Quiz 4

The nurse is working with several clients who are using maladaptive defense mechanisms. Which situation is an example of the maladaptive defense mechanism known as identification? A client criticizes the nurse after his family fails to visit him. A married man flirts with his secretary and then brings flowers home to his wife. A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. A nursing student who fears failure on a final exam develops a terrible headache and is unable to take the exam.

A young boy thinks that a neighborhood gang leader who sells illegal drugs is someone to look up to. RATIONALE: Identification is an unconscious attempt to change oneself to resemble an admired person. A young boy's belief that a neighborhood gang leader who sells illegal drugs is someone to look up to is identification as a maladaptive defense. Displacement is a defense mechanism in which feelings toward one person are directed at another who is less threatening, thereby satisfying an impulse with a substitute object. The client who criticizes a nurse after his family fails to visit him is engaging in displacement. Undoing is engaging in behavior that is considered the opposite of a previous unacceptable behavior, thought, or feeling (e.g., a married man flirts with his secretary and then brings flowers home to his wife). Conversion is the expression of emotional conflicts through physical symptoms. A nursing student who fears failure on a final exam and develops a terrible headache becoming unable to take the exam is an example of conversion. TEST-TAKING STRATEGY: Focus on the subject of the question, identification, and think about its definition. Next, note the strategic word "maladaptive," which will direct you to the correct option. Review: examples of adaptive and maladaptive defense mechanisms.

A client is experiencing anxiety and requests help with using constructive coping mechanisms. When recommending coping mechanisms, the nurse should discuss which responses as most likely to be successful? Select all that apply. A response that is protective It is an effort to relieve anxiety. It may involve behaviors such as using relaxation techniques. A response that encourages relaxation techniques A response that involves repression of a painful experience into the unconscious. A response used by the individual to consciously confront a threat.

A response that is protective It is an effort to relieve anxiety. It may involve behaviors such as using relaxation techniques. A response that encourages relaxation techniques A response used by the individual to consciously confront a threat. RATIONALE: A coping mechanism is any effort to adjust and relieve anxiety. Constructive coping mechanisms are protective responses that an individual uses to consciously confront a threat. Constructive coping mechanisms can include distractions such as reading, praying, meditation; relaxation techniques; or seeking social support. Destructive coping mechanisms involve repression into the unconscious and tend to be ineffective. Examples of destructive coping mechanisms include withdrawal from social contacts, poor dietary habits, smoking, and alcohol and drug abuse. TEST-TAKING STRATEGY: Focus on the subject, constructive coping mechanisms. Read each option, carefully noting the word "repression" in the incorrect option. Review: the characteristics of constructive and destructive coping mechanisms.

The nurse employed in the mental health unit of a hospital is leading a group psychotherapy session. Which is the nurse's role in the termination of stage of group development? Encourage problem-solving Encourage accomplishment of the group's work Acknowledge the contributions of each group member Encourage members to become acquainted with one another

Acknowledge the contributions of each group member RATIONALE: In the termination stage, the group leader's task is to acknowledge the contributions of each member and the experience of the group as a whole. In this stage, the group members prepare for separation and help one another prepare for the future. Encouragement of problem-solving and accomplishment of the group's work is part of the working stage. Encouragement of members to become acquainted with one another is a task of the orientation stage. TEST-TAKING STRATEGY: Focus on the subject, the termination stage. Eliminate the comparable or alike options that address problem-solving and accomplishment of the group's work. To select from the remaining options, focus on the subject and note its relationship and the correct option. Review: the stages of group development.

The nurse is discussing Claudia's nutritional status with the hospital dietitian. Which menu is best for Claudia? Roast beef, mashed potatoes, broccoli, fruit, and coffee Broiled chicken, baked potato, green beans, gelatin, and tea Cheeseburger, French fries, carrot sticks, fruit, and a milkshake Turkey breast with gravy, sweet potatoes, cranberry sauce, spinach, and milk

Cheeseburger, French fries, carrot sticks, fruit, and a milkshake RATIONALE: The client with mania may be too active, distracted, agitated, or disorganized to sit down and eat. Because of the client's constant activity, adequate intake of fluids and calories is needed. Therefore high-calorie protein drinks and milkshakes and finger foods such as sandwiches and fruit should be offered. Such foods allow the client to eat "on the run." Foods that require the client to sit and beverages containing caffeine should be avoided in the diet of the client with mania. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that include beverages that contain caffeine. To select from the remaining options, look for the option that comprises finger foods. Review: the nutritional needs of the client with mania.

The family of a client at the end-of-life has requested their pastor visit the client in the hospital. Privately, the client tells the nurse, "He's not my pastor. My daughter is always trying to get me to go to her church. I don't want to see him." Which response by the nurse is most appropriate? "A crisis of faith is common at the end of life." "Have you shared your feelings with your family?" "Spiritual needs can be as important as the needs of the body." "I will communicate to your family that you do not want to see the pastor."

"I will communicate to your family that you do not want to see the pastor." RATIONALE: Care during the dying experience needs to be based on the client's wishes. Therefore, the nurse should recognize family dynamics and advocate on behalf of the client, who is in a vulnerable condition, and communicate the client's wishes to the family. By meeting separately with the family, the nurse may help the family understand how they can support the client's dignity and autonomy. The incorrect options are inappropriate and do not address the client's expressed wishes and needs. TEST-TAKING STRATEGY: Note the strategic words, most appropriate. This indicates that you will need to prioritize. Focus on the data in the question. The nurse's priorities are to act as a client advocate and address the client's preferences. This will direct you to the correct option.

An employee from the dietary department is stocking the kitchen of a mental health unit. A client who is nearby says to the nurse, "The terrorists are here, and they're out to get me! They're putting anthrax in the sugar containers!" Which response should the nurse give to the client? "There aren't any terrorists in the kitchen." "No one is trying to hurt you. It's all in your mind." "You will scare the other clients if they hear you talking that way." "The person you saw is from the dietary department. He's here to stock the unit kitchen with food."

"The person you saw is from the dietary department. He's here to stock the unit kitchen with food." RATIONALE: When dealing with a client experiencing a delusion, the nurse should be open, honest, and reliable in interactions to ease the client's suspicion. The nurse should also present reality to the client. The nurse should avoid arguing about the content of the delusion, instead focusing on the feelings the delusion generates in the client. The nurse should not dwell on the delusion but instead should focus conversation on more reality-based topics. TEST-TAKING STRATEGY: Focus on the information in the question. Recalling that the nurse needs to reinforce reality will direct you to the correct option. Review: care of the client experiencing delusions.

The home care nurse makes a phone call to arrange a visit from a hospice nurse. A few hours later, the hospice nurse arrives to talk to the family and set up the hospice program. Laura takes the nurse into Louis' room, and says "He's been so sleepy for the last few hours. It won't bother him if we talk in here." Which of these responses by the hospice nurse would be appropriate? Select all that apply. "Sure. How long has he been like this?" "Well, first I'd like to introduce myself to your husband." "OK. Do you have his advance directive for me to review?" "Mrs. Mast, let's step into the next room to talk for a few minutes." "Yes, let's pull up some chairs and chat about what's going on."

"Well, first I'd like to introduce myself to your husband." "Mrs. Mast, let's step into the next room to talk for a few minutes." RATIONALE: Clients who are near death may be withdrawn from the external environment, but it is believed that the sense of hearing remains intact until death. Family members and caregivers should converse in the client's room or near the client as if the client is alert. This includes introducing yourself directly to the client. The caregiver should talk directly to the client in a soft tone. Reviewing the client's advance directive and having a conversation about him in his presence are inappropriate response. TEST-TAKING STRATEGY: Use knowledge of the subject, communication with a client who is near death, to help with this question. Read each option carefully and consider whether that response is appropriate in this situation, which is communication with a client who is near death. Review: appropriate communication techniques in end-of-life care situations.

After a thorough mental health assessment, Joseph is transferred to the mental health unit in a voluntary admission. The nurse in the mental health unit reviews the emergency department notes in preparation for the interview with Joseph. Which would the nurse determine because Joseph has consented to voluntary admission? Joseph cannot request and be granted hospital discharge. Admission to the mental health unit was sought by Joseph. Admission to the hospital was made without Joseph's consent. Joseph will not be making decisions about his treatment or care.

Admission to the mental health unit was sought by Joseph. RATIONALE: Voluntary admission is generally sought by the client or by the client's guardian. Voluntary admitted clients have the right to request and be granted release from the hospital. Clients admitted to a mental health facility do not lose the right to informed consent or decision-making. Involuntary admission is made without the client's consent. TEST-TAKING STRATEGY: Focusing on the words "voluntary admission" will direct you to the correct option. Also note that the incorrect comparable or alike options reflect a restriction of Joseph's right to make decisions. Review: the procedure for voluntary admission.

The hospice nurse is caring for a client with end-stage heart failure. The nurse should monitor the client for which signs of impending death? Select all that apply. Diarrhea Increased urine output Increased pain perception Decreasing blood pressure Irregular and noisy respirations Mottled and cyanotic extremities

Decreasing blood pressure Irregular and noisy respirations Mottled and cyanotic extremities RATIONALE: Some signs of impending death are decreasing blood pressure, irregular and noisy respirations, and mottled, pale, or cyanotic extremities. The client is more likely to experience constipation from decreased peristalsis. The urine output decreases, rather than increasing. Pain perception decreases. TEST-TAKING STRATEGY: Use knowledge of the subject, signs of impending death, to help you with this question. Eliminate the comparable or alike options that indicate increasing functions of the body, such as diarrhea, increased urine output, and dulled pain perception. Review: signs of impending death.

A client with claustrophobia is seen in the mental health clinic and is told that one treatment for the disorder is systematic desensitization. When the client asks the nurse to describe the treatment, what information does the nurse provide? It involves focus on the consequence of a behavior. A stimulus attractive to the client is paired with an unpleasant experience. The therapist will perform certain behaviors, and the client will imitate the behaviors. It involves exposure to the phobic situation, starting with short periods and gradually increasing, until the fear has ceased.

It involves exposure to the phobic situation, starting with short periods and gradually increasing, until the fear has ceased. RATIONALE: With systematic therapy, incrementally increasing exposure to a feared stimulus is paired with an increasing level of relaxation, helping reduce the intensity of fear to a more tolerable level. Operant conditioning is the manipulation of selected reinforcers to elicit and strengthen desired behavioral responses; the reinforcer refers to the consequence of the behavior, which is defined as anything that increases the occurrence of a behavior. Aversion therapy is a form of behavioral therapy in which negative reinforcement is used to change behavior; for example, a stimulus attractive to the client is paired with an unpleasant event in the hope of endowing the stimulus with negative properties, thereby dissuading the behavior. Modeling is a type of behavioral therapy in which the therapist acts as a role model for specific identified behaviors so that the client learns through imitation. TEST-TAKING STRATEGY: Focus on the subject of the question, systematic desensitization. Note the relationship between the words "systematic desensitization" in the question and the description in the correct option. Review: systematic desensitization.

Thomas, quite upset, begins to cry. He tells the nurse that he feels overwhelmed because of what his health care provider has told him and that he just doesn't know what to do or how he will manage without his foot. The nurse determines that Thomas is experiencing a situational crisis and which problem? Lack of control Inability to grieve Lack of family support Inability to think clearly

Lack of control RATIONALE: Thomas is expressing concern about how he will manage without his foot and therefore the problem he is experiencing is a lack of control over the current situation. There is no indication in that question that Thomas is unable or unwilling to acknowledge or mourn his loss. Additionally, there is no information in the question that indicates that Thomas lacks family support or is unable to think clearly. TEST-TAKING STRATEGY: Focus on the subject, the client's feelings when coping with the provider's information. The client is having difficulties coping with the change in health he is experiencing. This can direct you to the lack of control option as that accurately reflects Thomas's response to the news. Review: situational crisis.

The home care nurse making a visit to a client who is receiving hospice care understands that hospice care is intended to achieve certain outcomes. What are these outcomes? Select all that apply. Relief of symptoms Postponement of death Hastening of disease remission Facilitation of a peaceful death Provision of the best possible quality of life

Relief of symptoms Facilitation of a peaceful death Provision of the best possible quality of life RATIONALE: In hospice care, an interdisciplinary approach is used to assess and address the holistic needs of clients and families to ensure the best possible quality of life and a peaceful death. The holistic approach neither hastens nor postpones death, nor does it hasten remission of the disease; instead, it provides relief of symptoms. TEST-TAKING STRATEGY: Focus on the subject, the purpose of hospice care. It is necessary to recall that hospice care focuses on addressing the unmet needs of the terminally ill client. This will help you select the correct options. Review: the purposes of hospice care.

The nurse is conducting a group therapy session. One client with mania talks constantly, dominating the session and her behavior is disrupting group interaction. The nurse should take which initial action? Ask the client to leave the group session Ask another nurse to escort the client out of the group session Tell the client she needs to allow other clients in the group to talk Tell the client that she will not be allowed to attend future group sessions

Tell the client she needs to allow other clients in the group to talk RATIONALE: A manic client may be extremely talkative, dominating group meetings or therapy sessions. If this occurs, the nurse should initially set limits on the client's behavior. It is inappropriate initially to ask the client to leave the session or to ask another person to escort the client from the session, which could agitate the client and further escalate the client's behavior. Telling the client that she will not be allowed to attend future group sessions is also an inappropriate initial action. It violates a client's right to receive treatment and is a threatening action. TEST-TAKING STRATEGY: Note the strategic word, "initial." Eliminate the option that violates the client's right to treatment; this is a threatening and illegal action. Next, eliminate the comparable or alike options that indicate that the client will leave the group session. Remember, it is best to initially set firm limits with the client. Review: care of the client with mania.

The nurse caring for Joseph discusses the plan of care with the psychiatrist, who tells the nurse that Joseph would benefit from cognitive therapy. What information does the nurse provide to Joseph about this type of therapy? Medication is the main treatment in this form of therapy. A reward will be given to Joseph for every hour in which he does not have a suicidal thought. The psychiatrist will function as a role model, helping Joseph learn to prevent thoughts of suicide. Therapeutic techniques are designed to identify, reality-test, and correct distorted or dysfunctional beliefs.

Therapeutic techniques are designed to identify, reality-test, and correct distorted or dysfunctional beliefs. RATIONALE: The therapeutic techniques of cognitive therapy are designed to identify, reality-test, and correct distorted conceptualizations and the dysfunctional beliefs underlying these cognitions. The client learns to master problems in situations he or she previously considered insurmountable by evaluating and correcting his or her thinking. Medication is not a primary component of cognitive therapy. In modeling, the psychiatrist or therapist acts as a role model for specific identified behaviors. In operant conditioning, a reward would be given for not having a suicidal thought. TEST-TAKING STRATEGY: Focus on the subject, cognitive therapy. Note the relationship of the name of this therapy and the description in the correct option. Review: cognitive therapy.

The nurse is planning activities for a client, hospitalized in the mental health unit, who is experiencing a moderate level of anxiety. Once the nurse has conducted a physical assessment, which activity is most appropriate for the client? Painting Drawing Walking Board games

Walking RATIONALE: Interventions for the client with moderate anxiety include providing outlets through which to work off excess energy and direct the client's attention outward. Physical activity can provide relief of built-up tension, increase muscle tone, and increase release of endorphins. Such activities include walking, table tennis, dancing, and exercising. Painting, drawing, and board games are sedentary activities. TEST-TAKING STRATEGY: Note the strategic words, most appropriate. Note that the client is experiencing a moderate level of anxiety. Eliminate the comparable or alike options and identify sedentary activities. Review: the interventions for the client with anxiety.

Thomas undergoes amputation of the foot, has an uneventful recovery, and is discharged home. He is to receive home care visits from a visiting nurse and a physical therapist for rehabilitation measures, including preparation for a prosthesis. Angela, his wife, tells the visiting nurse that Thomas has been agitated and refuses to talk to anyone or allow any of his friends from the limousine company to visit him. During the home care visit, Thomas says to the nurse, "I can't drive my limousine! Life just isn't worth living anymore. Some days I wish I were dead." Which response should the nurse make first? "Are you having thoughts of suicide?" "Things will work out. It's just going to take some time." "Tell me why you don't want to talk to or see any of your friends." "Once you learn how to walk with the prosthesis, you'll feel better about yourself."

"Are you having thoughts of suicide?" RATIONALE: If the client makes a statement indicating a desire to end his or her life, the nurse must immediately validate the statement. The statement made by Thomas is one such overt verbal clue. Other such clues include "I can't take it any more" and "Everyone would be better off if I died." If a client makes such a statement, the nurse should specifically ask the client about his or her intention of committing suicide. Telling the client, "Things will work out" or "Once you learn to walk with the prosthesis, you will feel better" is nontherapeutic and provides false reassurance. Asking the client why he does not want to talk or see his friends may be appropriate at some point but, in light of Thomas' statement, is not the initial concern. TEST-TAKING STRATEGY: Focus on the strategic word, "first." Use your knowledge of therapeutic communication techniques to eliminate options that provide false reassurances. To select from the remaining options, focus on the words "Life just isn't worth living anymore. Some days I wish I were dead." This will direct you to the correct option. Review: clues to suicidal ideation and assessment of the potentially suicidal client.

The nurse is providing physical care to a client who has recently been told that he has inoperable lung cancer with a poor prognosis. The client says to the nurse, "I am so scared of dying. You hear so many stories about death. If only someone could tell me what it is really like." Which response should the nurse give the client? "What stories have you heard?" "You're scared of dying. Let's talk about what makes you scared." "I've heard a lot of stories, too. I wish I could give you an answer to this one." "People who have died and been resuscitated say it's a beautiful experience."

"You're scared of dying. Let's talk about what makes you scared." RATIONALE: The nurse should use the therapeutic communication technique of paraphrasing and a response that is open-ended, which is also therapeutic. The nurse should restate the client's message and provide the client an opportunity to express his feelings, concerns, and fears. The responses in the incorrect options do not focus on the client's concern. TEST-TAKING STRATEGY: Use therapeutic communication techniques. Eliminate the comparable or alike options that are nontherapeutic and do not address the client's feelings or concerns. Note that the correct option paraphrases the client's statement and provides the client an opportunity to express his feelings. Review: therapeutic communication techniques.

Which action on the part of the nurse would best help Katie in regaining her self-worth? Suggesting that she quit her job and find a new one Assisting Katie in exploring solutions to the problem Teaching Katie how to stand up to her boss when he reprimands her Encouraging Katie to use any defense mechanism necessary to deal with the problem

Assisting Katie in exploring solutions to the problem RATIONALE: A client who is experiencing anxiety may feel helpless and may be overwhelmed by feelings of inadequacy. The fact that the client has found it necessary to seek outside help may further increase feelings of inadequacy. Therefore, increasing the client's self-esteem and feeling of self-worth is important. The nurse would help Katie regain her feelings of self-worth by communicating confidence that she can find solutions to problems. The nurse would also convey the impression that Katie is a worthwhile person by listening to and accepting her feelings, being respectful, and praising her help-seeking efforts. Quitting her job and finding a new one is unrealistic. Use of any defense mechanism to deal with the problem is incorrect, because the use of nonconstructive defense mechanisms should be discouraged. Standing up to her boss might cause additional problems between Katie and the boss. TEST-TAKING STRATEGY: Use concepts of therapeutic communication techniques to assist you with this question. Eliminate the option that is an unrealistic action (quitting her job). Next eliminate the option recommending the use of "any" defense mechanism. Standing up to her boss could cause additional problems between Katie and her new boss, so eliminate this option. Review: the techniques for helping a client use constructive defense mechanisms.

During an interview, a client reveals having an interest in sexual activity with others of the same sex. Which nursing action is most appropriate? Asking the client why this activity is preferred. Asking the client how long this has been going on. Encouraging the client to discuss this with a minister. Encouraging the client to discuss how this affects overall health.

Encouraging the client to discuss how this affects overall health. RATIONALE: The nurse should encourage the client to discuss how this is affecting overall health. Asking the client "why" questions could cause the client to feel a need to defend their actions. It is not relevant to ask the client to explain how long this has been going on. Encouraging the client to discuss this with a minister is not appropriate because it suggests disapproval, not acceptance. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that place judgment on the client's activity. Use knowledge of therapeutic communication techniques to assist with answering this question. Review communication techniques and psychosexual health.

A client with a history of panic disorder is brought to the emergency department complaining of dizziness, palpitations, and chest pain. The client states that he feels as if he is "going crazy." Which action should the nurse take first? Performing a physical assessment Calling the crisis intervention team Asking the client what brought on the panic attack Asking the unit secretary to obtain records of the client's previous hospitalizations

Performing a physical assessment RATIONALE: Panic attacks are a distinctive feature of panic disorder. Symptoms include dizziness, faintness, choking, palpitations, trembling, nausea or abdominal distress, numbness, chest pain, and the fear of dying or going crazy. The symptoms of panic disorder mimic a variety of medical conditions, so the nurse would first perform a physical assessment of the client to help rule out a medical problem. Once the client's physical needs have been attended to, other needs may be addressed. The nurse would then ask the client about the precipitant of the attack and obtain records of the client's previous hospitalizations. The crisis team may or may not be needed for intervention. TEST-TAKING STRATEGY: Focus on the strategic word "best," Use Maslow's Hierarchy of Needs theory. Remembering that physiological needs are the priority will direct you to the correct option. Review: initial care of the client with a panic disorder.

Thomas tells the nurse that even though he is upset about his situation, he sometimes says things that he doesn't really mean. The nurse talks to Thomas about counseling, and he agrees to speak with a crisis counselor. The nurse also talks to Thomas about a no-suicide contract, and Thomas agrees to sign one. Which statement should be included in the contract? "I will call my crisis counselor if I have any thoughts of harming myself." "If I start feeling that I want to kill myself, I will try to ignore the thought." "I will ask my wife to hide my medication if I have any thoughts of harming myself." "I will try to do something such as watching television or reading the newspaper if I have any thoughts of harming myself."

"I will call my crisis counselor if I have any thoughts of harming myself." RATIONALE: A no-suicide contract should provide an appropriate resource for the client in the event that the client experiences thoughts of self-harm. Calling the crisis counselor is the only option that is an appropriate resource for the client. Ignoring the thoughts does not provide a resource for the client; instead, it relies on the client to deal with the thoughts of self-harm. Placing the responsibility on the client's wife is an inappropriate intervention. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that ignore the thoughts. For the remaining options, select the one that provides a resource for the client in the event that the client experiences thoughts of self-harm. Review: no-suicide contracts.

Louise tells the nurse that she will try the deep-breathing exercises but asks whether there is anything else that she can try to help her feel calmer. The nurse reviews several stress-reducing strategies with Louise. Which of these statements by Louise indicate a good understanding of stress-reduction techniques? Select all that apply. "I'll start going to bed 30 minutes earlier." "I'll limit my coffee to one cup in the morning." "I'll go to the gym at least three times a week after work." "I'll exercise just before bedtime to help improve my sleep." "A cup of hot tea will help me relax in the evening." "During my break at work, I can find a quiet place and focus on feeling calmer."

"I'll start going to bed 30 minutes earlier." "I'll limit my coffee to one cup in the morning." "I'll go to the gym at least three times a week after work." "During my break at work, I can find a quiet place and focus on feeling calmer." RATIONALE: People who are stressed are often fatigued; for this reason, going to bed 30 to 60 minutes earlier each night may be helpful. Reducing or even eliminating caffeine can help a person feel more relaxed, and both tea and coffee contain caffeine. Exercise can help reduce stress, but it is best to exercise at least 3 hours before going to bed. Exercising for at least 30 minutes three or more times a week is recommended. Meditation takes practice, but it can help produce a relaxation response by quieting the sympathetic nervous system. TEST-TAKING STRATEGY: Focus on the strategic words "stress-reduction." Read each option carefully and think about how the technique will alleviate stress; this will direct you to the correct options. Review: stress-reduction techniques.

Suicide precautions are enacted for Joseph, and the nurse assigned to care for Joseph sits down to talk with him. During the conversation Joseph states, "I don't want to live if I can't see my son. He's the only thing that matters to me." Which response by the nurse will most likely promote therapeutic communication? "Tell me more about how important your son is to you." "Do you have other family members whom you enjoy spending time with?" "I'm concerned about you, Joseph. You need to look for other activities to occupy your free time." "I understand what you mean. I have a daughter, and I always look forward to seeing her when I get home from work."

"Tell me more about how important your son is to you." RATIONALE: The correct option focuses on Joseph's thoughts and feelings and encourages Joseph to talk about them. It also indicates that the nurse is listening to the client. The remaining statements are nontherapeutic, focus on other issues, and avoid the client's concern. TEST-TAKING STRATEGY: Use your knowledge of therapeutic communication techniques. Focus on the client's feelings and how they relate to the client's concern addressed in the question. Also remember to look for the option that encourages the client to communicate. This will direct you to the correct option. Review: therapeutic communication techniques.

After 2 weeks, Isabel undergoes surgery to remove her ovaries and surrounding tissues. One week later, she visits her surgeon and gets the news that the cancer has spread to three lymph nodes in the area. "Not the best prognosis," she is told, "but we can still give it a good try." The nurse, helping Isabel get ready to leave, sees that she is sitting very still with her eyes closed. She tells the nurse, "I don't know how I'm going to get through this. I don't want to leave my children alone!" Which response to Isabel's statement is therapeutic? "If I were you, I'd get a second opinion before doing anything." "This must be a terrible time for you. Would you like to talk about it?" "It's too early to be upset. You haven't even had any chemotherapy yet!" "Don't worry. Everything will be all right. Dr. Smythe is the best oncologist in the area."

"This must be a terrible time for you. Would you like to talk about it?" RATIONALE: When a person who is experiencing grief or facing death wants to talk, the nurse needs to take the time to listen and avoid creating barriers to communication. Offering to take the time to listen to Isabel's concerns is a therapeutic response. Providing unsolicited advice is nontherapeutic. Telling Isabel that it's "too early to be upset" essentially denies her grief; telling her not to worry offers false reassurance. These three options are examples of barriers to communication. TEST-TAKING STRATEGY: Use your knowledge of therapeutic communication techniques. Read each option carefully and consider the principles of therapeutic communication to help eliminate the incorrect options. Also note that the correct option is focused on the client's feelings. Review: barriers to communication and principles of therapeutic communication.

A client tells the nurse that he is experiencing a great deal of work-related stress and is taking an anxiolytic medication. He tells the nurse that he read on the Internet that St. John's wort, an herbal product, is helpful in reducing stress and says that he would like to try taking it. Which is the best response for the nurse to give the client? "It's an herbal product made from a plant, so it's harmless." "You'll need to discuss the use of St. John's wort with your health care provider before taking it." "I read the same thing, and I know that you can buy St. John's wort at any health food store." "You should give it a try. I would suggest taking it every morning that you're scheduled to work."

"You'll need to discuss the use of St. John's wort with your health care provider before taking it." RATIONALE: The use herbal therapies in combination with other medications can result in significant and potentially dangerous medication interactions. The nurse should tell the client that he should discuss the use of St. John's wort with his health care provider. Therefore the other options are incorrect. TEST-TAKING STRATEGY: Note the strategic word "best." Eliminate the comparable or alike options that indicate that it is acceptable for the client to take the medication. Finally, note that the client is taking an anxiolytic medication; this will help you determine that the best response is the one that indicates the need to discuss the use of St. John's wort with the health care provider. Review: herbal therapies.

After several months and six rounds of chemotherapy treatments, Isabel begins to experience an aching pain in her back and hips. A bone scan reveals that the cancer has spread to her bones, and her oncologist tells her that her prognosis at this time is poor. He also tells her that she may have only weeks to live. Isabel again calls her family together and shares the news with them. She has been quietly working with an attorney to get her affairs in order, and her parents have agreed to serve as legal guardians of her children after her death. She has a living will and has included Regina in these discussions about the arrangements. Isabel has noticed that Regina has been quieter and has not talked to Isabel as much as usual. Isabel talks to the social worker at the oncology office about this, and the social worker suggests that Regina may be experiencing anticipatory grieving. Which examples are characteristics of anticipatory grieving? Select all that apply. The person experiences grief weeks after the actual loss. A family member begins to withdraw emotionally from the terminally ill person. A family member may choose to be with friends instead of staying with a dying family member. A person is overwhelmed by grief and cannot carry out day-to-day actions such as going to work. A family member is unable to sleep after a loss but does not connect the altered sleeping pattern to the loss.

A family member begins to withdraw emotionally from the terminally ill person. A family member may choose to be with friends instead of staying with a dying family member. RATIONALE: Anticipatory grief is the process of letting go that occurs before an actual loss (such as death) has occurred. It occurs when there is time for the person or family members to accept the reality of a terminal illness. However, some family members may actually begin withdrawing emotionally from the ill person as a self-protective mechanism, leaving the ill person with less support at the end of his or her life. Delayed grief occurs later, some time after the actual loss, instead of at the time of loss. Exaggerated grief is when a person experiences grief to such a degree that he or she cannot carry out daily functions. Masked grief is when a person is unable to recognize that the physical or emotional symptoms he or she is experiencing is a result of the loss that has been experienced. TEST-TAKING STRATEGY: Focus on the subject, the characteristics of anticipatory grieving. Recalling that anticipatory grief occurs before the actual loss has occurred will direct you to the correct option. Also note that the correct options involve withdrawal from the ill person. Review: the characteristics of anticipatory grieving and the other types of grief.

A client is told that the computed tomography scan she has just undergone has revealed a pancreatic mass that is most likely cancer. The client becomes upset and anxious on hearing this news and tells the nurse that she feels nauseated. Checking the client's vital signs, the nurse notes that the client's heart rate, respiratory rate, and blood pressure are increased compared with previous readings. The nurse plans interventions to correspond with which stage of Selye's general adaptation syndrome that the client is experiencing? Eustress Alarm reaction Stage of resistance Stage of exhaustion

Alarm reaction RATIONALE: According to Hans Selye, general adaption syndrome comprises three stages: the alarm reaction, the stage of resistance, and the stage of exhaustion. During the alarm reaction stage, the fight-or-flight response is initiated. Physical signs and symptoms of sympathetic nervous system stimulation appear. In the stage of resistance, few overt physical signs and symptoms occur. When internal and external resources are adequate, the individual may successfully recover from a stressor. If adaptation does not occur, the person may move to the next stage, exhaustion. In the stage of exhaustion, physical symptoms of the alarm reaction stage may briefly reappear in a final effort by the body to survive. This stage can often be reversed with external sources of adaptive energy such as medication or psychotherapy. Eustress is a term used by Selye that refers to stress associated with positive events. TEST-TAKING STRATEGY: Focus on the data in the question and note the physiological signs and symptoms. Think about the stages of general adaption syndrome and recall that physical signs and symptoms related to sympathetic nervous system stimulation appear in the alarm reaction stage. Review: Selye's general adaptation syndrome.

A client who has been diagnosed as having an antisocial personality is hospitalized after being involved in a fight. Which interventions included in the plan of care are most crucial? Select all that apply. Encourage the client to place bets and play poker with other clients. Assess the client for thoughts of suicide and report these if they occur. Explain to the client that he will need to spend time in his room if he assaults others. Discuss with the client the need for him to refrain from hurting staff or other clients. Encourage the client to find contact information for those he has injured and to apologize.

Assess the client for thoughts of suicide and report these if they occur. Explain to the client that he will need to spend time in his room if he assaults others. Discuss with the client the need for him to refrain from hurting staff or other clients. RATIONALE: The person with an antisocial personality has a tendency to be aggressive and to ignore social expectations. The nurse should assess clients with a personality disorder for thoughts of suicide and report this if it occurs. By explaining consequences of behavior, the nurse sets clear limits on expectations and consequences. Playing poker and placing bets could increase the risk of the client hurting others. The client should not be encouraged to find contact information, because this increases the risk of the client hurting others. Clients with antisocial behavior do not experience true regret over actions taken. TEST-TAKING STRATEGY: Use knowledge of the subject, interventions for those with antisocial personality, to help answer this question. Recall that clients with antisocial behavior could potentially hurt self or others, and eliminate comparable or alike options that encourage potentially harmful behaviors. Review nursing interventions for clients with an antisocial personality.

Claudia says to the nurse "I don't need your help! I can control my own behavior!" and storms out of the lounge. A few minutes later she rushes back into the lounge, wearing a tight miniskirt and a halter top. She sits down in front of Charles and says to him, "Look, Charles. Do you like what I'm wearing?" Which action by the nurse is appropriate? Telling Claudia to behave Telling Claudia to go to her room Escorting Claudia to her room and helping her change clothes Escorting Charles to another chair and telling him to ignore Claudia's behavior

Escorting Claudia to her room and helping her change clothes RATIONALE: A client with mania has poor judgment and may choose clothing that is noticeably inappropriate. The client's speech may be marked by sexual or obscene comments, and the client may make inappropriate sexual propositions to strangers. The nurse should escort Claudia to her room and help her change clothes. This action will help Claudia maintain her dignity. The nurse should supervise the client's choice of dress and discourage the use of flamboyant and bizarre clothing to lessen the potential for ridicule, which lowers self-esteem and increases the need for manic defense. Telling Claudia to behave or to go to her room and telling Charles to ignore Claudia are all inappropriate because they do not maintain Claudia's dignity and may escalate Claudia's mania. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that do not maintain the client's dignity. Note that in the correct option the nurse directly helps the client in maintaining her dignity. Review: nursing care to the client with mania.

The nurse is assigned to work with a client who has just been admitted to the mental health unit. Which action should the nurse plan to take in the orientation or introductory phase of the nurse-client relationship? Establish a contract with the client Increase the client's independence Promote the use of constructive coping mechanisms Refer and transfer the client to other sources of support

Establish a contract with the client RATIONALE: The tasks of the orientation or introductory phase of the nurse-client relationship are to establish trust, acceptance, open communication, and formulate a mutual contract with the client. The contract begins with the introduction of the nurse and client, the exchange of names, and the explanation of roles. Promotion of the use of constructive coping mechanisms and increasing the client's independence are tasks of the working phase. Referring and transferring the client to other sources of support is a task of the termination or separation phase. TEST-TAKING STRATEGY: Use the process of elimination. Focus on the subject and note the relationship of the subject and option 1. Review: orientation or introductory phase with the mental health client.

Joseph is discharged from the hospital, but his new mental health contract states that he will attend twice-weekly cognitive therapy sessions. During the working phase of the nurse-client relationship, what specific tasks does the nurse plan? Select all that apply. Establishing a rapport Promoting Joseph's problem-solving skills Gathering further data about Joseph's problems Summarizing the goals achieved in the relationship Discussion of problems and goals, and redefining as needed Helping Joseph explore how to practice alternative adaptive behaviors

Promoting Joseph's problem-solving skills Gathering further data about Joseph's problems Discussion of problems and goals, and redefining as needed Helping Joseph explore how to practice alternative adaptive behaviors RATIONALE: During the working phase of a nurse-client relationship, nurse and client work together to identify and explore issues that are causing problems in the client's life, then set goals for the sessions. It is also a time for data-gathering and identifying and promoting the client's problem-solving skills, as well as for exploring new behaviors for problem-solving. Establishing a rapport is part of the first phase of the nurse-client relationship, the orientation phase. Summarizing the goals that have been achieved is part of the termination phase. TEST-TAKING STRATEGY: Focus on the subject, "specific tasks of the working phase of the nurse-client relationship." To decide whether each activity belongs in the working phase or in one of the other phases (e.g., orientation phase, termination phase). Note that the incorrect options include the words "establishing" (orientation phase) and "summarizing" (termination phase). Review: the components of the working phase of the nurse-client relationship.

A client with a paranoid disorder refuses to eat because he believes that the food being served in the mental health unit is poisoned. Which response is an appropriate way for the nurse to defuse the client's delusional thoughts? Providing the client with food items in sealed containers Telling the client that he is safe now that he is in the hospital Setting firm limits and telling the client that the food is not poisoned Asking the client whether he would like to visit the hospital kitchen to watch the food being prepared

Providing the client with food items in sealed containers RATIONALE: A client with a paranoid disorder fears that others will exploit, harm, or deceive him or her, to the point of endangering the client's life. Adequate nutrition may be a problem with such clients. A common distortion or delusion is that food is poisoned, and the client may not eat as a result. In this situation, special foods should be provided in sealed containers to minimize the suspicion of tampering. The client should be allowed to prepare his or her own food, if possible. Although the nurse should assure the client that he or she is safe, this action alone will not eliminate the client's delusional thoughts. Likewise, inviting the client to visit the hospital kitchen to watch how the food is prepared and setting firm limits about discussion of food being poisoned will not help eliminate the client's delusional thoughts. TEST-TAKING STRATEGY: Focusing on the subject, the client's belief that food is being poisoned, will direct you to the correct option. The correct option is the only option that minimizes the client's suspicion that the food has been tampered with. Review: nursing interventions for the client with a paranoid disorder.

Claudia's health care provider prescribes a blood draw for a basic metabolic panel (BMP) and determination of Claudia's lithium level. Later that day, the nurse reviews the results. Which results are of concern, requiring follow-up? Select all that apply.Medical Record - Claudia Stone Sodium Glucose Chloride Potassium Lithium

Sodium Lithium RATIONALE: Clients undergoing lithium therapy must avoid dehydration and sodium imbalances, because they may result in an increased level of lithium. Claudia's sodium level is slightly higher than normal; the normal range is 135 to 145 mEq/L (145 to 145 mmol/L). This may be an early indication of dehydration and should be investigated. The serum lithium level is also slightly high; the maintenance level ranges between 0.6 and 1.2 mEq/L. The dosage of lithium may need to be adjusted and measures should be taken to reduce dehydration. The glucose level is slightly increased (the normal range is 70 to 110 mg/dL [4 to 6 mmol/L]), but this finding may not reflect a fasting blood level. The other laboratory values are within the normal ranges. TEST-TAKING STRATEGY: Use knowledge of the subject, lithium toxicity. Read each option carefully and determine whether the laboratory value is within the normal range. Also keep in mind that a client's hydration status is important if lithium is being taken, so take special note of the sodium and chloride levels and the lithium level. Review: laboratory monitoring for lithium drug therapy and normal laboratory results.

During the assessment, Joseph discusses his feelings of self-harm with the nurse and hints that he even had a plan for carrying out his suicide if his life "got worse." Which methods of suicide are considered of lower risk, or "soft"? Select all that apply. Hanging Swallowing pills Inhaling natural gas Slashing one's wrists Staging a high-speed car crash into a cement wall

Swallowing pills Inhaling natural gas Slashing one's wrists RATIONALE: The evaluation of a suicide plan is extremely important in determining the degree of suicide risk. The lethality of a method in person's suicide plan indicates how quickly the individual would die if that plan were enacted. Guns, hanging, carbon monoxide, and car crashes are extremely lethal and are therefore considered higher-risk, or 'hard,' methods. Slashing the wrists, inhaling natural gas, and ingesting pills are lower-risk, or 'soft,' methods. TEST-TAKING STRATEGY: The question involves differentiating lower- and higher-risk methods of suicide. For each item listed, decide on its lethality. Eliminate the comparable or alike options that are lower risk or "soft" options. This will direct you to the correct options. Review: the lethality of various suicide plans.

The nurse is evaluating the grief process for a woman whose husband died in an automobile accident 2 months ago. Which outcomes would the nurse identify as successful? Select all that apply. The client refuses to take on new responsibilities. The client demonstrates lengthening periods of stability. The client expresses positive expectations about the future. The client reports decreased preoccupation with the loss of her husband. The client's daughter reports that her mother has not paid any bills since the death of her husband.

The client demonstrates lengthening periods of stability. The client expresses positive expectations about the future. The client reports decreased preoccupation with the loss of her husband. RATIONALE: Grieving is a normal process in which people come to terms with losses. Successful outcomes associated with the grief process include the ability to tolerate intense emotions, reduced preoccupation with the deceased (loss), demonstration of increasing periods of stability, tending to previous responsibilities, taking on new roles and responsibilities, having the energy to invest in new endeavors, the expression of positive expectations about the future, and remembering positive as well as negative aspects of the deceased loved one. Refusing to take on new responsibilities and not attending to responsibilities are unsuccessful outcomes. TEST-TAKING STRATEGY: Focus on the subject of the question, successful outcomes of grieving. Eliminate the comparable or alike options (i.e., refusing to take on responsibilities and not paying bills). Review: the grief process and the successful outcomes of the process.

The nurse plans care for a client experiencing stress. Which characteristics are associated with the stage of resistance in Selye's description of general adaptation syndrome? Select all that apply. All energy for adaptation has been expended. The body makes some effort to resist the stressor. When resources are adequate, the person may successfully recover from a stressor. Successful adaptation depends on the adequacy of the person's internal and external resources. The person in this stage may become ill and die if assistance from an outside source is not available.

The body makes some effort to resist the stressor. When resources are adequate, the person may successfully recover from a stressor. Successful adaptation depends on the adequacy of the person's internal and external resources. RATIONALE: In the stage of resistance, physiologic reserves are mobilized to increase the resistance to stress. Few overt physical signs and symptoms occur. The individual is expending energy to adapt, and successful adaptation depends on the adequacy of the person's internal and external resources. When resources are adequate, the person may successfully recover from a stressor; if adaptation does not occur, the person may move to the next stage, exhaustion. The stage of exhaustion occurs when all energy for adaptation has been expended. Physical symptoms of the alarm reaction stage may briefly reappear in a final effort by the body to survive. This stage of exhaustion can often be reversed with an external source of adaptive energy (e.g., medication or psychotherapy). However, the person in this stage may become ill and die if assistance from an outside source is not available. TEST-TAKING STRATEGY: Focus on subject of the question, the stage of resistance. Think about the stages of general adaption syndrome to answer correctly. Note the relationship of the word "resistance" and the correct options. Also, note that the incorrect options relate to the stage of exhaustion. Review: Selye's general adaptation syndrome.

The nurse providing information to the wife of a client who abuses alcohol encourages the woman to attend an Al-Anon support group. The wife tells the nurse that she is embarrassed by her husband's behavior and that it would be difficult for her to face other people. Which response should the nurse give the woman to help alleviate her concerns? The support group is always led by a nurse and health care provider. She will not know any of the members of the support group. She does not need to provide her name or any other identifying information to the group. The members of the group have experienced or are experiencing the same problem she is facing.

The members of the group have experienced or are experiencing the same problem she is facing. RATIONALE: Al-Anon is a support group for spouses and friends of alcoholics or addicts. Support groups are based on the premise that people who have experienced a particular problem are able to help others with the same problem. Although a nurse or other health care professional may be asked to speak at a support group meeting, the members of the group lead the group. The nurse cannot ensure that the wife will not know any of the members. Although the wife does not need to provide her name or any other identifying information to the group, this response is not helpful and will not alleviate the wife's concerns. TEST-TAKING STRATEGY: First eliminate the option using the closed-ended word "always." Next eliminate the comparable or alike options that focus on the wife's identity. Focusing on the subject, alleviating the wife's concerns, will direct you to the correct option. Review: the purpose and function of a support or self-help group.

Katie, anxious about her work, is now afraid of her new boss. She dislikes going to work because she is afraid of being reprimanded, hates feeling inadequate and worthless, and fears demotion. Katie decides to seek help for her problem because she doesn't like taking her frustrations out on her children and makes an appointment to speak to the nurse at the mental health clinic. Which conclusion regarding Katie's defense mechanisms does the nurse make? They need restructuring. They must be used at work to deal with this situation. They are used to cope with the stress and to maintain self-esteem and ego integrity. They should not be used at all, because Katie must learn to deal with the situation on her own.

They are used to cope with the stress and to maintain self-esteem and ego integrity. RATIONALE: A defense mechanism is used to protect oneself from painful awareness of feelings that can provoke anxiety. Use of defense mechanisms help an individual cope with stressful situations and maintain self-esteem and ego integrity. The nurse would encourage the client to use constructive defenses and discourage the use of nonconstructive defenses. Returning the client to an earlier level of function, not the restructuring of defenses, is the goal of the nurse-client interaction. TEST-TAKING STRATEGY: Eliminate the options that include the closed-ended words "must" and "not." To choose from the remaining options, recall the purpose of defense mechanisms, which will direct you to the correct option. Review: the effect of using defense mechanisms.

Hospice care has been initiated for Louis, and he is being provided with several daytime services. His condition is deteriorating. During the night, Laura notices that Louis' breathing pattern has changed, and she calls the hospice nurse. The nurse comes quickly to assess Louis and notes periods of apnea alternating with periods of deep, rapid breathing. What is the appropriate explanation for the nurse to give to Laura? Louis probably has some sinus congestion. This type of breathing is a sign of pneumonia. This type of breathing is a sign of approaching death. Louis needs to be turned and repositioned more frequently.

This type of breathing is a sign of approaching death. RATIONALE: An abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing is a physical manifestation of approaching death. Sinus congestion, pneumonia, and the need for more frequent repositioning are not associated with this type of breathing. TEST-TAKING STRATEGY: Use knowledge of the subject, signs of impending death, to help answer this question. Note the relationship between the word "apnea" in the question and "death" in the correct option. Review: the physical manifestations of impending death.

A week later, Thomas calls his crisis counselor. "I feel totally useless and I know my wife would be better off without me," he says, "but I promised to call you, because I signed that contract." The counselor evaluates the lethality of Thomas' suicide plan. Which of these methods are considered higher risk, or "hard," methods of suicide? Select all that apply. Using a gun Ingesting pills Slashing one's wrists Jumping from a high place Inhaling carbon monoxide

Using a gun Jumping from a high place Inhaling carbon monoxide RATIONALE: Lethality is how quickly or easily a person would die if he or she used that method to attempt suicide. Higher-risk, or hard, methods include using a gun, jumping from a high place, inhaling carbon monoxide, hanging, and staging a car crash. Lower-risk, or "soft," methods include slashing one's wrists, ingesting pills, and inhaling natural gas. TEST-TAKING STRATEGY: Read each option carefully and decide whether it would be considered a higher- or a lower-risk method. Eliminate the comparable or alike options that are "soft" or lower-risk methods. Keep in mind that the lethality of a method is predicated on how quickly a person would die if he or she used the method to attempt suicide. Review: the lethality of various methods of suicide.

The nurse is caring for a Muslim client who is dying of gastric cancer. Which specific request from the client's family might the nurse anticipate? "One of us must be present when he passes." "Can we please turn him to face the southwest?" "We are expecting the priest to come to administer sacraments." "We will need to cremate the body within 24 hours of his passing."

"Can we please turn him to face the southwest?" RATIONALE: At the end of life, the Muslim client or family may prefer the client face Mecca, which is in a south or southwest direction from the United States. Mecca is the birthplace of the prophet Muhammad and the spiritual center of Islam. Followers of Hinduism may wish for a relative to be present at death and request the body be cremated within 24 hours of passing. In the Catholic faith, the priest administers sacraments including Holy Communion and Reconciliation. TEST-TAKING STRATEGY: Knowledge regarding the subject, religious considerations in end-of-life care, is necessary to answer this question. Recalling that Mecca is important to followers of Islam, and that it lies west or southwest from the United States, will direct you to the correct option. Review: religion and end-of-life care.

The nurse provides information to a client about stress-management techniques. Which statement by the client indicates a need for further information? "Listening to music can be really soothing." "Getting enough sleep every night will help me deal with the stress." "I should get regular exercise as part of my stress-management program." "Everyone thinks that caffeine can make the stress worse, but that's a myth."

"Everyone thinks that caffeine can make the stress worse, but that's a myth." RATIONALE: Stress-management techniques include listening to music, having pets around, getting a massage, laughter and humor, participating in a regular exercise program, getting adequate sleep, and reducing or eliminating caffeine intake. Reducing or eliminating caffeine intake can yield more energy and help produce a relaxing feeling. TEST-TAKING STRATEGY: Note the strategic words "indicates a need for further information." These words indicate a negative event query and the need to select the incorrect client statement. Focus on the subject, reducing stress, and recall that reducing caffeine intake will lead to increased energy and a more relaxed feeling. This will direct you to the correct option. Review: stress-management techniques.

Louise calls the firm's nurse's office and schedules an appointment. She tells the nurse that she is feeling tired and stressed and that she is experiencing palpitations every time one of the lawyers places a document on her desk. Louise tells the nurse that she has heard that taking ginseng will relieve the stress and asks whether it is safe to take. How should the nurse respond to Louise? "Many reports indicate that ginseng reduces stress." "Ginseng is a natural herbal substance and is safe to take." "It's a good idea to try ginseng, because it is so important to keep the stress level down to prevent illness." "It's best to consult a health care provider regarding the use of ginseng, because it may not be appropriate for you."

"It's best to consult a health care provider regarding the use of ginseng, because it may not be appropriate for you." RATIONALE: Herbal substances that have been used to relieve anxiety and stress include ginseng, St. John's wort, and kava. Contraindications to the use of these substances do exist. The client should be warned of this fact and advised to consult a health care provider regarding the use of herbal substances. Therefore the other responses are inappropriate. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that indicate that ginseng keep the stress level down. Remember that herbal substances have side effects and contraindications associated with their use. This will direct you to the correct option from those remaining. Review: herbal therapies.

A client is found to have post-traumatic stress disorder (PTSD) after witnessing a terrorist attack and seeing several people jump to their deaths from a burning building. The client, who is undergoing counseling, says to the nurse, "Those people who jumped were my friends and coworkers. The only reason I wasn't there is that it was my turn to get the coffee and doughnuts for everyone that morning. If I hadn't gone, I would have been with them. Maybe I could have helped." Which response should the nurse give to the client? "You just weren't meant to be there." "It was a horrible attack, and there wasn't anything anyone could do." "You need to think about the families of the victims and what they are dealing with." "You are not responsible for the attack but are responsible for learning how to cope with the trauma."

"You are not responsible for the attack but are responsible for learning how to cope with the trauma." RATIONALE: PTSD is precipitated by a specific overwhelming and devastating event. A positive outcome for the client is that the client will cope effectively with thoughts and feelings associated with the traumatic event. To help reduce the client's feelings of powerlessness and guilt, the nurse should note that the client was not responsible for the event. Stating that it was a horrible attack or that the client wasn't meant to be there does not help the client interpret the event or develop coping skills. Thinking about the families of victims and how they are dealing avoids addressing the client's thoughts and feelings. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that do not address the client's thoughts and feelings. Recalling that a positive outcome for the client is to cope effectively with thoughts and feelings associated with the traumatic event will also direct you to the correct option. Review: outcomes for the client with PTSD.

Laura calls her daughter and son to inform them that Louis does not have much time left. The daughter comes quickly to her parents' house, and Louis dies shortly thereafter. The daughter, who is crying, says to the hospice nurse, "It's all my fault. If I hadn't refused to have that test 10 years ago, I could have donated a kidney, and my father would still be alive. It's all my fault!" Which response by the nurse is appropriate? "It's not your fault! You have to stop thinking that way." "You shouldn't feel so guilty. Your brother also refused to have anything to do with being a donor." "Probably so — but, then again, a lot has changed in 10 years. Ten years ago, there was more risk involved in the procedure." "You made the best decision at the time. Let's talk about what makes you feel as though your father's death is your fault."

"You made the best decision at the time. Let's talk about what makes you feel as though your father's death is your fault." RATIONALE: The correct option involves the therapeutic communication technique of paraphrasing. It is open ended as well, making it therapeutic. The nurse provides support, restates the daughter's message, and provides the daughter an opportunity to express her feelings. "It is not your fault" is an aggressive response and is a communication block because it does not encourage the daughter to express her feelings. Addressing guilt and change are incorrect because they reinforce the daughter's belief that she is responsible for her father's death. TEST-TAKING STRATEGY: Use therapeutic communication techniques and note that the client in this case is Louis's daughter. Remember to focus on the client's feelings. This will direct you to the correct option. Review: therapeutic communication techniques.

The nurse employed in hospice care is reading the records of assigned clients. Which client does the nurse identify as being at risk for disenfranchised grief? The mother of a child who was killed in an automobile accident A same-sex partner of a client with acquired immunodeficiency syndrome A client with terminal cancer who is receiving a great deal of support from his wife A client with end-stage renal disease who relies heavily on religious beliefs for hope

A same-sex partner of a client with acquired immunodeficiency syndrome RATIONALE: Disenfranchised grief occurs when societal norms do not define a loss as a loss within its traditional definition. Basically, the survivor is not acknowledged for the loss and as a result is not given support by others. One example of disenfranchised loss is the death of a same-sex lover. In such a situation, grief may need to be hidden for the surviving partner to avoid negative social pressure. The mother of a child killed in an automobile accident, a client with terminal cancer, and a client with end-stage renal disease who relies heavily on religious beliefs for hope are not at risk for disenfranchised grief. TEST-TAKING STRATEGY: Focus on the subject, the client at risk for disenfranchised grief. Recalling that disenfranchised grief occurs with nontraditional losses will direct you to the correct option. Review: disenfranchised grief and other types of grief.

A client is admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. After the clinical intake assessment, the nurse observes that the client is repetitively wiping the furniture in her room with a facecloth and warm water. Which action should the nurse take initially? Allow the client to perform the repetitive act Stop the client from performing the repetitive act Help the client wipe the furniture while talking to her about her repetitive act Tell the client that it is not necessary to repetitively wipe the furniture because it has been thoroughly disinfected by the housekeeping staff

Allow the client to perform the repetitive act RATIONALE: Initially the nurse should not interfere with the repetitive act, as long as the act is not harmful, and the nurse should never ridicule the client's behavior. The client is performing the repetitive act to keep anxiety at a tolerable level. Also, the nurse should not attempt to argue with the client about the repetitive behavior, attempt to reason with the client and persuade him or her to stop the behavior, or reinforce the ritual by focusing attention on it and talking about it a great deal. With time, the nurse can begin to set limits on the client's behavior to modify the behavior. TEST-TAKING STRATEGY: Note the strategic word "initially" and remember that the client was just admitted to the mental health unit. Keeping in mind that performing a compulsive act eases the client's anxiety will direct you to the correct option. Review: care of the client with an obsessive-compulsive disorder.

A female client is brought to the emergency department by a neighbor after experiencing sudden paralysis in both arms. On assessing the client, the nurse discovers that the paralysis developed 2 days after the client's husband told her that he wanted a divorce. The client sighs and says, "Oh well, I guess I will eventually learn to live without my arms working." During the assessment, the nurse learns the client is a computer programmer and needs her hands to perform her work. Which action should the nurse undertake first? Requesting a psychiatric consult Contacting the crisis intervention team Conducting a thorough mental-health assessment Assessing the client for any physical basis for the paralysis

Assessing the client for any physical basis for the paralysis RATIONALE: A conversion disorder is a somatic symptom disorder in which a physical symptom appears when no organic cause exists. The most common conversion symptoms are blindness, deafness, paralysis, and inability to talk. Symptoms are not intentionally produced by the client and are directly related to conflict and increasing anxiety. This type of illness should never be dismissed as psychosomatic, and the nurse should initially plan to carefully assess the client to help rule out an organic cause for the paralysis. Requesting a psychiatric consult, contacting the crisis intervention team, and conducting a mental health assessment may be components of treatment, but they are not the first considerations. TEST-TAKING STRATEGY: Note the strategic word "first." Use Maslow's Hierarchy of Needs theory to answer the question. Recalling that physiological needs are the priority will direct you to the correct option. Review: care to the client with a conversion disorder.

Louis' respiration pattern is illustrated below. How should the hospice nurse document the respiratory findings in the medical record? Bradypnea Hyperventilation Biot respirations Cheyne-Stokes respirations

Cheyne-Stokes respirations RATIONALE: Cheyne-Stokes respirations are an abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing. This type of breathing is a physical manifestation of approaching death. Bradypnea is an abnormally slow breathing rate. Hyperventilation is breathing at an abnormally rapid rate, thus increasing the rate of loss of carbon dioxide. Biot respirations is an abnormal pattern of breathing characterized by groups of regular deep inspirations that tend to be similar in size and are followed by regular or irregular periods of apnea. TEST-TAKING STRATEGY: Knowledge regarding the subject, the respiratory pattern associated with approaching death is needed to answer this question. Review: the various types of respiratory patterns.

With her parents beside her, Isabel carefully explains her situation to her children and outlines the plans for surgery and chemotherapy over the next few months. The children listen, in tears, and ask questions about what Isabel is facing. Later in the day, Regina starts to talk about looking forward to next summer's trip to Florida, a trip they have taken every year. Isabel says nothing about it but worries that her daughter may not fully understand her situation. Which stage of grief is Regina exhibiting at this time? Denial Bargaining Depression Acceptance

Denial RATIONALE: According to Elisabeth Kübler-Ross, a person who is undergoing a significant loss — the a person who is dying or people close to a dying person — will experience five stages of grief. The first of these stages is the denial stage, during which the person acts as if nothing has changed. The subsequent stages are anger, bargaining, depression, and finally, acceptance. TEST-TAKING STRATEGY: Focus on the strategic words "stage of grief" and identify which stage that Regina is experiencing in this situation. Noting that Regina speaks about a future event and keeping in mind that it is early in the process of her learning about her mother's illness will direct you to the correct option. Review: Kübler-Ross' five stages of grief.

Katie, very upset about her boss' comments, returns home from work to find her children sprawled on the couch, watching television and eating cookies and milk. She immediately yells at them, telling them to get off the couch and get their rooms cleaned and homework done. Which defense mechanism is exemplified by Katie's behavior toward her children? Introjection Dissociation Identification Displacement

Displacement RATIONALE: In using displacement, Katie directs her feelings toward one person (her boss) at another (or others; in this situation, her children) who is less threatening. Introjection is the incorporation or internalization of values, standards, or traits of another person with whom intense emotional ties exist. Dissociation involves the blocking off of an anxiety-provoking event or period from the conscious mind. Identification is an unconscious attempt to change oneself to resemble an admired person. TEST-TAKING STRATEGY: Use your knowledge of the subject, defense mechanisms to answer the question. Focusing on the information in the question and noting that Katie is redirecting her feelings about her boss at others will direct you to the correct option. Review: the defense mechanisms identified in the options.

Which therapeutic nursing actions should the nurse use when dealing with the husband of a client who is dying? Select all that apply. Encouraging the husband to express his feelings and concerns Making decisions for the husband to lessen his burden of grief Determining how much the husband wishes to know about the care being provided to his wife Refraining from demonstrating emotion over the client's terminal situation in the presence of the husband Telling the husband that it will be easier to accept the loss if he avoids reminiscing and talking about his life with his wife

Encouraging the husband to express his feelings and concerns Determining how much the husband wishes to know about the care being provided to his wife RATIONALE: The nurse needs to assist the client, family, and significant others through the process of grief. The use of therapeutic communication techniques is important in promoting the process. It is important for the nurse to determine the needs of the family or significant other and how much information they wish to receive about the client's condition and the care being provided to their loved one. The nurse should also encourage reminiscing and the expression of feelings and concerns, which will help loved ones move through the grief process. The nurse should not make decisions for the family unless they specifically request that the nurse do so. Instead, the nurse should assist with the decision-making process if asked and avoid interjecting personal views or opinions. The nurse should acknowledge his or her own feelings. It is also acceptable for the nurse to express his or her own emotions with the family as appropriate. TEST-TAKING STRATEGY: Recall therapeutic communication techniques to answer the question. Eliminate the options that are nontherapeutic and do not address the husband's feelings or concerns and do not assist the husband in the grief process. Also note the words "Making decisions for," "refraining from demonstrating emotion," and "avoids" in the incorrect options. Review: therapeutic nursing actions for dealing with the family of a client who is dying.

A client says to the nurse, "I give you a lot of credit for what you do. I could never be a nurse or do anything that has to do with the medical profession — I have a panic attack whenever I see blood." Which type of phobia does the nurse identify from the client's statement? Acrophobia Agoraphobia Hematophobia Claustrophobia

Hematophobia RATIONALE: A phobia is a persistent, irrational fear of a specific object, activity, or situation that leads to an intense desire to avoid the object, activity, or situation. Hematophobia is the fear of blood. Acrophobia is the fear of heights. Agoraphobia is the fear of open spaces. Claustrophobia is the fear of enclosed spaces. TEST-TAKING STRATEGY: Use medical terminology to answer the question. Eliminate the comparable or alike options that describe space. Note the relationship between the word "blood" in the question and the word "hematophobia" to direct you to the correct option. Review: the various types of phobias.

A client admitted to the mental health unit has a diagnosis of moderate depression. The nurse, formulating a nursing care plan, is concerned about the client's nutritional status. Which nursing interventions should be included in the care plan? Select all that apply. Weighing the client daily Filling out the menu for the client Restricting visitors during mealtimes Including the dietitian in meal planning Providing small high-calorie, high-protein snacks throughout the day

Including the dietitian in meal planning Providing small high-calorie, high-protein snacks throughout the day RATIONALE: The client with depression experiences anorexia, and poor nutrition puts the client at risk for illness, so maintaining adequate nutrition is crucial. The nurse should involve the dietitian in meal planning to ensure that the client is obtaining adequate nutrients. The client should be asked about food dislikes and provided with the opportunity to fill out the menu, because the client is more likely to eat foods he or she has selected. Small high-calorie, high-protein snacks and fluids should be offered frequently throughout the day and evening. Frequent small snacks are more easily tolerated than large plates of food when a client is anorexic. The client is weighed weekly (not daily) to monitor the nutritional status. Weighing the client daily is unnecessary. When possible, the nurse should encourage family or friends to remain with the client during meals. This intervention reinforces the idea that someone cares, may increase the client's self-esteem, and may serve as an incentive to eat. TEST-TAKING STRATEGY: Focus on the information in the question and note that the client is moderately depressed. Read each intervention and determine its effect in promoting a positive outcome with regard to the client's nutrition status. Review: interventions related to nutrition for the client with depression.

A client is seen in the emergency department for complaints of chest pain and difficulty breathing. The results of laboratory and diagnostic tests are normal, indicating that there is no physiological basis for the complaints. On further assessment, the client tells the nurse that chest pain and difficulty breathing are the symptoms that his wife had before she died. Which type of defense mechanism does the nurse recognize in this behavior? Projection Introjection Rationalization Reaction formation

Introjection RATIONALE: Introjection is a type of identification in which the individual incorporates the traits or values of another into himself or herself. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior. Reaction formation is the development of conscious attitudes and behaviors and acting out behaviors opposite of what one really feels. TEST-TAKING STRATEGY: Focus on the information in the question. Noting that the client's complaints are the same as those of his dead wife will help you determine the defense mechanism being used. Review: the defense mechanism identified in the options.

The nurse is performing an assessment of a client who abuses alcohol. During the assessment, the client preaches about the evils of drinking. Which adaptive defense mechanism should the nurse recognize in the client's behavior? Projection Identification Rationalization Reaction formation

Reaction formation RATIONALE: Reaction formation is the development of conscious attitudes and behaviors and the acting out of behaviors that may conflict with what one really feels. The client's proclamations about the evils of drinking are an example of this adaptive defense mechanism. Projection is the transfer of one's internal feelings, thoughts, and unacceptable ideas and traits to someone else. Identification is an unconscious attempt to change oneself to resemble an admired person. Rationalization is an attempt to make unacceptable feelings and behaviors acceptable by justifying the behavior. TEST-TAKING STRATEGY: Focus on the information in the question. Next, think about the description of each item in the options. Noting that the client is an alcoholic yet preaches about the evils of alcohol will direct you to the correct option. Review: the defense mechanisms identified in the options.

Two police officers arrive at the emergency department with a client who was been displaying violent behavior in a local park. The police report to the nurse that they tried unsuccessfully to reason with the client and that the client continued to direct violent behaviors at other individuals in the park. After a thorough psychosocial assessment of the client, the health care provider determines that the client requires emergency involuntary admission to the mental health facility. What determination does the nurse make with regard to this type of admission? It requires the client's consent. It takes away the client's right to informed consent. It is normally sought by the client or the client's guardian. It is necessary for a client who is a danger to self or others.

It is necessary for a client who is a danger to self or others. RATIONALE: Involuntary admission is made without the client's consent. Generally involuntary admission is necessary when the client is a danger to self or others, is in need of psychiatric treatment, or is unable to meet his or her own needs. Voluntary admission is usually sought by the client or by the client's guardian. Clients who are involuntarily admitted do not lose their right to informed consent. TEST-TAKING STRATEGY: Focus on the data in the question and use the process of elimination. Noting the words "emergency involuntary admission" will direct you to the correct option. Review: admission procedures for the mental health client.

The nurse teaches Louise deep-breathing exercises to help her relax and reduce stress. She tells Louise that she may perform these exercises while sitting at her desk and that she should perform them whenever she begins to feel stressed. Which observation by the nurse indicates that Louise is performing the breathing exercises correctly? Louise breathes in through her nose, holds her breath for 10 seconds, and then breaths out through her nose. Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. Louise breathes in through her nose, holds her breath for 15 seconds, and then breathes out quickly through her mouth. Louise quickly breathes in through her mouth, holds her breath for 10 seconds, and then quickly breathes out quickly through her nose.

Louise breathes in through her mouth, holds her breath for 3 seconds, and then breathes out slowly through her nose. RATIONALE: To perform deep-breathing exercises, the client should shift to relaxed abdominal breathing. The client breathes in through the mouth, holds the breath for 3 seconds, and slowly breathes out through the nose. With every breath, the client should pay attention to the muscle sensations that accompany the expansion of the abdomen. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve holding the breath for an extended time. Review: the procedure for performing deep-breathing exercises.

The home care nurse arrives at Louis's home for a daily visit. Laura tells the nurse that she is fatigued and needs help taking care of her husband. She tells the nurse that her daughter and son are her only family but notes that they work all day. Which suggestion by the nurse is most appropriate? Obtaining a referral for hospice care Trying to rest when Louis is resting Hiring a nursing assistant to help provide personal care Asking her daughter and son to take some time off from work

Obtaining a referral for hospice care RATIONALE: Hospice care ensures that the needs of the client and family are the focus of any intervention. Hospice exists to provide support and care for persons in the last phases of incurable diseases so that they may live as fully and comfortably as possible. Hospice services are available 24 hours a day, 7 days a week, to provide help to clients and families in their homes. Staff and volunteers are available, and a multidisciplinary team approach provides holistic health care. Trying to take rest periods while Louis is resting might be helpful for Laura but may not always be possible. Hiring a nursing assistant is also possible, but it is not the most appropriate suggestion by the nurse, because it would be inappropriate to place the additional burden of having to hire someone on the wife. Although asking her daughter and son to take time off from work would be helpful, it is not the most realistic or reasonable solution. TEST-TAKING STRATEGY: Focus on the data in the question. Recalling the services provided by hospice will direct you to the correct option. Also note that this is the umbrella option. Review: the services provided by hospice.

After Louis has died, his family members gather around his bedside to pray and mourn. A little later, Laura asks the hospice nurse to call the funeral home and requests help in preparing her husband's body before the funeral home arrives. Which actions are appropriate components of postmortem care? Select all that apply. Placing a small pillow under the head Elevating the head of the bed to 45 degrees or higher Gently pulling the eyelids over the eyes to close them Removing Louis' dentures and placing them in a denture cup Washing soiled body parts and placing an absorbent pad under the buttocks

Placing a small pillow under the head Gently pulling the eyelids over the eyes to close them Washing soiled body parts and placing an absorbent pad under the buttocks RATIONALE: Postmortem care should be performed as soon as possible to prevent tissue damage, because the body goes through many physical changes after death. The head of the bed is elevated 30 degrees to prevent livor mortis of the face, and a small pillow is placed under the head. Dentures should be left in the mouth, because they give the face a more natural appearance. Closing the eyes helps convey a calm, natural appearance. At the time of death, the urinary and bowel sphincters may relax, resulting in the release of urine and feces, so the perineal area may need to be cleansed and an absorbent pad placed under the buttocks. The nurse should allow the family members to assist with these actions if they want to help. TEST-TAKING STRATEGY: Focus on the subject "appropriate components of postmortem care." Reading each option carefully and recalling those that will help prevent tissue damage during this time will direct you to the correct options. Review: postmortem care.

A client arrives at the clinic, extremely upset and crying, and asks to talk to someone. She tells the nurse that her husband has just told her that he wants a divorce because he is in love with someone else. The client says "I don't know what I'm going to do or how i'm going to deal with this. He was my whole life!" Which type of crisis does the nurse determine that the client is experiencing? Disaster Situational Maturational Adventitious

Situational RATIONALE: A situational crisis arises from an external rather than an internal source. Some examples of external situations that could precipitate a crisis include loss of a job, death of a loved one, a change in financial status, and divorce. A maturational crisis relates to developmental stages and associated role changes. An adventitious crisis relates to a crisis of disaster or an event that is not a part of everyday life. TEST-TAKING STRATEGY: Knowledge of the subject, types of crises, is needed to answer this question. Eliminate the comparable or alike options: an adventitious crisis relates to a crisis of disaster. To select from the remaining options focusing on the information in the question will help you determine that the client is experiencing a situational crisis. Review: the types of crises.

Just before a session with the nurse, Katie receives a call from her boss. After the call, Katie is extremely upset and unable to sit down. She paces the room, crying and repeating, "I don't know what to do. He hates me!" Which nursing interventions will be most likely to be effective at this time? Select all that apply. Speaking to Katie in slow, firm, short statements Leaving Katie alone until she has settled down Assessing the need for medication at this time Exploring problem-solving strategies with Katie Moving Katie to a quiet setting and staying with her Using nonverbal cues, without speaking, to convey concern

Speaking to Katie in slow, firm, short statements Moving Katie to a quiet setting and staying with her RATIONALE: Katie is showing signs of a severe to panic level of anxiety. During this time it is important to keep her safe, meet her physical needs, and reduce anxiety. Moving to a quiet environment and speaking to her in slow, firm, short statements can help. Medication may be considered if other measures do not help. Persons who are experiencing severe anxiety are not able to solve problems; leaving Katie alone would not be safe, and she would be too upset to respond to nonverbal cues from the nurse. TEST-TAKING STRATEGY: It is important to recognize that Katie is experiencing a severe to panic level of anxiety. Use knowledge of the subject, interventions for severe/panic anxiety, to assist with the process of elimination to decide which interventions are appropriate at this time to keep her safe and to reduce her anxiety. Review: the interventions for a severe to panic level of anxiety.

Claudia, pacing back and forth across the lounge, begins to yell at a client named Charles. She tells Charles that she will hit him if he doesn't start paying attention to her. What is the appropriate response by the nurse who witnesses the incident? Telling Claudia to leave the lounge Escorting Charles from the lounge Telling Claudia, "Claudia, do not yell at Charles or hit him. If you can't control yourself, we'll help you." Telling Claudia, "Claudia, your behavior is inappropriate. If you don't stop yelling, we're going to have to restrain you and put you in seclusion."

Telling Claudia, "Claudia, do not yell at Charles or hit him. If you can't control yourself, we'll help you." RATIONALE: The nurse must set limits on Claudia's behavior in simple, clear, and concrete terms and provide Claudia with reassurance that she will be given assistance if she is unable to control her behavior. Escorting Charles from the lounge is inappropriate; another client should not be expected to leave the lounge because of Claudia's behavior. Telling Claudia to leave the lounge and making threats or putting pressure on Claudia may escalate her behavior; additionally, these options are inappropriate and violate the client's rights. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that involve violations of the client's rights. To select from the remaining options, recall that it is most appropriate to deal directly with the client's behavior. Review: care to the client with mania.

Claudia has exhibited constant motor activity and is showing signs of exhaustion. The nurse plans for which appropriate activity for Claudia? Dancing Writing Exercise Walking

Writing RATIONALE: The constant motor activity of the manic client can lead to physical exhaustion, so the nurse must provide frequent rest periods for the client. The nurse would plan structured and solitary activities such as writing and drawing or tearing rags. A structured solitary and noncompetitive activity provides security and focus for the client and permits the use of energy and the expression of feelings. Dancing, exercising, and walking are appropriate for the client who is not exhausted. TEST-TAKING STRATEGY: Eliminate the comparable or alike options that identify gross motor activities. Review: the plan of care for a client with mania.

The nurse has provided the family of a client with Alzheimer's disease with guidelines for caring for the client at home. Which statement indicates the education has been effective? The family mentions encouraging physical activity during the day. The family members indicate they will dress the client to prevent client frustration. The family informs the nurse they will restrain the client at night if the client tends to wander. The family members agree they will feed the client to ensure that the client receives adequate nutrition.

The family mentions encouraging physical activity during the day. RATIONALE: Physical activity during the day should be encouraged for the client with Alzheimer's disease. Exercise will help the client sleep at night and reduce the likelihood of nighttime wandering. If the client wanders, safety measures (e.g., placing complex locks on doors or placing locks at the tops of doors) may be instituted. The client should perform all tasks within the capacity of his or her condition. This will help maintain the client's self-esteem and minimize further regression. Providing step-by-step instructions whenever necessary will help the client focus on small pieces of information and allows the client to perform at an optimal level. The client should not be restrained. Restraints can cause the client to become more terrified and agitated, until he or she is exhausted to a dangerous degree. TEST-TAKING STRATEGY: Eliminate comparable or alike options that indicate that activities should be performed for the client. Recalling that restraints will further agitate the client will help you eliminate this option. Review: home care guidelines for the client with Alzheimer's disease.

Joseph has been undergoing therapy, and suicide precautions have been discontinued. Joseph asks the nurse about being discharged from the mental health unit. What information does the nurse keep in mind as he responds to Joseph? Administrative approval is required before discharge. Because of his admission status, Joseph may not request discharge. Voluntarily admitted clients have the right to request and be granted release from the mental health unit. Discharge will not be considered unless Joseph is able to move in with a relative or friend who can stay with Joseph full time for at least 1 month.

Voluntarily admitted clients have the right to request and be granted release from the mental health unit. RATIONALE: Voluntarily admitted clients have the right to request and be granted release from the mental health unit. Administrative approval is not required. Asking Joseph to move in with a relative or friend who will stay with him on a full-time basis for at least 1 month is incorrect and unrealistic. TEST-TAKING STRATEGY: Use the process of elimination. Eliminate the options that include the closed-ended words "required," "may not," and "will not." Review: the procedure for and client rights in regard to admission and discharge from a mental health facility.

A client with depression who is scheduled to undergo electroconvulsive therapy (ECT) for the first time says to the nurse, "I'm nervous about this treatment. Someone told me there's a risk of electrocution." The nurse should make which response to the client? "Did your health care provider talk to you about this when you signed the informed consent?" "Electrocution is not a risk associated with this treatment. Let's discuss your concerns." "Electrocution can only happen during a thunderstorm. That's why we always check the weather report before starting a treatment." "The side effects of this treatment are minimal, so don't worry. Your health care provider can talk to you about them in greater detail if you'd like."

"Electrocution is not a risk associated with this treatment. Let's discuss your concerns." RATIONALE: Electroconvulsive therapy, or ECT, is a treatment in which a brief seizure is artificially induced in an anesthetized client by the passage of an electrical stimulus through electrodes applied to the client's head. The stimulus is generally adjusted to the lowest level of energy that will produce a seizure. While the client is being prepared for the treatment, it is important for the nurse to give the client the opportunity to express his or her feelings, including myths, about ECT. Clients may describe fears related to pain, dying of electrocution, suffering permanent memory loss, or experiencing impaired intellectual function. ECT is not associated with electrocution. Telling the client that electrocution can only happen during a thunderstorm is inaccurate and will instill additional fear in the client. Asking the client whether he or she has spoken with the health care provider regarding side effects avoids the client's concerns. TEST-TAKING STRATEGY: Your knowledge of therapeutic communication techniques. Eliminate the option that will instill additional fear in the client and the comparable or alike options that avoid the client's concern. Review: therapeutic communication techniques and ECT therapy.

After a week, Claudia's lithium level is within the normal range and she is preparing to go home. The nurse has reviewed client teaching about lithium therapy with Claudia. Which statements by Claudia reflects the need for further teaching? Select all that apply. "I'll cut down on the salt I eat." "I'll take the pills on an empty stomach." "I'll take the pill every day at the same time." "I need to be very careful, because lithium can be addictive." "It's important for me to see my doctor to have my lithium level checked."

"I'll cut down on the salt I eat." "I'll take the pills on an empty stomach." "I need to be very careful, because lithium can be addictive." RATIONALE: Lithium, which can be irritating to the lining of the stomach, should be taken with meals. The client must be taught that lithium is not addictive and that consistent dosing is important. The client should be taught to consume a normal amount of sodium, not to cut down on sodium, because a low sodium level can lead to an increase in the lithium level, leading in turn to toxicity. Periodic follow-up appointments are important for monitoring of the drug level and of kidney and thyroid function, which may be affected by lithium therapy. TEST-TAKING STRATEGY: Note the strategic words "need for further teaching." These words indicate a negative event query and the need to select the incorrect client statements. Reading each option carefully and thinking about client teaching and lithium therapy will direct you to the correct option. Review: client teaching points for lithium drug therapy.

Louise reads an article about herbal therapies for stress relief and decides that she wants to try drinking tea made with kava. She calls the company nurse to ask about using kava. Which instructions should the nurse provide? Select all that apply. "You shouldn't use kava if you think you might be pregnant." "Herbal products are safe to use, because they aren't really medications." "This herb helps some people feel more relaxed and may help you sleep." "It's safe to drink a small glass of wine at night with this tea right before bedtime." "If you drink this tea long enough, you may notice a yellow discoloration of your skin."

"If you drink this tea long enough, you may notice a yellow discoloration of your skin." "This herb helps some people feel more relaxed and may help you sleep." "You shouldn't use kava if you think you might be pregnant." RATIONALE: Kava is commonly used to relieve anxiety and stress and to promote sleep. It may cause a temporary yellow discoloration of the skin, and it should not be taken with alcohol or psychoactive drugs or by women who are pregnant or breastfeeding. Even though kava is an herbal product, those who use it must be aware of potential side effects and contraindications. TEST-TAKING STRATEGY: Use knowledge of the subject, the use of kava for the relief of stress, to answer the question. Keep in mind that herbal products do have certain contraindications to their use. Also use the general guidelines for medication administration and remember that the nurse would not recommend the use of alcohol to a client. Review: the use of kava.

A few weeks later, while under the care of a hospice program, Isabel dies peacefully at home. Her parents and her children, who have been at her side, are understandably upset. Which statements by the hospice nurse are appropriate at this time? Select all that apply. "It's OK to cry." "Everything will be fine." "I'll be here if you want to talk." "Don't cry. She wouldn't want that." "You need to be strong for your little brother." "Let me know if I can make any phone calls for you."

"It's OK to cry." "I'll be here if you want to talk." "Let me know if I can make any phone calls for you." RATIONALE: The nurse's statements should not minimize the family members' loss. The nurse must avoid trite statements such as "Everything will be fine," "Don't cry," and "You need to be strong." These statements are actually barriers to communication and do not demonstrate care and concern. The nurse should offer supportive statements, acknowledge the family's feelings, be ready to listen, remain present, and offer to help as needed. TEST-TAKING STRATEGY: Use the process of elimination. Read each option carefully. Recalling the principles of therapeutic communication and barriers to communication will direct you to the correct options. Review: the principles of therapeutic communication.

The nurse is talking to a client in the mental health unit. The client says, "I'm really angry with my boyfriend about the things he says to me. Women always get put down, as if we don't matter or have anything important to offer." Which response is the most appropriate one for the nurse to make? "Tell me how you feel as a woman." "I know how you feel. I see that happening with some of my friends." "Yes, it's sad that women are treated that way. I guess we need to deal with it." "Many women's groups are developing ways to deal with this. I'll give you the names and contact numbers of some of these groups before you're discharged from the hospital."

"Tell me how you feel as a woman." RATIONALE: Focusing helps a client expand on a topic of importance. It also helps the client become more specific, move from vagueness to clarity, and concentrate on reality. The nurse should focus on the client's verbalization of concern. Agreeing with the client and avoiding the issue does not address the client's concern. Although the client may need to be provided with referrals to self-help or support groups before discharge, offering the names and contact numbers of women's groups is not the most appropriate response because it does not address the client's concern at the current time. TEST-TAKING STRATEGY: Use therapeutic communication techniques to answer the question. Select the option that focuses on the client's feelings and addresses the client's concern. Review: therapeutic communication techniques.

Isabel has begun outpatient chemotherapy. After each session, she goes home to rest, and she has been unable to care for her children. Her mother comes over in the afternoons to be there when the children come home from school and to cook dinner for the family. Trevor comes home one day with a note from his teacher. He has been rude at school, using "bad language" and talking back to the teacher. When asked about this, Trevor replies, "I'm fine. The teacher is stupid." Isabel calls the clinic nurse to talk about Trevor's behavior. Which statement by the nurse provides the best interpretation of Trevor's behavior? "Yes, he's being rude and insensitive, but he'll grow out of it soon." "Trevor needs to accept what's happening to you and stop acting out." "This may be his way of running away from the situation. Let's try to get him to talk about it." "The teacher just doesn't understand the difficult time that Trevor is going through right now."

"This may be his way of running away from the situation. Let's try to get him to talk about it." RATIONALE: For a school-age child, the realization of impending death and loss is a major threat to the child's sense of security and ego strength. At this age, children are likely to show their fear through verbal uncooperativeness —using rude or bad language or being impolite and stubborn. The nurse should recognize this as an attempt to "run away" from stress and should encourage Trevor to talk about his feelings. The incorrect options avoid the situation and do not address Trevor's behavior or feelings. TEST-TAKING STRATEGY: Use your knowledge of therapeutic communication techniques to answer the question. Read each option carefully and think about the child's developmental stage to assist you in eliminating the incorrect options. Also note that the correct option addresses Trevor's feelings. Review: the responses to loss in children of different ages.

Now that Claudia is medically stabilized, plans are being made for her discharge home. Which patient goal is most relevant to include in the plan of care? Claudia will promise to attend a self-help group twice a week Claudia will be able to return to her previous job immediately Claudia will maintain medication compliance and avoid relapse Claudia's mother will take responsibility for administering Claudia's medication as prescribed

Claudia will maintain medication compliance and avoid relapse RATIONALE: After the manic phase of bipolar disorder and as the client is preparing for discharge from the hospital, measures are taken to maintain medication compliance and prevent relapse. Interventions are planned accordingly, depending on the client's interpersonal and stress-reduction skills, cognitive function, employment status, substance abuse problems, and social-support systems. During this time, psychoeducational teaching is critical. Evaluation of the need for communication and problem-solving skills training is also important. The need for referrals to community programs or self-help groups is evaluated, but the nurse should not ask the client to promise to do something. The client may not be ready to return to his or her previous employment immediately after discharge from the hospital. Asking Claudia's mother to take responsibility for administering Claudia's medication is inappropriate because the client needs to take responsibility for taking her own prescribed medications. TEST-TAKING STRATEGY: Note that the correct option is the umbrella option, addressing both medication compliance and the prevention of relapse. Review: discharge planning for the client with bipolar disorder.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of dissociative amnesia. Which intervention should the nurse include in the plan? Encouraging the client to perform self-care activities Encouraging the use of dissociation to cope with stress and anxiety Orienting the client and frequently reminding him of events in his past Making all decisions for the client to prevent him from feeling overwhelmed

Encouraging the client to perform self-care activities RATIONALE: Dissociative amnesia refers to the client's inability to integrate memories. The memory loss serves the purpose of preventing anxiety. The client should be encouraged to do things for himself and to make decisions about routine tasks. This will enhance the client's self-esteem by reducing his sense of powerlessness. The nurse would not encourage the use of dissociation. Rather, the nurse would help the client see the consequences of using dissociation to cope with stress. Although the nurse would orient the client, flooding the client with information on past events is inappropriate. The nurse should encourage the client to make some decisions. This will increase the client's insight and help the client understand his own role in choosing behaviors. TEST-TAKING STRATEGY: Eliminate the option using the close-ended word "all." Next, eliminate the option that uses the words "frequently reminding him of events in his past," because this action would flood the client with information about his or her past. To select from the remaining options, focus on the words "dissociative amnesia" to answer correctly. Review: the interventions for the client with dissociative amnesia.

In his first appointment with the crisis counselor, Thomas shares how helpless he feels now that he has only one foot and says he is worried about how he will be able to earn a living. The counselor listens to Thomas and implements interventions to help him at this time. Which interventions are examples of primary prevention interventions for mental health? Select all that apply. Ensuring Thomas's safety Exploring other possible occupational roles Referring Thomas to a critical incident stress debriefing program Assisting Thomas in his support system and coping style Assisting Thomas in evaluating his experience of stressful life events Teaching specific coping skills, such as problem-solving and relaxation techniques

Exploring other possible occupational roles Assisting Thomas in evaluating his experience of stressful life events Teaching specific coping skills, such as problem-solving and relaxation techniques RATIONALE: Primary care interventions promote mental health by helping reduce the incidence of crisis. Examples of primary care interventions include helping the client evaluate how he has responded to stressful life events; teaching specific skills, such as coping skills, problem-solving, and relaxation techniques; and assisting the client in exploring ways to reduce the negative impact of stress by making decisions and even discussing occupational changes. Secondary care interventions, such as ensuring the client's safety and assisting the client in his assessing support system and coping style, are implemented during an acute crisis to prevent prolonged anxiety from reducing personal effectiveness. Tertiary care interventions, such as a critical incident stress debriefing program, provides support for the client who has experienced a severe crisis and is trying to recover. TEST-TAKING STRATEGY: Focus on the strategic words, primary prevention interventions for mental health. Recall that primary prevention activities for mental health are those that promote mental health and reduce mental illness, thus decreasing the incidence of crisis. Review: the levels of prevention for mental health.

A female client with anorexia nervosa is transferred to the mental health unit from a medical unit after being treated for an electrolyte imbalance. Which action does the nurse in the mental health unit plan to take to ensure adequate nutritional intake? Being supportive but feeding the client if she refuses to eat Staying with the client during mealtimes and encouraging the client to eat Telling the client that an intravenous line or a nasogastric tube will be inserted if she does not eat Asking the client to call the nurse when she is done eating so that her calorie intake and fluid intake can be calculated

Staying with the client during mealtimes and encouraging the client to eat RATIONALE: Anorexia nervosa is an eating disorder in which the individual experiences hunger but refuses to eat because of a distorted body image. It can lead to life-threatening physiological disorders. To ensure adequate nutrition, the nurse should stay with the client during meals and snacks, watch the client eat, and remain with the client for at least 1 hour after the meal. These actions will ensure that the client does not hide or throw away food or purge after the meal or snack. Feeding the client is an inappropriate action that will lead to a power struggle between the client and nurse. Telling the client that an intravenous line or nasogastric tube will be inserted if she does not eat is threatening the client. This is also an inappropriate action. TEST-TAKING STRATEGY: Eliminate comparable or alike options that are inappropriate and are threatening to the client. To select from the remaining options, recall the nutritional and eating concerns associated with this disorder, which will direct you to the correct option. Review: care of the client with anorexia nervosa.

A client with a diagnosis of severe depression is being treated in an inpatient mental health unit. Which observation by the nurse indicates an increased risk for suicide? The client is pacing the hallway. The client is sitting in her room, wringing her hands. The client gives her handmade sweater to her roommate. The client is sitting alone in the corner of the clients' lounge.

The client gives her handmade sweater to her roommate. RATIONALE: The nurse must be alert for clues indicating a risk for suicide in the client with depression. Behavioral changes, especially those that occur when the depression lifts and the client has more energy available with which to carry out a suicide plan, may indicate such a risk. Signs include giving away prized personal possessions, writing farewell notes, making out a will, and putting personal affairs in order. Pacing the hallway, wringing the hands, and sitting alone are all behaviors that may be noted in a client with depression, and although they cannot be ignored, they are not direct signs of an increased risk for suicide. TEST-TAKING STRATEGY: Focus on the subject, a behavior associated with an increased risk for suicide. Remember that a sign is that the client gives away personal possessions. Review: the signs associated with increased risk of suicide.

The nurse in a mental health clinic is interviewing a client who was referred to the clinic by the client's primary health care provider. Which finding indicates to the nurse that the client needs assistance to restore and maintain mental health? The client has a positive self-concept. The client identifies strengths and uses these for goal attainment. The client has a distorted view of the world and communicates inappropriately. The client identifies coping mechanisms used to successfully cope with threats to the self.

The client has a distorted view of the world and communicates inappropriately. RATIONALE: A client who experiences a disturbance in homeostasis as a result of a threat to the self and experiences an alteration in reality may come to have a distorted view of the world and may communicate inappropriately and inadequately. This psychic discomfort felt by the individual may be manifested through various mental health problems such as adjustment disorders, psychophysiological manifestations, psychotic disorders, and behaviors indicative of sensory deprivation. The remaining options are all healthy mental health behaviors. TEST-TAKING STRATEGY: Note the words "needs assistance to restore and maintain mental health." Next, note the relationship between these words and the words "distorted view" in the correct option. Also note the incorrect comparable or alike options that all describe healthy mental health behaviors. Review: the characteristics of mental health and mental illness.

Several family members are sitting at the hospital with a client who is dying of cancer of the bladder. The dying client's roommate is found waiting outside the room after visiting hours have ended. He tells the nurse that he wants to give his roommate's family privacy. Which action should the nurse take? Transferring the roommate to another room Reminding the dying client's family that visiting hours have ended Informing the dying client's family that the client may have just two visitors at a time Telling the roommate that he may return to his room and that the curtain will be drawn around the dying client's bed to provide privacy

Transferring the roommate to another room RATIONALE: When a client is dying, it is important for the client and family members to acknowledge their sadness and say goodbye. The client and family should be given privacy to express their feelings and comfort one another. However, the nurse should also consider the needs of nearby clients, such as the client's roommate. Because the client is dying, it is inappropriate to prohibit family from visiting or to require them to leave once visiting hours have ended. In this situation, it would be best to transfer the roommate to another room. This action will meet the needs of both clients. TEST-TAKING STRATEGY: Note that the subject of the question involves both clients, the dying client and the roommate. And note that the only option that will address the needs of both clients is transferring the roommate to another room. Review: nursing interventions for the dying client.