saunders mental health

Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply.

- Electrolyte levels - Intake and output - Elimination patterns

Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply.

- Is related to abnormal melatonin metabolism - Improves during the spring and summer months - Is a result of alterations in the available amounts of sunlight - A craving for carbohydrates lessens during sunnier and spring months

Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply.

- Verbal communication is almost nonexistent. - The client needs frequent redirection because of short attention span.

adventitious crisis

- Witnessing a murder - A fire that destroyed the client's home - A recent rape episode experienced by the client

Which is the best therapeutic approach for the nurse to use in crisis counseling?

Active, with focus on the current situation

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. Which action should the nurse take at this time?

Call the nursing supervisor.

To create a safe environment for the client diagnosed with major depression with psychotic features, the nurse most importantly devises a plan of care that deals specifically with which problem?

Disturbed thinking

Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship?

Establishing the parameters of the relationship

The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primaryintervention?

Including the client's support system in the teaching

Which client behavior demonstrates denial of a sexual abuse event?

Sitting quietly and calmly reading a magazine

nyctophobia

fear of the dark

inappropriate affect

refers to an emotional response to a situation that is incongruent with the tone of the situation.

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

Dementia

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

Eating a lot of food in a short period of time and misuse of laxatives

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

"Discussing suicide with a client is not harmful."

Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning?

"My boss tells me that I'm being considered for a promotion and a raise."

Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initialnursing action?

Remain with the client until the anxiety decreases.

A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic?

"You need to grieve, and expressing anger can be part of grieving."

Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.

- Male gender - Abuses drugs as well as alcohol - History of at least one suicide attempt

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

Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply.

-The client will keep scheduled appointments. - The client's physical wounds will begin to heal properly. -The client will verbalize feelings about the abusive event. - The client will participate in the various aspects of the treatment plan.

Which roommate choice is least appropriate for a client diagnosed with anorexia nervosa who is in a state of starvation?

A client with pneumonia

A client admitted 72 hours ago with a diagnosis of major depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior?

Ask the client directly about the presence of any suicide-related thoughts.

When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration?

Assessing all activities for safety risks

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

Assure that an electrocardiogram is performed within 24 hours.

The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?

Atrophy of the lateral and/or third ventricles of the brain

The nursing care plan indicates a problem of self-directed violence and the risk for suicide, related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome?

Denies presence of suicidal ideations

The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking two packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury?

Diminishing the effectiveness of psychotropic medication

What is the priority nursing action when admitting a client who has just attempted suicide?

Ensure constant observation of the client at all times.

Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving?

Increased number of hours slept at one time and is increasingly alert

The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal?

Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis

The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind?

It sounds as though you are feeling all alone right now."

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

Making the client feel safe

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach?

Milieu therapy

When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?

Monitor closely for harm to self or others.

A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective?

My friends and I went out to lunch today."

The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?

Nausea, vomiting, diarrhea, muscle aches, and diaphoresis

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 participation.

The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine that which action is the priority of care at this time?

Providing a safe place for the client to pace that is away from the other clients

A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action?

Providing the clients with shelter, clothing, and food

The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which medical diagnosis, if noted on the client's record, would indicate a need to contact the health care provider scheduled to perform the ECT?

Recent myocardial infarction

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.

A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time?

Remaining with the client

During a group session, a client threatens to "punch every one of you." Which is the appropriate initial nursing action?

Remind the client that talking about personal anger is appropriate, but acting on it is not.

The nurse is creating a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care?

Reward the client when a desired behavior is performed.

An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client?

Risk for self-harm

Which client's death was achieved by what is considered a soft suicide method?

Sat in a running car parked in her locked garage to die of the carbon monoxide inhalation

A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy?

Short exposure to the phobic object

A client is withdrawn, immobile and mute. Which appropriate action should the nurse should take?

Sit beside the client and occasionally introduce open-ended questions.

The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Based on this fact, what assumption can the nurse make about the client?

The client has the right to demand and obtain release from the hospital.

Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli?

The client is convinced that the curtains are actually ghosts.

What is an appropriate short-term outcome for a client grieving the recent loss of a spouse?

The client verbalizes stages of grief and plans to attend a community grief group.

A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on?

The client's physical condition

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication?

Wernicke-Korsakoff syndrome

A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time?

What is causing you to behave so agitated?"

The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency?

When asked to pick up the cup, the client consistently fails to identify the cup.

Which is a primary behavior of a client diagnosed with antisocial personality disorder?

Will take personal items from other clients' rooms

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

The client diagnosed with mild depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue?

You haven't had an appetite at all?"

Hard suicide methods

include using a gun, jumping off a high place such as a bridge, hanging, and staging a car crash.

dependent personality

is the inability to make decisions with excessive dependence on others.

Operant conditioning

rewarding a client for desired behaviors and is the basis for behavior modification. It uses a positive reinforcement approach

confabulation

the act of filling in memory gaps by making up stories

soft suicide methods

those that are painless and include ingesting pills, or inhaling natural gas or carbon monoxide.

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.

When planning care for a client with a history of violent behavior toward others, the nurse should include which interventions? Select all that apply.

- Admitting the client to a room near the nurses' station - Arranging for a security officer to be nearby and available but out of the client's sight

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 should the nurse plan to respond to the client's statement?

Identify recent behaviors or accomplishments that demonstrate the client's skills.

During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response?

"Have you shared your concerns with the police?"

The client who is actively hallucinating is fearful that the voices will direct him to kill himself. Which therapeutic statement should the nurse make at this time?

"I don't hear them, but it must be frightening to hear voices that others can't hear."

The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?

"I don't know about a religious cult. Are you afraid that people are trying to hurt you?"

The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia?

Coffee, tea, and soda consumption should be limited.

The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation?

Making decisions about living arrangements after discharge

When a client is consistently 15 to 20 minutes late for weekly therapy sessions, the nurse attempts to best manage this behavior by implementing which intervention?

asking the client if she or he is dealing with some new stressor

A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the client is calm, the daughter anxiously tells the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which response by the nurse will best address the daughter's concerns?

"It sounds as though you are very concerned. Let's discuss the procedure."

During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likelythe result of which client factor?

Impaired pain perception

Which interventions should the nurse include in the plan of care for an acutely depressed client involved in cognitive-behavioral therapy? Select all that apply.

- Assisting the client to identify and test negative cognition - Assisting the client to participate in the treatment process - Assisting the client to develop alternative thinking patterns - Assisting the client to rehearse new cognitive and behavioral responses

The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction?

Impaired wound healing

The client asks the nurse, "Could you ask the health care provider (HCP) to let me have a pass for the weekend?" Which response is appropriate that assists the client in achieving the goal of optimal personal functioning?

"When the HCP arrives on the unit, I will let them know that you have a question."

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply.

- A birthday of March 30 - A loss of interest in hobbies - A suicide attempt 6 months ago - Magnetic resonance imaging shows temporal lobe atrophy

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?

"I hear what you are saying, but I have no reason to believe your roommate steals."

The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding?

Fist clenched, pounding table, fearful

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 health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?

An expected coping mechanism

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

adventitious crisis

a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior 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."

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."

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

"You're wearing a new blouse."

The nurse creating a plan of care for the client demonstrating paranoia should 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.

The nurse is preparing a client 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.

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

- The average series involves 8 to 12 treatments. - Some confusion may be noted after the procedure. - Memory loss will occur but will resolve with time

The nurse should plan which goals of the termination stage of group development? Select all that apply.

- the group evaluates the experience. - The group explores members' feelings about the group and the impending separation.

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

The nurse in the mental health unit is performing an assessment in 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

agnosia

the inability to identify well-known objects and people.

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 should be limited to no more than 10 members.

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

Somatization disorder

is characterized by a long history of multiple physical problems with no satisfactory organic explanation. Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. A psychological issue that causes to report physical symptoms such as pain

incongruent

is not the same, not compatible or out of place.

Which statement by the client best reflects the development of an effective coping response style and effective processing of information for a hospitalized client participating in Alcoholic Anonymous (AA)?

"I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people."

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 breech of boundaries?

"The focus of today's session is on your issues, so let's get started."

Which client is at greatest risk for committing suicide?

A client with metastatic cancer

A flat affect is manifested as an immobile facial expression or blank look

A flat affect is manifested as an immobile facial expression or blank look

A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem?

"I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep.

The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for acute depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment?

"I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."

A client admitted to the mental health unit after attacking his father for disturbing him at his computer, interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact?

"I will be back to talk with you in 15 minutes after I complete nursing rounds."

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."

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?

"Tell me more about the incident that causes you to feel like the rape just occurred."

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 go straight." Which response by the nurse would be therapeutic?

"Tell me what makes you feel that you are ready.

The nurse is preparing a client with a history of command hallucinations for discharge by 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 him what I should do."

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

"Wouldn't you want to know if your daughter was having difficulties so you could help if you could?"

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

1 week after the 3rd treatment session

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?

A client undergoing diagnostic tests rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia.

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.

A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?

Evidence of the client's disturbed body image

The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate?

Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now 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

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

Progressive muscle relaxation techniques are useful for easing tension from many causes.

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?

The death of a loved one

Psychomotor agitation

is a symptom related to a wide range of mood disorders. People with this condition engage in movements that serve no purpose. Examples include pacing around the room, tapping your toes, or rapid talking. Psychomotor agitation often occurs with mania or anxiety.

Retrograde amnesia

difficulty recalling information learned before ECT. This kind of amnesia may be long-term

The nurse suspects that the client hospitalized with a diagnosis of acute depression could benefit from further development of coping strategies. Which client statement supports this suspicion?

"I know that I won't become depressed again as long as I reduce my stressors."

The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the besttherapeutic value?

"Do you recall what it was like before you started your medication?"

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

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."

The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse?

"Our relationship is a therapeutic and helping one."

Milieu therapy

"therapeutic community," has as its focus a living, learning, or working environment

The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse should 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

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

- Loss of tooth enamel -Electrolyte imbalances - Dental decay

A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which are the most realistic goals for this client? Select all that apply.

- The client will develop adaptive coping patterns. - The client will identify a realistic perception of stressors - The client will express and share feelings regarding the present crisis. - The client will identify effective coping patterns that have worked in the past.

The nurse is creating a plan of care for a newly admitted client at high risk for suicide. With the focus of the plan being to promote a safe and therapeutic environment, which intervention should the nurse include?

Establish a therapeutic relationship.

A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior?

The client will employ new coping methods that will resolve the problem.

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

Attending a clay-molding class that is scheduled for today

Which goal addresses the therapeutic management needs of a client experiencing hallucinations?

Facilitate the client's awareness that the hallucination is not the reality of the world.

A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for?

Fever, hypertension, changes in level of consciousness, and hallucinations

A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion?

Gathering subjective and objective assessment from the caregiver and the client

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 should the nurse interpret this behavior as a cue to modify the treatment plan?

Increasing the level of suicide precautions

The nurse orienting a new client to a residential treatment center prepares to explain to the client that the emphasis of the center involves milieu therapy. Which is the focus of this type of therapy?

Involves group and social interaction with rules and expectations mediated by peer pressure

Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety?

Is pacing while describing the situation using a rapid speech pattern

A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor?

Lack of naturally occurring endorphins

Several nurses are engaged in an assignment report when a client with a history of aggressive behavior approaches the nurses' station. The client becomes very loud and offensive, and demands to be seen by the health care provider (HCP) immediately. Which intervention will address the needs of both the client and the milieu?

Offer to assist the client to an examination room until the HCP is notified.

The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking?

Present verbal instructions regarding expectations in single, simple commands.

The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client?

Provide a structured daily program of activities, and encourage the client to participate.

The nurse caring for a client with a diagnosis of acute schizophrenia should use which approach when planning care?

Provide assistance with grooming and nutrition until the client's thinking has cleared.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?

Removing the client from any immediate danger

The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms?

Signs may appear at any time.

A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement?

The charge nurse blames staff for wasting supplies.

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.

The nurse should interpret which comment by a client diagnosed with battered wife syndrome as being consistent with the presence of low self-esteem?

Things would be fine at home if I just could do better. He has a lot of pressures on him at work."

An adolescent has been prescribed an amphetamine to help manage a diagnosis of attention deficient hyperactivity disorder. To best minimize the risk of abuse and/or overdose, the nurse expects that the medication will be administered via which method?

Transdermal patch

An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury?

Turn off the television and radio, and use a night-light.

A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initialintervention?

Turn off the television.

alcohol withdrawal delirium symptoms

delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions.

Which statement by the nurse indicates a need for further teaching concerning family violence?

"Abusers are more often from low-income families."

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

"It seems that you needed Bobby's help to separate from your family

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

When the last alcoholic drink was consumed

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

The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse?

"What do you find difficult about this situation?"

A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?

"You're feeling angry that your family continues to hope for you to be cured?"

The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should 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.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

- Communicate expected behaviors to the client. - Assist the client in identifying ways of setting limits on personal behaviors. - Follow through about the consequences of behavior in a nonpunitive manner. - Have the client state the consequences for behaving in ways that are viewed as unacceptable.

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.

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

- Panic disorder - Posttraumatic stress disorder - Obsessive-compulsive disorder

The nurse is reviewing the medical record of a hospitalized client who received electroconvulsive therapy (ECT) 3 years ago. Which assessment data would support that the therapy resulted in retrograde amnesia in the client?

During the admission interview, the client can't remember why the ECT treatment was originally prescribed.

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 hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?

Call the nursing supervisor.

A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in 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 should be the focus of this consult?

Conversion disorder

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

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

Hypertension, changes in level of consciousness, hallucinations

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriatenursing intervention?

Sit beside the client in silence with occasional open-ended questions.

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 should plan to include which component as a priority in the plan of care?

Individualized 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 should 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 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

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

The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition?

Restrict the amount of chocolate and caffeine products in the home.

The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement?

Setting limits on the client's behavior

Agoraphobia

a fear of leaving the house and experiencing panic attacks when doing so.

A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of posttraumatic stress disorder? Select all that apply.

- I keep reliving the robbery." - "I see his face everywhere I go." - "I might have died over a few dollars in my pocket."

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 their safety requires that the client's HCP be notified.

situational crisis

arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness.

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

Share the observation with the client so the behavior can be recognized.