. -The client has a cognitive impairment. -The client is experiencing pain.

The nurse is planning treatment for a client with aggressive and psychotic behavior. What should be the immediate goals of treatment for this client? Select all that apply.

-The client will not harm the self. -The client will demonstrate decreased acting out behavior. -The client will withhold from harming others or damaging the hospital property.

The nurse is explaining the importance of expressing anger to a client. What should the nurse mention as the possible physical complications associated with suppressing anger? Select all that apply.

-Ulcers -Coronary artery disease -Migraine headaches

Under which circumstances can an expression of anger be considered a normal and healthy reaction? Select all that apply.

-When facing an unjust situation. -When personal rights are not respected. -When realistic expectations are not met.

The nurse is providing individual support to a female client who attends a group for people who have experienced loss of a family member to suicide. The client's son committed suicide one month ago. The client was not aware that her son experienced depression. Which risk factors for complicated grief are most likely for this client? (Select all that apply.)

-death of a child -sudden, unexpected death -death by suicide

Which of the nurse's assessment questions would best identify whether the client has insight into the illness?

"Do you think that your illness prevents you from functioning well, and if so, how?"

The nurse has entered a hospital client's room and asked the client if the client plans to attend the morning's scheduled group life-skills session. Which response should signal the presence of thought blocking to the nurse?

"I might. I'll give it some..."

On observing a client diagnosed with posttraumatic stress disorder (PTSD), the nurse suspects that the client is dissociating. What questions should the nurse ask the client to confirm the suspicion? Select all that apply.

-"Can you see me?" -"Are you able to hear me?"

A client is diagnosed with posttraumatic stress disorder (PTSD). What questions should the nurse ask the client to elicit information about the symptoms? Select all that apply.

-"Do you have recurrent and intrusive thoughts of the trauma?" -"Do you feel detached from others?" -"Do you get irritated by trivial issues?"

A nurse is performing a psychosocial assessment of the client. Which questions asked by the nurse can be identified as open ended? Select all that apply.

-"How can we help you?" -"How did your problems begin?"

A nurse is working in the emergency department. Which situation would lead the nurse to suspect possible abuse of a client? Select all that apply.

-A 6-year-old is being seen for the 5th time for a urinary tract infection -A baby with contrecoup injuries to the brain -A 3-month-old with a fractured femur

Which clients in the psychiatric inpatient unit should the nurse watch closely for risk of aggressive behavior? Select all that apply.

-A client with a history of violence. -A client with history of being personally victimized. -A client with a history of substance abuse.

A nurse is assessing risk for trauma and stress-related disorders for a child. Which areas are important for the nurse to ask about? Select all that apply.

-Incarceration of a parent -Childhood physical abuse -Unexpected death of a family member -Childhood exposure to mother experiencing violence

Which are forms of psychological abuse? Select all that apply.

-Insulting -Humiliating -isolating a person from family

A nurse is leading an anger management group in the inpatient program. A client says, "I'm feeling really tense, and I'm fidgety today." What is the nurse's most appropriate response to the client's comment?

Explore what is underlying the client's physical and emotional state

When lecturing about dissociative disorders to a group of nursing students, a nurse states that an essential feature of these disorders involves what?

Failure to integrate identity, memory, and consciousness

Asking the client to complete serial sevens assesses what?

Concentration

Which experience could be the possible cause of grief due the loss of security and belonging for the client?

Divorce

Which staff behaviors are most likely to trigger clients who are predisposed to aggressive or violent behavior?

Engaging in disputes over medication, supplies, or rules on the unit

Which type of affect is represented by showing no facial expression?

Flat

A nurse assesses a 29-year-old client in the outpatient mental health clinic. The nurse notes the client is speaking very quickly and jumping from topic to topic very rapidly. There is some connection between ideas, but they are difficult to follow. Which term most accurately describes this thought process?

Flight of ideas

Which statement requires additional education regarding the truth about rape?

Rape is a crime of passion.

A nurse is working on developing a safety plan with a client who is a survivor of violence. Which would the nurse address first?

Recognizing the signs of danger

The nurse is concerned that a victim of intimate violence is experiencing revictimization. Which client statement leads the nurse to this assessment? Select all that apply.

-"My parents used marijuana and cocaine." -"My uncle sexually abused me when I was 8 years old." -"I smoke marijuana and have several cocktails in the evening."

Which characteristics are found in violent families? Select all that apply.

-Abuse of power and control -Alcohol use disorder -Social isolation

Which is the most frequent and persistent bereavement-associated symptom?

Sleep disturbances

During an assessment, which would be the most important question topic?

Suicidal ideation

A client with a history of angry outbursts that have caused interpersonal and work problems has been in counseling for several months. The nurse judges the plan of care to be effective when which outcome is met?

The client uses adaptive coping to manage anger impulses.

A client belonging to the Vietnamese culture has passed away. The caregivers of the client ask the nurse to allow them to put some rice grains in the mouth and place money with the deceased client. What is the belief associated with this ritual?

This ritual would help the spirit buy a drink as it moves to the afterlife.

A nurse is considering using restraint and seclusion for a client who is acting out. Which is the primary guideline for the use of restraint and seclusion?

Use should be limited to emergencies in which the risk of a client physically harming self, staff, or others is imminent.

A nurse is caring for a client who is experiencing a flashback of a violent event and is curled up in bed. What should the nurse do?

Use supportive touch after asking for the client's permission.

A young adult client female is assessed after being raped. The client reports being tied up and beaten while the perpetrator forced sexual intercourse. She recalls the perpetrator saying, "I will make you pay." What most accurately describes this category of rapist?

anger retaliation

A middle-aged client with young children has been the victim of intimate partner violence (IPV). When providing initial care to this family, the nurse should:

carefully assess the children for signs of trauma.

Which type of grief occurs when a person is stuck in a state of chronic grieving?

complicated grief

A client is experiencing a high level of stimulation after a terrorist attack. In providing psychological first aid to the client, which intervention would be best for the nurse to select?

explaining to the client that the client is safe

Considering the nature of its content, which areas may be the most uncomfortable or difficult for the nurse to assess?

sexuality

The nurse is caring for a hospitalized client who just received the news that a mass in the neck is malignant. As the nurse engages in an assessment of the client's needs, the nurse asks, "Who has been a helpful person to you in the past when you were having a difficult time?" Which component of the assessment is the nurse exploring?

support while grieving

The nurse is planning education for a client on techniques to manage anger and aggression. Which client situation would be best for providing this education?

the client who is sitting in the dayroom reading a book

Which client will the nurse identify as having the greatest risk for developing disenfranchised grief?

the wife of a man who was shot to death by police during a robbery Correct response:

Which assessment question should the nurse ask of a client suspected of being ostracized by a school bully?

"Do you feel like a part of a group in school?"

A nurse is talking to a client who has been told the client has a terminal illness and is responding in an angry manner. What statement by the nurse would best facilitate the best possible client outcomes?

"How much do you know and what do you want to know?"

Which statement by a client would alert the nurse that the client is experiencing complicated grief?

"I am still so angry about my grandmother's death even after a year."

Which statement made by a client raises the greatest concern that the client may be experiencing relationship violence?

"I don't know what else I can do to keep him from getting angry at me."

Which phrase can do much to instill hope in the dying client?

"Let me tell you about your illness."

A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this?

"My partner tells me that he or she will tell child services I'm a bad parent."

A nurse is teaching a group of nursing students about the concept that long term stress causes an increase in the wear and tear on the brain and body. Which statement by the nursing student indicates understanding of this concept?

"The increase in the wear and tear on the body from stress is allostatic load."

The nurse is assessing a client of an Eastern culture who is admitted due to the need for anger management. What question should the nurse ask to determine the effect of culture on the client's expression of anger?

"What did you learn about anger when growing up?"

A new nurse asks the nurse manager about the best intervention to use when trying to de-escalate a potentially violent client. Which response would be most appropriate?

"What works best is what fits the client and the situation."

The nurse is counseling a client who has lost a spouse. According to the dual-process model, which of the client's statements to the nurse relate to restoration-oriented coping?

"With my spouse gone, I don't know how I can pay the bills."

A nurse is assessing a client in a community clinic who reports feeling anxious lately because she is considering leaving her marriage. The client describes a long history of partner abuse associated with this relationship. How should the nurse respond to this client?

"You have the right to be safe and respected."

The nurse assesses a 6-year-old child for posttraumatic stress disorder (PTSD). The caregiver explains that the child witnessed the mother being stabbed by a neighbor. Which is a behavior consistent with the child's diagnosis?

A two-month history of angry outbursts with minor provocation

The nurse is demonstrating de-escalation techniques on an aggressive client in a forensic setting. Which is the best explanation of this technique?

Resolution of anger in nonviolent ways

A client tells the nurse that the client has strong urges to damage property as a result of feelings of hostility and anger. Which is an appropriate nursing action?

Take the client to the gym for exercise.

The psychiatric-mental health nurse is providing care for a child who has been diagnosed with disinhibited social engagement disorder. What intervention best addresses the characteristics of this disorder?

Teaching the child how to interact appropriately with strangers

A client with posttraumatic stress disorder (PTSD) is admitted to a psychiatric unit. Which is the most appropriate reason for the head nurse to appoint one nurse to provide complete care for the client?

The client has difficulty with familiarizing and trusting people.

A client with posttraumatic stress disorder (PTSD) is treated with exposure therapy. What change is most likely expected in the client after receiving this therapy?

The client may be able to control thoughts and feelings about the event.

A nurse is performing a psychosocial assessment of a client in the psychiatric unit. The nurse finds that the client is unable to understand the questions. Which explanations should the nurse consider? Select all that apply.

The client may have a hearing disability. The client may not understand the nurse's language.

A nurse is caring for a client with posttraumatic stress disorder (PTSD) who has been referred for employment by the vocational service personnel. Which is the most likely reason the nurse fears that the client may be unable to sustain the job for a long period of time?

The client may not be able to work under supervision of an authority figure.

The nurse is reviewing the health record of a client who developed posttraumatic stress disorder (PTSD) following a spouse's cardiac arrest and death. The health record states that the client experienced derealization during the traumatic event. What assessment finding would substantiate this statement?

The client states that the client cannot remember what happened during and immediately after the event

The nurse has been asked to identify a location to conduct an interview with a psychiatric-mental health client. Which is an essential consideration when choosing a location?

The client's right to privacy

The nurse is working with a group of clients in the prewarning phase of a disaster. Which situation best describes this phase?

The clients are reviewing evacuation routes for a flood.

A client who is in the process of divorce tells the nurse the client will require some time off from work due to the inability to concentrate. According to Bowlby's phases of grieving, which phase best reflects this client's current experience?

disorganization and despair

A nurse is reading a journal article about anger and violence. Which would the nurse expect to see as being linked to excessive, outwardly directed anger?

myocardial infarction

A nurse is teaching a family about altered thinking patterns with PTSD. Which pattern is accurate regarding the thinking of a client who has PTSD?

negative personal beliefs

The nurse is providing discharge instructions for a client who has received a prescription for lorazepam after the death of a loved one. Which phase of psychopharmacologic treatment does this describe?

stabilization

A nurse is preparing a presentation for a senior center about elder abuse. When describing individuals associated with abusing older adults, which group would the nurse most likely identify? Select all that apply.

-Family member -Adults -Children -Spouses

Which is an example of a perceived loss?

An older client grieves for the loss of independence

After receiving word from the oncologist that the client's tumor is malignant, the client says to the nurse, "If you people had the faintest clue what you were doing, I wouldn't be like this." The nurse should recognize that the client may be experiencing which stage of grief?

Anger

Which type of hallucination is the most common?

Auditory

A client with posttraumatic stress disorder (PTSD) holds strong Christian beliefs. The nurse refers the client to an individual from the clergy as a part of treatment. What would be the most appropriate reason for the nurse to take this action?

It fosters resilience through allegiance to religious beliefs.

What is the most significant benefit of using Beck's Depression Inventory to the practice of evidence-based nursing practice?

It is a standardized, reliable depression tool.

A nurse is caring for a young adult in the mental health clinic. The client tells the nurse that the client was physically neglected as a child. The nurse should assess the client for symptoms of what?

Major depression

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

A nurse must assess a client's thought process and content to identify risk for aggression. The assessment of the client's thought process and content would allow the nurse to identify what?

Perceptions and delusions

In which of the phases of Bowlby's grief process does the bereaved person begin to understand the loss's permanence?

Phase of disorganization and despair

During which phase of Bowlby's grief process does the bereaved person begin to reestablish a sense of personal identity, direction, and purpose for living?

Phase of recognition

Which client should the nurse anticipate will be at greatest risk for alteration in quality of life as a result of loss?

45-year-old with severe depression

Which describes a strong emotional response to a real or perceived provocation?

Anger

The nurse is planning the environment for a newly-admitted client with a history of violence toward others. Which modification would the nurse implement?

Confirm that the utility and storage rooms are kept locked.

What percentage of women can expect to be a victim of an ongoing unwanted pursuit from stalking?

12-32%

Approximately what percentage of women rape victims are raped by someone they know?

65%

Which culture believes that leaving the body alone after death is disrespectful?

Orthodox Jewish Americans

A nurse's response to aggressive behavior on the unit is influenced by the which ability of the nurse?

Own awareness and reaction to aggression

A mental health nurse presenting an educational program on rape for high school students responds to the statement, "Women cry rape often times just to get even with the guy," by offering which answer?

"Actually, fewer than 2% of all reported rapes are found to be false."

A person brings a parent to the clinic and tells the nurse that the parent has begun to act strangely in the past few days, with unprovoked outbursts of anger. After the incidents, the parent expresses remorse for the outburst. The person says, "I've never seen my parent act this way." Which question would be most appropriate for the nurse to ask next?

"Has your parent suffered any traumatic injury to the brain recently?"

The nurse is working with a client who is experiencing a crisis due to a divorce. Which statement would alert the nurse to the client's need for referral for further mental health counseling?

"I am trying to work through this but have had to cut myself a few times."

A community care nurse is visiting a client at home. The client was discharged from the hospital one week ago after having a mastectomy. After the nurse completes the physical examination, the nurse asks, "How are you feeling about your body changes?" The client tells the nurse she is not interested in talking right now and would prefer that the nurse leave. Which is the nurse's most effective use of communication skills?

"I just want you to know that I am available to talk when you are feeling up to it."

While interviewing a client, a nurse asks, "What do you do when you get angry?" Which client response would indicate to the nurse that the client engages in anger suppression?

"People say I withdraw and pout about the problem."

A nursing instructor lecturing about death and grief realizes a need for further instruction when a student states what?

"The grieving process is the same for children and adults."

Which client statement indicates the most insight into his or her issue with auditory hallucinations? You Selected:

"The voices aren't real but it's hard to ignore them."

A nurse works in a psychiatric clinic. During a counseling session, the nurse finds that the client who has posttraumatic stress disorder (PTSD) is unable to identify the intensity of the client's emotions. The client states that extreme emotions appear out of nowhere and with no warning. What suggestion should the nurse provide to help the client get in touch with the client's emotions?

"Use a journal or a log to write down your feelings."

The nurse is preparing to assess a client's remote memory. Which questions would be most appropriate for the nurse to ask?

"When did you get your first job?"

The nurse is working with a client who yells at the nurse "I am angry about how you keep treating me without respect!" What is the nurse's best response?

"Why do you think I am not being respectful to you?"

A client is becoming increasingly angry while talking with the nurse. Which statement reflects the nurses's appropriate use of de-escalation with the client?

"You look like you are upset and I want to understand why."

When assessing orientation, the nurse completes the assessment by asking which questions? Select all that apply.

-"What is your name?" -"Can you tell me where you are?" -"What day of the week is it?"

A nurse is preparing to gather a health history of a client. Which questions can elicit disclosure if a client has been abused? Select all that apply.

-"When there are arguments at home, have you ever been hurt or afraid?" -"It looks like someone has hurt you. Tell me about it." -"Some other women I have cared for have described problems like yours. If this is happening to you, can we talk about it."

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

-A client who has frequent nightmares about the time a fellow soldier died from an improvised explosive device -A client who is unable to relax without first barricading the client's home after a violent home invasion and assault -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 robbed -A police officer who experiences panic attacks when thinking about the time the police officer was forced to shoot a violent suspect

A nurse is assessing a Haitian client. The caregiver of the client tells the nurse that the client is having an episode of Bouffée delirante. What symptoms would the nurse expect to find in this client? Select all that apply.

-Confusion -Hallucinations -Extreme aggression

The nurse is assessing a client who is aggressive. Which safety measures must the nurse ensure are in place prior to continuing the assessment? Select all that apply.

-Give the client plenty of space. -Sit in an open area -Request the presence of additional staff.

The nurse is planning to give health-related education to adolescents with posttraumatic stress disorder (PTSD). What topics should the nurse discuss specifically for these clients? Select all that apply.

-Have a healthy, balanced diet -Set small, specific, achievable goals -Abuse of alcohol and drugs can cause ill effects

A nurse is interviewing several clients who survived a school shooting ten years ago when they were in high school. Which clients should the nurse identify as having achieved adaptation following this event? Select all that apply.

-Nurse manager for the local hospital. -Married, mother of three, who is a stay at home mother. -Father of two who works in a tire store and has a second job as a mechanic.

The nurse is speaking to the caregivers of a client who is experiencing complicated grief. The nurse is explaining some of the consequences of complicated grief. What are the health-related consequences associated with this type of grieving? Select all that apply.

-Panic disorder -Psychosomatic disorder -Precipitation of a cardiac disease

Which tools would a nurse use to objectively assess a client's personality? Select all that apply.

-Tennessee Self-Concept Scale (TSCS) -Milton Clinical Multiaxial Inventory (MCMI) -Psychological Screening Inventory (PSI)

The nurse's suspicion that a child has been sexually abused is supported by what assessment data? Select all that apply.

-The anal area is bruised -The child reports "itching down there" -The vulva appears edematous -The urinalysis reports a bacterial infection

A client has recovered from an episode of aggressive and hostile behavior. Which behaviors in the client indicate that the client is in the post-crisis stage of the aggression cycle? Select all that apply.

-The client apologizes for the hostile behavior. -The client cries and is remorseful for the event. -The client remains withdrawn from others.

A community mental health nurse has come to know that the mother of a long-term client has passed away. What are ways for the nurse to determine if the client will be at risk for complicated grief? Select all that apply.

-The client has low self-esteem. -The client is unable to trust others. -The client has attempted suicide in the past.

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 client with posttraumatic stress disorder (PTSD) is treated with psychotherapy. Which behaviors would indicate that the client is well stabilized? Select all that apply.

-The client is able to express grief in a nondestructive manner. -The client demonstrates an increased ability to cope with stress. -The client voluntarily establishes contact with friends and family.

A nurse is teaching a client about how traumatic events affect a person. Which examples are included in the teaching plan? Select all that apply.

-Witnessing a fatal shooting -Being trapped inside a capsized boat -Receiving word of a terrorist attack in a nearby community

When the school nurse is assessing an adolescent who reports trouble sleeping, which characteristics of the client indicate there may be violence in the home?

-the client's father monitors contact with friends -has a family history of alcohol abuse -must go straight home after school each day

The nurse is preparing to perform a psychosocial assessment of a client with schizophrenia. The client has a history of extreme aggression. What is the optimal setting for conducting an interview with the client?

A physician's intake room with other medical personnel nearby.

Which client should the nurse assess most closely for signs and symptoms of posttraumatic stress disorder (PTSD)?

A service member in the military who has recently returned from two tours of duty

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

A client has just been diagnosed with terminal brain cancer and given approximately 2 months to live. The client wishes to visit the client's mother soon to "say goodbye." The nurse acknowledges this reaction as what?

Anticipatory

When completing a physical assessment of an individual's response to stress, the nurse should observe and inquire about what?

Appetite and sleep

A client with a diagnosis of posttraumatic stress disorder (PTSD) has been brought to the emergency department (ED) by concerned family members, who state that the client is experiencing a "nervous breakdown." The ED nurse should prioritize what aspect of care during the initial care of the client?

Assessing the client's risk for self-harm and ensuring safety

Which stages of grieving, according to Kubler-Ross (1969), occurs when the person asks God or fate for more time to delay the inevitable loss?

Bargaining

Which statement regarding posttraumatic stress disorder (PTSD) and children is accurate?

Best practices demonstrate that adolescents who have PTSD are at increased risk of drug

Which must be addressed to establish a trusting working relationship before proceeding with the assessment?

Client's feelings and perceptions

The nurse is preparing a psychosocial assessment for use with clients with various mental health conditions. For which group of clients should the nurse include mostly closed-ended questions?

Clients with adult attention deficit hyperactivity disorder

A nurse is assessing a hospitalized client who is hearing voices due to psychosis. The client is easily distracted, and this is creating a barrier to completing the assessment. What is the most effective way for the nurse to proceed?

Complete the assessment in several short interactions.

Which factor is likely to have the greatest impact on how a client responds to grief?

Cultural influences

The nurse is conducting an admission interview with a psychiatric-mental health client. The nurse uses observational skills to identify that the client has a flat affect. The nurse is engaging in which part of the nursing process?

Data collection

The client has been recently diagnosed with cancer. When the nurse tells the client about the diagnosis, the client says, "I have been eating healthy food and working out regularly." According to the Kubler-Ross's stages of grieving, which stage of grief is the client in?

Denial

A client visits the clinic and tells the nurse that no matter how difficult the client's child acts, the client simply cannot express any anger. The nurse should plan to assess the client for symptoms of which mental health condition?

Depression

A nurse is preparing a presentation for a group of staff nurses on anger. When describing maladaptive anger, which psychiatric condition would the nurse identify as being linked to this anger?

Depression

A mental health nurse is interviewing a child for suspected abuse. The parent states that the child is having disciplinary problems at school and stutters when approached. From the listed behavioral indicators, the nurse would suspect which type of abuse?

Emotional

Which occurs in the second phase of Bowlby's grieving process?

Emotional yearning for the loved one

When working with a grieving client, which is the most effective intervention a nurse can use?

Encourages the client to express grief verbally

A group of at-risk teenagers have successfully completed an outdoor training program in which they had to collaborate and conquer a number of challenges. The nurse should identify what likely outcome of this program?

Enhanced resilience for the participants

Which is the most effective way in which the nurse can assess the progress of a client's mental status based on the expected outcome of the therapeutic plan?

Evaluation

A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which is a necessary component of this assessment?

Evaluation of insight and judgment

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 nurse assesses a newly admitted client on the unit. When assessing the client in detail about his/her past medical history, it is important for the nurse to also explore which information about the client?

Experience of health problems and health professionals

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

The nurse is providing care for a client whose history of intimate partner violence has resulted in posttraumatic stress disorder (PTSD). The client has few friends and states that the client is estranged from the client's family. How can the nurse best enhance the client's social support?

Facilitate the client's participation in a support group

While talking with a schizophrenic client, the nurse observes that the client is looking straight ahead, maintains no eye contact, and moves facial muscles very little, even though the client is telling the nurse about a very emotional episode the client just experienced with a roommate. When describing the client's affect, the nurse documents it as what?

Flat

During a conversation, the client states, "It's raining outside and raining in my heart. Did you know that St. Valentine used to visit jails? I've never been to jail." The nurse can correctly identify this thought process as what?

Flight of ideas

Under which component of the psychosocial assessment should the nurse document observations concerning the client's cultural considerations?

History

A psychiatric-mental health client informs the nurse that a tornado that hit a neighboring town was the client's fault because the client dislikes a neighbor. This disturbance of thought content is known as what?

Ideas of reference

During an initial assessment, a client exhibits pressured speech and points to patterns on the wallpaper stating, "This is the writing about the tsunami. Thousands of people died because I read the writing." Which term should the nurse use to document this observation?

Ideas of reference

An adult male client with a history of PTSD is brought to the emergency department (ED). The client was startled by a dog while out for a walk and kicked it. He was calm and apologetic when he presented to the triage nurse. Which is a priority nursing intervention?

Identify risks for self-harm and aggression

The nurse finds that a client with a history of aggressive behavior is restless, is pacing up and down in the hallway, and has clenched fists. The client also talks in a loud voice. Which intervention would be most appropriate at this point?

Immediately approach the client to engage in communication

A mental health nurse is caring for a client with schizophrenia. The nurse observes the client laughing about the recent death of the client's father. The nurse would correctly document this mood as what?

Incongruent

A client comes to the mental health clinic and reports feeling depressed for the last 3 months. The client also admits to having thoughts of suicide. When the nurse inquires about the client's relationships, the client tells the nurse that the client's spouse constantly belittles the client, telling the client often that the client is "stupid and fat." Which problem should the nurse assess for further?

Intimate partner violence

Which explanation would be the nurse's best response when asked about the denial stage of grief?

It provides the individual with a temporary escape from the reality of dying

A psychiatric-mental health nurse is feeling highly anxious before conducting an interview with a client. The nurse's experience of anxiety will impact the client assessment in which way?

It will be detrimental to the interaction by decreasing the nurse's focus and attention.

A client with psychosis who was recently admitted to a psychiatric unit says to the nurse, "The car is red. Are you ready for lunch? My head is hurting. Dogs bark loud." The client is exhibiting which type of speech?

Loose associations

As the nurse is conducting an interview with a client with a diagnosis of schizophrenia, the client states, "Bunnies are cute as a button, buttons are on my shirt, shirts can be bought in a store." Which is a term used to describe this thought process?

Loose associations

A nurse must assess for characteristics that are predictive of violent behavior. Research suggests violent behavior is influenced by possession of which attribute?

Low self-esteem

An 8-month-old infant has been brought to the emergency department unresponsive by the infant's teenage parent and the care team suspects shaken baby syndrome. When providing care for this infant, the nurse should prioritize which assessment?

Neurological assessment

When determining a client's potential for aggression and violence prior to engaging in a detailed psychosocial assessment, which would be most important for the nurse to do?

Obtain a thorough client history

When assessing a client who has been referred to the outpatient mental health clinic with symptoms of depression, the psychiatric nurse should closely observe the client's affect and which assessment component?

Physical appearance

A woman has had a breast removed to treat cancer. What type of loss will she most likely experience?

Physiologic loss

A client has just adopted a child whose traumatic history resulted in a diagnosis of reactive attachment disorder. What nursing action best addresses this child's diagnosis?

Planning activities where the client and the child can bond

The Rorschach test is designed to provide what type of information about the client?

Preferred coping styles

Which would not be included as a purpose of the psychosocial assessment?

Previous compliance with treatment regimen

The nurse is assessing a group of clients on an inpatient psychiatric unit. The nurse determines that a client most likely to be violent has what?

Previous episodes of rage

The nurse is caring for a client who has been placed in palliative care. The nurse observes the client constantly looking at photographs from youth. According to the tasks of grieving by Rando, which task is being accomplished here?

Recollect

A client is crying continuously from having lost a friend in an accident. According to the tasks of grieving by Rando, which task of grief is expected to be accomplished next?

Recollect and reexperience

During which phase of the aggression cycle does the client regain physical and emotional control?

Recovery

During the nurse's assessment of a new client on a medical unit, the client confides in the nurse that the client's spouse often "slaps me around" after the client has been drinking. What action should the nurse take in response to this statement?

Report the client's statement promptly to the appropriate authorities.

A client has been admitted to the detoxification unit after binge drinking. Even though the client is not currently intoxicated, the client is combative and exhibits altered thought processes. Which nursing diagnosis would be the priority?

Risk for other-directed violence related to alcohol withdrawal

The nursing student learning about intimate partner violence correctly identifies its prevalence in same-sex couples as what?

Same frequency as in heterosexual couples

A 3-year-old who has been seen in the emergency department for various fall-related injuries is being treated for apparent blindness in the left eye as a result of retinal hemorrhage. The nurse should suspect that which form of child abuse is part of the cause of the child's condition?

Shaken baby syndrome

The nurse is informing the client about being diagnosed with cancer. Which is most likely going to be the client's initial reaction?

Shock

Aggression control can be measured by the nurse's observation of a client's ability to do what?

Show an increased tolerance for frustration

The nurse is performing a physical health assessment of a client who has been diagnosed with posttraumatic stress disorder (PTSD). What aspect of this assessment should the nurse prioritize?

Sleep assessment

Eight months ago, a client was in a hotel fire and was the last person to be rescued from the roof. The client watched the client's spouse burn to death from the helicopter. The client continues to have nightmares and is fearful that the client will die in a fire. An appropriate nursing diagnosis for the client is what?

Sleep pattern disturbance related to recurrent nightmares

The nurse is caring for a client who has recently developed psychomotor retardation. Based on this information, which behavior would the nurse expect to see in this client?

Slowness of body movements

The nurse is counseling a client couple who are trying to reconcile and hold their marriage together. During therapy the wife states, "He makes me so mad when he spends all his weekend time with his friends instead of us. He makes me want to hurt him back." Using concepts from assertiveness training and effective communication techniques, the nurse implements which intervention after hearing the wife's remarks?

Teach the client to make "I" statements.

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 Explanation:

What action by a 6-year-old child would most strongly suggest a diagnosis of disinhibited social engagement disorder?

The child gives adults enthusiastic hugs immediately after meeting them

The nurse is assessing a 6-year-old child who witnessed the murder of the child's parents. The nurse suspects that the child has developed posttraumatic stress disorder (PTSD). Which specific behavioral manifestation leads the nurse to interpret this?

The child is easily startled and hyper-vigilant.

The nurse is working with two children who have been apprehended from a neglectful and abusive home. Initial assessments reveal that one child is much more traumatized than the other, despite similarities in their circumstances. The nurse should consider what possible explanation for their differing responses?

The children have differing levels of resilience

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 performing an assessment of a client with psychiatric illness. The nurse documents that the client has a restricted affect. Which behavior of the client is indicative of restricted affect? Choose the best answer.

The client displays only one type of facial expression.

A nurse is assessing a client who is depressed but unwilling to discuss the client's feelings. After speaking with the client's caregiver, the nurse learns that the client's pet died recently. Which is the most likely reason the client has hesitated to express the client's feelings?

The client feels that the nurse would not consider the grief as significant.

The nurse is assessing a client who is deeply upset and is not expressing feelings. At the end of the assessment, the nurse concludes that the client is extremely depressed because of the death of a loved one. The client has disenfranchised grief. What is the most likely reason for the client not being willing to speak about it to the nurse?

The client feels uncomfortable speaking about the relationship with the deceased.

A nurse is assessing a Korean client. The caregiver of the client tells the nurse that the client had been diagnosed with Hwa-Byung by their local health care provider. What should the nurse interpret from this?

The client had health-related issues due to suppression of anger.

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

Of the following clinical information, which one would be the most important in determining whether the client would be diagnosed with a mental disorder?

The client is unable to continue school work and has been sitting on the client's bed for 3 days.

The nurse is assigned to care for a client with posttraumatic stress disorder (PTSD). Which is the most appropriate reason for the nurse to be nonjudgmental while interacting with the client?

The client may have negative feelings about the self.

A nurse is caring for a client with dissociative disorder. The nurse tells the client, "Hello, I'm Robin, your nurse. It is 9 o'clock in the morning now. You are in room number 303. My name is Robin, I'm your nurse." What is the most appropriate reason for the nurse to repeat this statement?

The client may need to be reoriented.

The nurse finds that the client is constantly rubbing the hands. Under which component of psychosocial assessment should the nurse document this finding?

The general assessment and motor behavior component

A nurse is counseling a client who was diagnosed with posttraumatic stress disorder (PTSD). During the session, the client states that the client feels worthless and starts crying. The nurse reassures the client that the client is a survivor rather than a victim. What intervention is the nurse using?

The nurse is promoting the client's self-esteem.

Which would not increase the likelihood that an older adult will incur physical abuse?

The older adult is independent with activities of daily living.

A nurse is caring for a Jewish client with a terminal illness who is on a ventilator. The spouse of the client intends to stay near the client when the ventilator is removed. What is the reason for such a request, according to the Jewish culture? Choose the best answer.

The soul of the deceased should not be alone while leaving the body.

A nurse is seeing a client for a weekly therapeutic session in an outpatient psychiatric clinic. The client discloses to the nurse that the client often has thoughts about killing a neighbor. What should be the nurse's first response?

Warn the client's neighbor and report to the authorities.

The nurse working in a psychology clinic finds that suppression of anger is more common in women than in men. What is the possible explanation for such a finding? Choose the best answer.

Women are expected not to express so-called negative feelings like anger.

After losing the client's father in a car accident, a client has started practicing effective coping strategies. According to Horowitz's stages of loss and adaptation, which stage is this indicative of?

Working through

The nurse in the emergency room is assessing a client who was brought in by the police for evaluation after receiving a call from a neighbor. The client reports to the nurse that the person who has been cooking and helping around the house has not been home for days. Which type of abuse does the nurse suspect based on the client's statement?

abandonment

A nurse is reviewing material about assessing mental status. The nurse demonstrates a competent understanding of this assessment by identifying which area as a component of cognition?

abstract reasoning

A nurse is conducting a visit to a client who is receiving palliative care at home for dying. The client's husband tells the nurse, "I know she needs to be with God. This is not a good place for her now." The client is experiencing which stage of Kubler-Ross' stages of grieving?

acceptance

A nurse documents that "the client describes the recent breakup of a dating relationship with an emotionless tone and a flat facial expression." In which section of the mental status exam would the nurse have documented this statement?

affect

A client's roommate yells at the client and the client acts as if nothing has occurred and ignores the roommate. The nurse identifies that the client may have which style of anger expression related to this incident?

anger suppression

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.

Considering the spiritual response to grief, which nursing intervention has the potential of providing the most support to a grieving client?

asking, "Do you find comfort in your religion at times like this?"

A client who has been in recovery from alcohol abuse for over one year tells the nurse he is drinking 5 to 6 beers per night since the client's mother's death. Which is the nurse's most accurate explanation for the client's grief response?

behavioral

The nurse asks the parent of a school-age child about intimate partner violence in the home. Which assessment finding caused the nurse to complete this assessment?

child crying and appearing sad

The nurse is performing an assessment on a client admitted with a diagnosis of schizophrenia. Which factor is the most predictive of the client's potential for aggression and violence?

client's history

A client runs to the urgent care center because the spouse is at home drinking and waving a gun around while yelling at the children. Which action should the nurse take first?

contact the police

A group of nurses is reviewing information about maladaptive anger. The nurses demonstrate a need for additional study when they identify which physical condition as being linked to suppressed anger?

coronary heart disease

Which client behavior would the nurse document as being an automatism?

drumming one's fingers on the table top

A client has been referred for care because the client's primary care provider suspects that the client has posttraumatic stress disorder (PTSD) following a motor vehicle accident. When working with this client, the psychiatric-mental health nurse should begin by:

establishing therapeutic rapport with the client.

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.

The nurse is orienting a new staff member in an inpatient mental health unit when a client begins to act in a violent manner. The nurse should explain to the new staff member that some clients use violence and aggression to ...

have their needs met.

The nurse assesses a client who comes to the emergency room for vaginal bleeding and swelling. The client reports she had sexual intercourse with her boyfriend the previous night and states, "It was consensual, but sometimes he is rough." The client begins to cry and looks away. What should the nurse suspect?

intimate partner violence

During an assessment of a client with bipolar disorder, the nurse observes the client laughing loudly, then sobbing immediately after. How should the nurse most accurately describe this observation?

labile mood

The school health nurse is asked to see a child who has been coming to school with no lunch for the past week. The child tells the nurse, "I don't get a lunch this week, I have been wetting the bed." The nurse identifies that this child is experiencing which type of abuse?

neglect

When assessing a 6-year-old child believed to be a victim of emotional abuse, the possibility is supported when the child is ...

observed to be anxious and rejecting adult attention.

A client with poorly controlled type 1 diabetes has just been informed that an amputation of the lower leg is required. The nurse can anticipate that the client will experience a reaction to the loss of which human need according to Maslow's hierarchy?

physiologic

The nurses on a mental health unit are reviewing aspects of the unit environment in a staff meeting. Which factor would be predictive of a client becoming aggressive or violent?

strict hierarchy of authority

A nurse in charge on a unit with a client who is receiving postoperative care for a below the knee amputation is deciding which nurse to assign to this client. Which nurse would be most beneficial for the client?

the nurse who has worked with the client before and after the amputation