Saunders Mental Health and Pharmacology Psychiatric

A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent. My one child is my only family, but I don't want to burden my child with my problems." Which response by the nurse would best address the client's concern?

"Wouldn't you want to know if your child was having difficulties so that you could help if you could?" The therapeutic communication technique of clarification in option 3 attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client's feelings and actions. Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client's concerns and feelings on hold.

A client diagnosed with depression is scheduled to receive three sessions of electroconvulsive therapy. The nurse would tell the client that they will likely start to see improvement in approximately what time frame?

1 week after the third treatment session Psychiatrists generally prescribe electroconvulsive therapy (ECT) treatments 3 times a week, with an average series including six to 12 treatments. After three sessions of ECT, the client would start to demonstrate improvement in 1 week. The remaining options are incorrect.

On review of the client's record, the nurse notes that the admission to the mental health unit was voluntary. Based on this information, the nurse plans care, anticipating which client behavior?

A willingness to participate in the planning of the care and treatment plan. In general, clients seek voluntary admission. If a client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program since they are actively seeking help. The remaining options are not characteristics of this type of admission. Fearfulness, anger, and aggressiveness are more characteristic of an involuntary admission. Voluntary admission does not guarantee that a client understands the illness, only the client's desire for help.

A client is unwilling to go to church because the client's ex-partner goes there and the client feels that the ex-partner will laugh at and make fun of the client in church. Because of this hypersensitivity to a reaction from the ex-partner, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?

Avoidant The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after witnessing a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that would be the focus of this consult?

Conversion disorder A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person's mental capacity to recognize reality, communicate, and relate to others is impaired, interfering with the person's ability to deal with life's demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply.

Dental decay Loss of tooth enamel Electrolyte imbalances Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride?

Dementia Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication.

A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention would the nurse implement?

Escort the client to the hospital room, with the assistance of other staff. The client is at risk for injury to self and others and would be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.

During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with post-traumatic stress disorder?

Making the client feel safe It is important to make a confused client feel safe. Explaining the unit rules and orienting the client to the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.

The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care?

Nutritional imbalance because of lack of intake The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance since it is the basis of the condition. Although the problems identified in the other options may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.

A nurse attends an educational session on family violence. Which statement by the nurse indicates a need for further teaching concerning family violence?

"Abusers are more often from low-income families." Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. Abusers often use fear and intimidation to the point at which their victims will do anything just to avoid further abuse. The statement that abuse occurs more often in lower socioeconomic groups is incorrect.

During a nursing interview, a client says, "My child was murdered. I can't help wondering if the spouse killed my child, but they have been eliminated as a suspect." Which statement is a therapeutic nursing response?

"Have you shared your concerns with the police?" The correct option addresses the subject of the client's statement. Avoid options that identify the process of agreeing with the client. The option of telling the client "I don't think that you should blame yourself" is not directly related to the subject of the client's statement.

The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the spouse make which statement?

"I no longer feel that I deserve the beatings my spouse inflicts on me." Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for their own behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates codependence.

When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement?

"I will take the medicine until I am sure I can handle my own problems." The client does not demonstrate an understanding of the continued need for medication and suggests that the illness can be controlled by decreasing stress. The remaining options are common concerns of a client on discharge but do not indicate the need for further teaching.

The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis?

"I'd be sure to have a panic attack if I left my house." Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. The remaining options describe obsessive-compulsive behavior, claustrophobia, and a social phobia.

A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavioral modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy?

"It uses negative reinforcement." Operant conditioning entails rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach. Positive reinforcement, increases in social behaviors, and increases in the level of self-care are accurate characteristics of this form of therapy.

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement?

"My rituals are ways for me to control unpleasant thoughts or feelings." In obsessive-compulsive disorder (OCD), the rituals performed by the client are an unconscious response that helps to divert and control the unpleasant thought or feeling and prevent acting on it. This decreases the client's anxiety. OCD is not associated with a need for control or punishment, or with hallucinations.

The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to stop using drugs." Which response by the nurse would be therapeutic?

"Tell me what makes you feel that you are ready." Clients with a long history of drug abuse need to demonstrate motivation to change the behavior, not just verbalization of the intent to change the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. The correct option is the only one that will provide this direction to the client.

During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breach of boundaries?

"The focus of today's session is on your issues, so let's get started." The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse would confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Avoid options that may be judgmental and may provide an opening for a verbal struggle or those that are a social response and could be misinterpreted by the client.

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

"This form of therapy provides a negative reinforcement when the stimulus is produced." Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.

The nurse is preparing a client with schizophrenia for discharge. The client has a history of command hallucinations, and the nurse is providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?

"When I have command hallucinations, I'll call a friend and ask what I should do." The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations especially if the hallucination is commanding to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt self or others. The client statements in the remaining options will aid in wellness and are helpful.

The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse, "I can't sing," and refuses to attend. Which nursing response is most likely to meet the client's needs?

"You don't have to sing. Just listen and enjoy the music." The correct option encourages the client to socialize and indicates that it is not necessary to sing. Avoid the use of the word why since it can be insulting to the client. Don't make or imply a demand. Focus on addressing the client's concern. The correct option is the only one that addresses the client's concern.

A client who has recently lost their spouse says, "No one cares about me anymore. All the people I loved are dead." The nurse would make which therapeutic response when dealing with a grieving client?

"You must be feeling all alone at this point." The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. None of the remaining options encourage the client to discuss feelings but rather minimize and/or trivialize the feelings expressed.

The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication?

"You're having difficulty sleeping?" The correct option uses the therapeutic communication technique of restatement. Although restatement is a technique that has a prompting component to it, it repeats the client's major theme, which assists the nurse to obtain a more specific perception of the problem from the client. The remaining options are nontherapeutic responses since none encourages the client to expand on the problem. Offering personal experiences moves the focus away from the client and onto the nurse.

The nurse assigned to care for a client diagnosed with acute depression would be appropriate in making which statement to the client?

"You're wearing a new blouse." A client who is depressed sees the negative side of everything. Telling the client that they look lovely today can be interpreted as "I didn't look lovely last time we met." Neutral comments such as that identified in the correct option will avoid negative interpretations. The client would not be told not to worry, that everyone gets depressed once in a while, or that they will feel better because such statements are inappropriate and minimize the client's feelings.

Which client is at greatest risk for committing suicide?

A client with metastatic cancer The person at greatest risk for suicide is the client with terminal illness. Other high-risk groups include adolescents, drug abusers, persons who have experienced recent losses, those who have few or no social supports, and those with a history of suicide attempts and a suicide plan.

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply.

Acknowledge the client's behavior. Assist the client to an area that is quiet. Maintain a safe distance from the client. During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.

The nurse is assessing a client who has been admitted to the coronary care unit. The client seems to fluctuate in the ability to focus during the day. On the basis of this assessment, which client problem would the nurse suspect?

Acute confusion as a result of hospital-induced psychosis Coronary care unit (CCU) psychosis occurs in some clients in the critical care milieu. The ability to focus fluctuates over the course of a day. It usually is directly caused by sensory deprivation or underlying medical conditions or is medication-related. There are no data in the question to indicate that dementia exists. The question presents no data directly indicating that alcohol is a concern.

A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse would tell the client that which is the first step in this 12-step program?

Admitting to having a problem The first step in the 12-step program is to admit that a problem exists. Substituting other activities for gambling may be a strategy, but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my doctor's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?

An expected coping mechanism The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.

The nurse is monitoring a stress management therapy group that is in the forming stage. Which activity is characteristic of this stage of group development?

Setting the rules of conduct for members of the stress management group In the forming or initial stage, the members are identifying tasks and boundaries (setting rules). Storming involves responding emotionally to tasks. In the norming stage, members express intimate personal opinions and feelings concerning personal tasks (options 1 and 2). In the performing stage, members direct group energy toward the completion of tasks (option 4).

The nurse creating a plan of care for the client demonstrating paranoia would include which interventions in the plan of care? Select all that apply.

Ask permission before touching the client. Eliminate all unnecessary physical contact with the client. Defuse any anger or verbal attacks with a nondefensive stance. Use simple and clear language when communicating with the client. When caring for a client with paranoia, the nurse would ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client unless necessary and with the client's permission. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language would be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse would avoid a warm approach because warmth can be frightening to a person who needs emotional distance.

The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action would the nurse take to plan appropriate nursing care?

Ask the client about the amount of drug use and its effect. Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit?

Assigning the client to a room at the end of the hall The client would be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse would not become isolated with a potentially violent client. The nurse would never turn away from the client, and the door to the client's room would be kept open. A security officer would be within immediate call in case violent behavior appears imminent.

A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?

Assigning to the client a staff member who will remain with the client at all times Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion would not be the initial intervention, and the least restrictive measure needs to be used.

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression?

Assure that an electrocardiogram is performed within 24 hours. Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.

The nurse is monitoring a hospitalized client who abuses alcohol. Which findings would alert the nurse to the potential for alcohol withdrawal delirium?

Hypertension, changes in level of consciousness, hallucinations Symptoms associated with alcohol withdrawal delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed?

Disulfiram Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety. Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.

The nurse caring for a client diagnosed with severe depression is planning activities for the client. Which activity would be most appropriate for this client?

Drawing Concentration and memory are poor in severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration, such as drawing. Activities that have no right or wrong choices and that require no decisions minimize opportunities for the depressed client to experience a sense of failure. The remaining options do not meet the criteria and are incorrect.

The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation?

During the entire family visit, the client presented with an expressionless, blank look. A flat affect is manifested as an immobile facial expression or blank look. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation.

During a home visit, the nurse suspects that a young child of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia?

Eating a lot of food in a short period of time and misuse of laxatives Eating binges and purging are the characteristics that would be seen in bulimia. Eating only certain types of foods may reflect a preference but does not indicate bulimia. Bulimic persons usually do not refuse to eat; rather, they binge and purge. Hoarding of food may indicate another problem.

A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom?

Encourage frequent fluid intake and a high-fiber diet. Constipation is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question in combination with antipsychotic medications are indicators of constipation. A high-fiber diet and increased fluids can reduce constipation.

A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered demeanor?

Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide. The sudden change in the depressed client's mood and affect may indicate that the client has come to a decision about suicide. The only way to be sure is to ask the client directly. Eliminate options that present strategies that would be used with any client. Avoid options that make unfounded assumptions such as a meaning of the behavior. Notifying others of your concern may be necessary at some point but does nothing to address the problem directly.

A client in a manic state presents to the dayroom only partially dressed and is making sexual remarks and gestures toward the staff and other clients. Which is the initial nursing action?

Escort the client to own room to get appropriately dressed. A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety in the client. Use of a quiet, firm approach and distracting the client (walking to own room and assisting in getting dressed) will achieve the goal of having the client dressed appropriately while preserving their psychosocial integrity. While restating boundaries is appropriate, the initial task relates to controlling inappropriate behaviors while protecting the client. Telling the other clients to go to their rooms immediately is inappropriate and does not address the client's behavior.

The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care?

Establish a trusting nurse-client relationship... The priority is to establish a trusting relationship with the client. Demanding anything from the client would never occur. The remaining options are appropriate components of the plan of care but are not the priority. A trusting nurse-client relationship needs to be established first.

Parents tell the nurse in a pediatrician's office that they are concerned because their children must let themselves into the house after school each day while they are at work. The nurse explores which suggestion with the parents to decrease the children's sense of isolation and fear?

Find community after-school programs or activities. In most communities, free or low-cost after-school programs or activities are available that minimize the amount of time during which school-age children are at home alone. These programs would include adult supervision, which is needed by school-age children. Prohibiting cooking enhances safety but does not address isolation and fear. Neighborhood play is inadequate because no one is assuming responsibility for the after-school safety of the children; no formal agreement to provide child care has been made with the other families. Calling a parent at work hourly may reassure the parent that the children are home and safe, but it does not address feelings of isolation and fear.

The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply.

Have the client void. Obtain an informed consent. Remove dentures and contact lenses. Withhold food and fluids for 6 hours. Enemas are not a component of the pretreatment care for a client scheduled for electroconvulsive therapy (ECT). The nurse would teach the client and family what to expect with ECT and allow the client to discuss their feelings regarding the procedure. The remaining options are a part of the pretreatment plan.

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How would the nurse plan to respond to the client's statement?

Identify recent behaviors or accomplishments that demonstrate the client's skills. Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal?

Identifying anxiety-producing situations Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

The nurse notes that a client attending a group therapy session is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How would the nurse interpret this behavior?

Improvement The behaviors identified in the question indicate improvement in the client's condition. The question presents no information indicating that the client is being manipulative. Acting out is attention-seeking behavior. All clients have a desire to be accepted.

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concern regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?

Lack of ability to cope effectively Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.

The nurse is developing a plan of care for a client who experiences anxiety after the loss of a job. The client is verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?

Lack of ability to cope effectively Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; the client experiences anxiety, and the client's concern is the ability to meet role expectations and financial obligations. There is no information in the question that indicates panic (fright or acute, extreme anxiety), an unrealistic outlook, or disturbances in thoughts and ideas.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?

Observing rigid rules and regulations Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety.

The client tells the nurse they cannot leave home without checking numerous times that "everything electrical has been shut off." The client's statement supports which mental health diagnosis?

Obsessive-compulsive disorder A repetitive behavior that interferes with activities of daily living and functioning is indicative of obsessive-compulsive disorder (OCD). This repetitive behavior is not associated with phobias, generalized anxiety disorder, or post-traumatic stress disorder.

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply.

Panic disorder Post-traumatic stress disorder Obsessive-compulsive disorder Multiple personality disorder is considered to be a dissociative disorder rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Dementia may or may not be associated with anxiety.

The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support?

Post-traumatic stress disorder The major clinical manifestation associated with post-traumatic stress disorder (PTSD) is client experience of flashbacks. Flashbacks are not specifically associated with anxiety, agoraphobia, or schizophrenia.

The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept would the nurse plan to include in the content of the seminar?

Progressive muscle relaxation techniques are useful for easing tension from many causes. Biofeedback, guided imagery, progressive muscle relaxation, and meditation are techniques that the nurse can teach the client to reduce the physical impact of stress on the body and to promote a feeling of self-control. Biofeedback uses electronic equipment, whereas each of the other techniques requires no equipment after it is learned. Confrontation is not a stress management technique; it is a communication technique.

A client diagnosed with depression is not eating adequately and at times refuses to eat at all. What would the nurse plan to do to meet the client's nutritional needs?

Provide small, frequent meals that include the client's food preferences. A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing further. Forcing foods and fluids and restricting social activities will cause further withdrawal by the client since both will be viewed as a punishment. Providing snacks and meals when the client requests them will not ensure adequate nutritional intake.

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?

Remain with the client until the anxiety decreases. This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.

During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care, knowing that the client is most likely to experience which type of compulsive behavior?

Repetitive actions to manage anxiety A compulsion is a repetitive act. The client with a phobia is likely to experience unreasonable fears. Illusions are characterized by misinterpretation of events. An obsession is a repetitive thought.

The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.

Restating. Listening Maintaining neutral responses Providing acknowledgment and feedback Therapeutic communication techniques include listening, maintaining silence, maintaining neutral responses, using broad openings and open-ended questions, focusing and refocusing, restating, clarifying and validating, sharing perceptions, reflecting, providing acknowledgment and feedback, giving information, presenting reality, encouraging formulation of a plan of action, providing nonverbal encouragement, and summarizing. Asking why is often interpreted as being accusatory by the client and should also be avoided. Providing advice or giving approval or disapproval are barriers to communication.

The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit would expect to note which behaviors in the client?

Rigidness in thought and inflexibility Rigid and inflexible behaviors are characteristic of the client with obsessive-compulsive disorder (OCD). Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion because this behavior is what decreases the anxiety. None of the other options are associated with OCD.

A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement describes the nurse's obligation to the client?

Share that the risk to the client's safety requires that the client's PHCP be notified. In this situation, the nurse must override the duty to observe confidentiality and must notify the client's PHCP about the client's suicidal ideation. The nurse's first duty is to keep the client safe. None of the other options addresses the client's need for protection regarding his or their suicidal ideations.

The nurse is caring for a client just admitted to the mental health unit; the client is displaying immobile and mute behaviors and is withdrawn. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?

Sit beside the client in silence with occasional open-ended questions. Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. While overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis?

Somatization disorder Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. None of the other options are associated with loss of physical function.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?

Thank the client for the input, but inform the client that others now need a chance to contribute. If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed toward helping the client in a therapeutic manner.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?

The adolescent gives away a DVD and a cherished autographed picture of a performer. A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of an adolescent.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect?

The client giggled while describing being physically abused as a child. An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions.

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?

Use of confabulation The clinical picture of dementia ranges from mild cognitive deficits to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of something being "wrong" to the client's significant others (e.g., the client may undress in front of others, or the formerly well-mannered client may exhibit slovenly table manners). As the dementia progresses, the client will have difficulty sleeping and episodes of wandering or sundowning. Often, a lack of hygiene care may be noted in a client with dementia.

A client with an anxiety disorder is experiencing disturbed thought processes and believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat?

Using open-ended questions and silence Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are unhelpful to the client because they do not encourage the client to express feelings. The nurse would not offer opinions and would encourage the client to identify the reasons for the behavior.

Before giving the client the initial dose of disulfiram, what would the psychiatric home health nurse determine?

When the last alcoholic drink was consumed Disulfiram is an adjunctive treatment for some clients with chronic alcoholism to assist in maintaining enforced sobriety. Because clients must abstain from alcohol for at least 12 hours before the initial dose, the most important assessment is when the last alcoholic drink was consumed. The medication would be used cautiously in clients with hypothyroidism, diabetes mellitus, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in persons with severe heart disease, psychosis, or hypersensitivity to the medication. Food is not a consideration with this medication.

Which statement made by an assistive personnel (AP) indicates to the registered nurse that the AP understands the concepts related to suicide?

"Discussing suicide with a client is not harmful." An open discussion of suicide will not encourage a client to make a decision to commit suicide and in fact often will help to prevent it. Such a discussion offers the health care professional the opportunity to assess the reality of suicide for the client and take necessary precautions to keep the client safe. The remaining options are inaccurate statements regarding suicide.

The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk?

"Do you have a plan to commit suicide?" When assessing for suicide risk, the nurse must determine whether the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although the other options are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.

A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms?

"I am concerned about you. Are you now or have you ever been abused?" The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. The remaining options are insensitive, not focused on the possible sexual abuse, or too indirect to be useful.

What statement would the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety?

"I can see that you are becoming upset." The correct option is the only one that addresses the client's feelings and concerns. Avoid options that provide false reassurance and place the client's feelings on hold. Avoid options that ask "why"; this nontherapeutic communication technique will increase the client's anxiety.

The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a priority basis?

"I exercise 3 to 4 hours every day to keep my slim figure." Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to immediately assess this statement further to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check weight every day. Many clients with anorexia nervosa check their weight 20 times or more each day. A body weight 15% below the ideal weight or less is most significant with anorexia nervosa. Although it is unfortunate that the client's best friend had the disease, this is not considered a major threat to the client's physical well-being

A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met my partner. One of my parents beats me every day, and my other parent has sexually abused me since I was 10 years old!" Which response is appropriate for the nurse to make?

"It seems that you needed your partner's help to separate from your family." Adolescent pregnancy outside marriage can arise from low self-esteem, fears of inadequacy, and desperation to escape from an abusive and dysfunctional family. The most therapeutic communication technique is the one that uses restatement and repeats the main thought that the client expressed. This assures the client that the nurse is listening and is attempting to validate what the client has said. The remaining options are nontherapeutic because they reflect a knowledge deficit on the nurse's part, imply bias, are insensitive, or place responsibility on the adolescent.

The nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action?

Assess the client for organic causes of the paralysis. The initial nursing action would be to assess for any physiological causes of the paralysis. Although the client may be referred to a psychiatrist, this is not the initial action. It is inappropriate to encourage the client to use the arm without ruling out a physiological cause of the paralysis. Although a component of the plan of care would be to encourage the client to discuss feelings, this would not be the initial nursing action.

The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse would include which interventions in the plan of care? Select all that apply.

Assist the client in selecting foods from the food menu. Offer high-calorie fluids throughout the day and evening. Offer small high-calorie, high-protein snacks during the day and evening. In caring for a client with depression whose nutritional intake is poor, the nurse needs to remain with the client during the meal. The nurse also would assist the client in selecting foods from the menu because the client is more likely to eat the foods that they like. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.

Which activity would the nurse include in the plan of care for a client with mania who is experiencing psychomotor agitation?

Attending a clay-molding class that is scheduled for today When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include volleyball, finger painting, drawing, and working with clay. These activities provide an appropriate way for the client to discharge motor tension. Reading and simple card games are sedentary activities. Playing checkers requires concentration and more intensive use of thought processes.

The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention would the nurse include?

Avoid using a whisper voice in front of the client. Disturbed thought processes related to paranoid personality disorder are the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.

The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse would plan for which interventions that are associated with increased compliance? Select all that apply.

Including the family in the medication planning process Working with the psychiatrist to find the right medication at the right dose Providing the client with the injectable, long-acting form of the medication if available Working with the psychiatrist to find the medication that provides the least side effects for the client Including the family in the medication planning process; providing clients with the injectable, long-acting form of the medication; and finding the right medication at the right dose that provides the fewest side effects for the client are measures that will promote compliance. Not all medications can be given on a once-per-day dosing regimen because of their short half-life.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How would the nurse interpret this behavior as a cue to modify the treatment plan?

Increasing the level of suicide precautions A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm self. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse would plan to include which component as a priority in the plan of care?

Individualized goals and objectives The priority would be to develop individualized goals and objectives in the plan of care. Goals and objectives are a mutual working tool between the client and the nurse. Although the medical diagnosis of the client is considered in planning care, it is not specifically a component of a nursing care plan. Attendance at group therapy sessions and promotion of self-care measures may be components of the plan of care, but these interventions would follow after development of the goals and objectives.

The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action would the nurse engage in during the working phase of the nurse-client relationship?

Inquiring about and examining the client's feelings for any that may block adaptive coping The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply.

Looking at old photographs of family Participating in a senior citizens program Visiting the spouse's grave once a month Decorating a wall with the spouse's pictures and awards received Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate. When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

When would the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior?

No aggressive behavior has been observed for 1 hour after the release of two of the extremity restraints. The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. The remaining options do not ensure that the client has controlled the behavior.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?

Nonstop physical activity and poor nutritional intake Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?

Provide authority, action, and assistance with problem-solving. A crisis is an acute, time-limited state of disequilibrium resulting from situational, developmental, or societal sources of stress. A person in this state is temporarily unable to cope with or adapt to the stressor by using previous coping mechanisms. The person who intervenes in this situation (the nurse) "takes over" (authority) for the client who is not in control and devises a plan (action) to secure and maintain the client's safety. When this has occurred, the nurse works collaboratively with the client (assistance) in developing new coping and problem-solving strategies.

The nurse is developing a plan of care for a client with depression who is scheduled to have electroconvulsive therapy. Which problem is a priority for this client?

Risk for aspiration Priority is focused on physical problems. Aspiration is safeguarded against by keeping the client on nothing by mouth status for 6 to 8 hours before electroconvulsive therapy, removing dentures, and administering preprocedure medications as prescribed. Body image is not associated with this procedure. Although the remaining options could be appropriate problems, they are not the priority.

What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget?

Share the observation with the client so that the behavior can be recognized. Sharing observations with the client may help the client recognize and acknowledge feelings. Allowing the client to pace may also allow the client to get out of control. Moving to a quiet room or changing the subject will not help the client to recognize their behaviors and feelings.

A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action?

Sit and talk with the client about the feelings. The appropriate initial nursing action is to sit and talk with the client expressing anxiety. An assistive personnel is not prepared to deal with the client's anxiety. Antianxiety medication may be necessary, but this would not be the initial appropriate nursing action. While it may become necessary, calling the health care provider is premature initially.

The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder?

Somatization disorder Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.

Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply.

The average series involves 8 to 12 treatments. Amnesia may be noted after the procedure. Memory loss may occur but will resolve with time. Electroconvulsive therapy (ECT) as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered 3 times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client's condition.

Which assessment data would indicate that a client is most at risk for suicide?

The client has an immediate plan for a suicide attempt. Having a plan, particularly if the method is immediate and available, places the client at very high risk. Clients also at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse; those with a personal or family history of suicide attempts, depression, or alcoholism; or those with a history of psychotic episodes. Although impulsiveness, disorganization in actions and thoughts, and previous suicide attempts are related to suicide risk, these are not data that make the client most at risk from the options provided.

Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia?

The client's noncompliance with medication therapy Clients often forget to take their medications as scheduled, and this is the most prominent problem since medication therapy is vital to the function of clients with such a diagnosis. While the situations described in the remaining options may occur, these problems are not as impacting on the client's prognosis and can be addressed and often controlled.

The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle?

The group would be limited to no more than 10 members. The ideal number of clients in a psychotherapy group ranges from six to 10. Having more than 10 members is not recommended because the group will subdivide, which is counterproductive. Too large a group also can create more opportunities for acting out as opposed to working through issues. None of the other options is necessarily true.

A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study?

White blood cell count Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count needs to be assessed before initiation of treatment and would be monitored closely during the use of this medication. The client also would be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.

The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?

Writing Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.