Saunders Review Mental Health
A hospitalized client has begun taking bupropion as an antidepressant agent. The nurse determines that which is an adverse effect, indicating that the client is taking an excessive amount of medication? 1. Constipation 2. Seizure activity 3. Increased weight 4. Dizziness when getting upright
Answer: 2 Rationale: Seizure activity can occur in clients taking bupropion dosages greater than 450 mg daily. Weight gain is an occasional side effect, whereas constipation is a common side effect of this medication. This medication does not cause significant orthostatic blood pressure changes.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1.Communicate expected behaviors to the client. 2.Ensure that the client knows that they are not in charge of the nursing unit. 3.Assist the client in identifying ways of setting limits on personal behaviors. 4.Follow through about the consequences of behavior in a nonpunitive manner. 5.Enforce rules by informing the client that they will not be allowed to attend therapy groups. 6.Have the client state the consequences for behaving in ways that are viewed as unacceptable.
Answer : 1, 3, 4, 6 Rationale: Interventions for dealing with the client exhibiting manipulative behavior include setting clear, consistent, and enforceable limits on manipulative behaviors; being clear with the client regarding the consequences of exceeding the limits set; following through with the consequences in a nonpunitive manner; and assisting the client in identifying a means of setting limits on personal behaviors. Ensuring that the client knows that they are not in charge of the nursing unit is inappropriate; power struggles need to be avoided. Enforcing rules by informing the client that they will not be allowed to attend therapy groups is a violation of a client's rights.
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? 1. "I no longer feel that I deserve the beatings my partner inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my partner's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my partner." 4. "I can tolerate my partner's destructive behaviors now that I know they are common among alcoholics."
Answer: 1 Rationale: 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 that the nonalcoholic partner remains codependent.
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? 1. Milieu therapy 2. Interpersonal therapy 3. Behavior modification 4. Support group therapy
Answer: 1 Rationale: All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for clients to examine other relationships in their lives. Behavior modification is based on rewards and punishment. Support groups are based on the premise that individuals who have experienced and are insightful concerning a problem are able to help others who have a similar problem.
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff in caring for the client in a controlled environment. 4. Offer the client a less stimulating area in which to calm down and gain control.
Answer: 1 Rationale: Safety of the client and other clients is the immediate priority. The correct option is the only one that addresses the safety needs of the client as well as those of the other clients.
A client admitted voluntarily for treatment of an anxiety problem demands to be released from the hospital. Which action would the nurse take initially? 1. Contact the client's primary health care provider. 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay "for only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment.
Answer: 1 Rationale: In general, clients seek voluntary admission. Voluntary clients have the right to demand and obtain release, unless they pose an immediate danger to themselves or others, in which case the admission could become involuntary, depending on the circumstances and regulations in that area and facility. The nurse needs to be familiar with the state and facility policies and procedures. The initial nursing action is to contact the PHCP, who has the authority to discuss discharge with the client. While arranging for safe transportation is appropriate, it is premature in this situation and would be done only with the client's permission. While it is appropriate to discuss why the client feels the need to leave and the possible outcomes of leaving against medical advice, attempting to get the client to agree to staying "for only a few more days" has little value and is unlikely to be successful. Many states require that the client submit a written release notice to the facility psychiatrist, who reevaluates the client's condition for possible conversion to involuntary status if necessary, according to criteria established by law. While this is a possibility, it would not be used as a threat with the client.
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 would provide which intervention for this client? 1. Monitor closely for harm to self or others. 2. Assist in completing an application for admission. 3. Supply the client with written information about their mental health problem. 4. Provide an opportunity for family members to discuss why they felt the admission was needed.
Answer: 1 Rationale: Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment regardless of the client's willingness to consent to the hospitalization. A written request is a component of a voluntary admission. Providing written information regarding the mental health problem is probably premature initially. The family may have had no role to play in the client's admission.
A client taking lithium reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is 2.5 mEq/L (2.5 mmol/L). The nurse plans care based on which representation of this level? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal
Answer: 1 Rationale: Maintenance serum levels of lithium are 0.6 to 1.2 mEq/L (0.6 to 1.2 mmol/L). Symptoms of toxicity begin to appear at levels of 1.5 mEq/L (1.5 mmol/L). Lithium toxicity requires immediate medical attention and the primary health care provider is notified if symptoms of toxicity occur.
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention would the nurse initially implement? 1. Setting limits on the client's behavior 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions
Answer: 1 Rationale: Manic clients may be talkative and can dominate group meetings or therapy sessions by their excessive talking. If this occurs, the nurse initially would set limits on the client's behavior. Initially, asking the client to leave the session or asking another person to escort the client out of the session is inappropriate. This may agitate the client and escalate the client's behavior further. Barring the client from group sessions is also an inappropriate action because it violates the client's right to receive treatment and is a threatening action.
A hospitalized client with a history of alcohol use disorder tells the nurse: "I am leaving now. I must go. I do not 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 would the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the primary health care provider (PHCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.
Answer: 1 Rationale: Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client would be asked to wait to speak to the PHCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse would call the nursing supervisor. The nurse can be charged with false imprisonment if clients are made to believe wrongfully that they cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.
The nurse is planning care for a client being admitted to the nursing unit who attempted suicide. Which priority nursing intervention would the nurse include in the plan of care? 1. One-to-one suicide precautions 2. Suicide precautions with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking the client to report suicidal thoughts immediately
Answer: 1 Rationale: One-to-one suicide precautions are required for a client who has attempted suicide. Options 2 and 3 may be appropriate, but not at the present time, considering the situation. Option 4 also may be an appropriate nursing intervention, but the priority is identified in the correct option. The best intervention for clients who may attempt to harm themselves is constant supervision so that the nurse may intervene as needed.
A client experiencing disturbed thought processes believes that the food is being poisoned. Which communication technique would the nurse use to encourage the client to eat? 1. Using open-ended questions and silence 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat 4. Offering opinions about the necessity of adequate nutrition
Answer: 1 Rationale: 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 not helpful to the client because they do not encourage the client to express feelings. The nurse would not offer opinions and should encourage the client to identify the reasons for the behavior.
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information would be included in the discharge instructions? 1. Information regarding shelters 2. Instructions regarding calling the police 3. Instructions regarding self-defense classes 4. Explanation of the importance of leaving the violent situation
Answer: 1 Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse would provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the locations of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.
A client is unwilling to go to church because the ex-spouse goes there and the client feels that the ex-spouse will laugh at the client. Because of this hypersensitivity to a reaction from the spouse, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder? 1. Avoidant 2. Borderline 3. Schizotypal 4. Obsessive-compulsive
Answer: 1 Rationale: 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 preparing to attend a Gamblers Anonymous meeting for the first time. The nurse would plan to tell the client that which is the first step in this 12-step program? 1. Admitting to having a problem 2. Substituting other activities for gambling 3. Stating that the gambling will be stopped 4. Discontinuing relationships with people who gamble
Answer: 1 Rationale: 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.
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? Carol is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask Carol yourself." 3. "Only because you're worried about a friend, I'll tell you that Carol is improving." 4. "Being a friend, you know that Carol is having a difficult time and deserves privacy."
Answer: 1 Rationale: The nurse is required to maintain confidentiality regarding the client and the client's care. Confidentiality is basic to the therapeutic relationship and is a client's right. The most appropriate response to the neighbor is the statement of that responsibility in a direct, but polite manner. A blunt statement that does not acknowledge why the nurse cannot reveal client information may be taken as disrespectful and uncaring. The remaining options identify statements that do not maintain client confidentiality.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 4. Provide stimulation in the environment. 5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.
Answer: 1, 2, 3, 5 Rationale: 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 needs to be maintained.
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply. 1. Restating 2. Active listening 3. Asking the client "Why?" 4. Maintaining neutral responses 5. Providing acknowledgment and feedback 6. Giving advice and approval or disapproval
Answer: 1, 2, 4, 5 Rationale: 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 by the client as being accusatory and would also be avoided. Providing advice and giving approval or disapproval are barriers to communication.
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. 1. Dental decay 2. Moist, oily skin 3. Loss of tooth enamel 4. Electrolyte imbalances 5. Body weight well below ideal range
Answer: 1, 3, 4 Rationale: 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 would plan which goals for the termination stage of group development? Select all that apply. 1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with one another. 5. Some structuring of group norms, roles, and responsibilities takes place. 6. The group explores members' feelings about the group and the impending separation.
Answer: 1, 6 Rationale: The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with one another, and some structuring of group norms, roles, and responsibilities takes place. During the initial stage, group interaction involves superficial conversation. During the working stage, the real work of the group is accomplished. During the termination stage, the group evaluates the experience and explores members' feelings about the group and the impending separation.
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1. The adolescent runs out of the therapy group, swearing at the group leader. 2. The adolescent gives away a DVD and a cherished autographed picture of a performer. 3. The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4. The adolescent gets angry with a roommate who borrowed the client's clothes without asking.
Answer: 2 Rationale: A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 1, 3, and 4 deal with anger and acting-out behaviors that are often typical of an adolescent.
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? 1. Witnessing a murder 2. The death of a loved one 3. A fire that destroyed the client's home 4. A recent rape episode experienced by the client
Answer: 2 Rationale: A 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. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis or 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).
The nurse is describing the medication side and adverse effects to a client who is taking amitriptyline. Which information would the nurse incorporate in the discussion? 1. Consume a low-fiber diet. 2. Increase fluids and bulk in the diet. 3. Rest if the heart begins to beat rapidly. 4. Walk if you have difficulty urinating because this is a normal side effect.
Answer: 2 Rationale: Amitriptyline causes constipation, and the client is instructed to increase fluid intake and bulk (high fiber) in the diet. If the heart begins to beat fast, the primary health care provider (PHCP) is notified, because this could indicate an adverse effect. Difficulty urinating is an adverse effect and indicates urinary retention; this should also be reported.
A client who has been taking buspirone for 1 month returns to the clinic for a follow-up assessment. The nurse determines that the medication is effective if the absence of which manifestation has occurred? 1. Paranoid thought process 2. Rapid heartbeat or anxiety 3. Alcohol withdrawal symptoms 4. Thought broadcasting or delusions
Answer: 2 Rationale: Buspirone is not recommended for the treatment of paranoid thought disorders, drug or alcohol withdrawal, or schizophrenia. Buspirone most often is indicated for the treatment of anxiety.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes an interest in buying new clothes, but expresses that money is 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 personal caloric intake to 800 calories daily. How would the nurse evaluate this behavior? 1. Normal behavior 2. Evidence of the client's disturbed body image 3. Regression as the client is moving toward the community 4. Indicative of the client's ambivalence about hospital discharge
Answer: 2 Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
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? 1. Increase socialization of the client with peers. 2. Avoid using a whisper voice in front of the client. 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes.
Answer: 2 Rationale: Disturbed thought process related to paranoid personality disorder is 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 in the emergency department is caring for a young victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How would the nurse interpret these behaviors? 1. Signs of depression 2. Reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission
Answer: 2 Rationale: During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate an expected reaction. Options 1, 3, and 4 are incorrect interpretations.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention would the nurse implement initially? 1. Move the client next to the nurses' station. 2. Use an indirect light source and turn off the television. 3. Keep the television and a soft light on during the night. 4. Play soft music during the night, and maintain a well-lit room.
Answer: 2 Rationale: Provision of a consistent daily routine and a low-stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1. Suppressing feelings of anxiety 2. Identifying anxiety-producing situations 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily situations
Answer: 2 Rationale: 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.
A client's medication sheet contains a prescription for sertraline. To ensure safe administration of the medication, how would the nurse administer the dose? 1. On an empty stomach 2. At the same time each evening 3. Evenly spaced around the clock 4. As needed when the client complains of depression
Answer: 2 Rationale: Sertraline is classified as an antidepressant. Sertraline generally is administered once every 24 hours. It may be administered in the morning or evening, but evening administration may be preferable because drowsiness is a side effect. The medication may be administered without food or with food if gastrointestinal distress occurs. Sertraline is not prescribed for use as needed.
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? 1. Chess 2. Writing 3. Board games 4. Group exercise
Answer: 2 Rationale: 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 or are group activities and need to be avoided because they can stimulate aggression and increase psychomotor activity.
The nurse is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine. Which information would be important for the nurse to obtain during this client visit regarding specific side and adverse effects of the medication? 1. Renal dysfunctions 2. Gastrointestinal dysfunctions 3. Problems with mouth dryness 4. Problems with excessive sweating
Answer: 2 Rationale: Specific side and adverse effects related to fluoxetine include central nervous system and gastrointestinal system dysfunction. Fluoxetine affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea. Renal dysfunctions, dry mouth, and excessive sweating are not side and adverse effects associated with this medication.
The nurse notes that a client with schizophrenia who is receiving an antipsychotic medication is moving the mouth, protruding the tongue, and grimacing while watching television. The nurse determines that the client is experiencing which medication complication? 1. Parkinsonism 2. Tardive dyskinesia 3. Hypertensive crisis 4. Neuroleptic malignant syndrome
Answer: 2 Rationale: Tardive dyskinesia is a reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Parkinsonism is characterized by tremors, masklike facies, rigidity, and a shuffling gait. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity.
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-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? 1. A client with pneumonia 2. A client undergoing diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtime
Answer: 2 Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger.
The police arrive at the emergency department with a client who has lacerated both wrists. Which is the initial nursing action? 1. Administer an antianxiety agent. 2. Assess and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client to ventilate feelings.
Answer: 2 Rationale: The initial nursing action is to assess and treat the self-inflicted injuries. Injuries from lacerated wrists can lead to a life-threatening situation. Other interventions, such as options 1, 3, and 4, may follow after the client has been treated medically.
The nurse is teaching a client who is being started on imipramine about the medication. The nurse would inform the client to expect maximum desired effects at which time period following initiation of the medication? 1. In 2 months 2. In 2 to 3 weeks 3. During the first week 4. During the sixth week of administration
Answer: 2 Rationale: The maximum therapeutic effects of imipramine may not occur for 2 to 3 weeks after antidepressant therapy has been initiated. Options 1, 3, and 4 are incorrect time periods.
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation." Which is the most helpful response by the nurse? 1. "Why don't you tell your spouse about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation."
Answer: 2 Rationale: The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse would not agree with the client, and the nurse would not request that the client provide explanations.
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? 1. Ask the client why they started taking illegal drugs. 2. Ask the client about the amount of drug use and its effect. 3. Ask the client how long they thought that they could take drugs without someone finding out. 4. Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.
Answer: 2 Rationale: 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 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. 1. Initiate confinement measures. 2. Acknowledge the client's behavior. 3. Assist the client to an area that is quiet. 4. Maintain a safe distance from the client. 5. Allow the client to take control of the situation.
Answer: 2, 3, 4 Rationale: 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 calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. 1. Libel 2. Battery 3. Assault 4. Slander 5. False imprisonment
Answer: 2, 3, 5 Rationale: False imprisonment is an act with the intent to confine a person to a specific area. The nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. Assault and battery are related to the act of restraining the client in a situation that did not meet criteria for such an intervention. Libel and slander are not applicable here since the nurse did not write or verbally make untrue statements about the client.
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 would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply. 1. "I'm afraid of spiders." 2. "I keep reliving the robbery." 3. "I see that face everywhere I go." 4. "I don't want anything to eat now." 5. "I might have died over a few dollars in my pocket." 6. "I have to wash my hands over and over again many times."
Answer: 2, 3, 5 Rationale: Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with post-traumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.
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." Based on the client's behavior and statement, which intervention would the nurse include in the plan? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed
Answer: 3 Rationale: A client who is moderately depressed and has been in the hospital only 2 days is unlikely to have such a dramatic cure. When clients suddenly exhibit a lift in depression, it is likely that they may have made the decision to harm themselves. Suicide precautions are necessary to keep such clients safe. The remaining options are therefore incorrect interpretations.
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 mental health condition? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder
Answer: 3 Rationale: 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 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 appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli. 3. Sit beside the client in silence with simple open-ended questions. 4. Take the client into the dayroom with other clients to provide stimulation.
Answer: 3 Rationale: 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 simple open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although 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 client receiving tricyclic antidepressants arrives at the mental health clinic. Which observation would indicate that the client is following the medication plan correctly? 1. Client reports not going to work for the past week. 2. Client complains of not being able to "do anything" anymore. 3. Client arrives at the clinic neat and appropriate in appearance. 4. Client reports sleeping 12 hours per night and 3 to 4 hours during the day.
Answer: 3 Rationale: Depressed individuals sleep for long periods, are unable to go to work, and feel as if they cannot "do anything." When these clients have had some therapeutic effect from their medication, they report resolution of many of these complaints and exhibit an improvement in their appearance. Options 1, 2, and 4 identify continued depression.
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? 1. Requesting that a peer remain with the client at all times. 2. Removing the client's clothing and placing the client in a hospital gown. 3. Assigning to the client a staff member who will remain with the client at all times. 4. Admitting the client to a seclusion room where all potentially dangerous articles are removed.
Answer: 3 Rationale: 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 or 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 would be used.
A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern? 1. "I don't believe this is true." 2. "The guards are not out to kill you." 3. "Do you feel afraid that people are trying to hurt you?" 4. "What makes you think the guards were sent to hurt you?"
Answer: 3 Rationale: It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.
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? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "It sounds as if you are feeling angry that your family continues to hope for you to be cured." 4. "You are probably very depressed, which is understandable with such a diagnosis."
Answer: 3 Rationale: Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Although it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse's direct attempt to expect the client to talk more about the anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.
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? 1. Place the client in seclusion for 30 minutes. 2. Tell the client that the behavior is inappropriate. 3. Escort the client to their room, with the assistance of other staff. 4. Tell the client that their telephone privileges are revoked for 24 hours.
Answer: 3 Rationale: The client is at risk for injury to self and others and should 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
A victim of a sexual assault is being seen in the crisis center. The client states, "I still feel 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? 1. "You need to try to be realistic. The rape did not just occur." 2. "It will take some time to get over these feelings about your rape." 3. "Tell me more about the incident that causes you to feel as if the rape just occurred." 4. "What do you think that you can do to alleviate some of your fears about being raped again?"
Answer: 3 Rationale: The correct option allows the client to express ideas and feelings more fully and portrays an unhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem-solving totally on the client.
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? 1. "You need to stop that behavior now." 2. "You will need to be placed in seclusion." 3. "You seem restless; tell me what is happening." 4. "You will need to be restrained if you do not change your behavior."
Answer: 3 Rationale: The most appropriate statement is to ask the client what is causing the agitation. This will assist the client to become aware of the behavior and may assist the nurse in planning appropriate interventions for the client. Option 1 is demanding behavior that could cause increased agitation in the client. Options 2 and 4 are threats to the client and are inappropriate.
The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"
Answer: 3 Rationale: The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach? 1. Providing a supportive environment 2. Examining intrapsychic conflicts and past issues 3. Emphasizing social interaction with clients who withdraw 4. Helping the client to examine dysfunctional thoughts and beliefs
Answer: 4 Rationale: Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts. The remaining options, while therapeutic in certain situations, are not the focus of cognitive behavioral therapy.
The nurse is preparing a client with schizophrenia and 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? 1. "My medications will help my anxious feelings." 2. "I'll go to support group and talk about what I am feeling." 3. "When I have command hallucinations, I'll call a friend for help." 4. "I need to get enough sleep and eat well to help prevent feeling anxious."
Answer: 3 Rationale: The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, would be contacted to discuss whether the client has intentions for self-harm or to hurt others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.
A hospitalized client is started on a monoamine oxidase inhibitor (MAOI) for the treatment of depression. The nurse would instruct the client that which foods are acceptable to consume while taking this medication? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal raisin cookies
Answer: 3, 5 Rationale: With MAOIs, the client should avoid ingesting foods that are high in tyramine. Ingestion of these foods could trigger a potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; and fruits such as avocados, raisins, or figs.
A client with schizophrenia has been started on medication therapy with clozapine. The nurse would assess the results of which laboratory study to monitor for adverse effects from this medication? 1. Platelet count 2. Blood glucose level 3. Liver function studies 4. White blood cell count
Answer: 4 Rationale: A client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication.
A client is admitted to the mental health unit with a diagnosis of depression. The nurse would develop a plan of care for the client that includes which intervention? 1. Encouraging quiet reading and writing for the first few days 2. Identification of physical activities that will provide exercise 3. No socializing activities until the client asks to participate in milieu 4. A structured program of activities in which the client can participate
Answer: 4 Rationale: A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse would consider which factor? 1. A crisis state indicates that the client has a mental illness. 2. A crisis state indicates that the client has an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4. A client's response to a crisis is individualized, and what constitutes a crisis for one client may not constitute a crisis for another client.
Answer: 4 Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client, because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"
Answer: 4 Rationale: Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse would ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings.
The nurse is caring for a client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. Allow the client to complete the exercise program. 2. Interrupt the client and weigh the client immediately. 3. Tell the client that exercising rigorously is not allowed. 4. Interrupt the client and offer to take the client for a walk.
Answer: 4 Rationale: Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities. The correct option stops the harmful behavior yet provides the client with an activity to decrease anxiety that is not harmful. Weighing the client immediately reinforces the client's preoccupation with weight. Allowing the client to complete the exercise program can be harmful to the client. Telling the client that completing the exercise is not allowed will increase the client's anxiety.
A client gives the home health nurse a bottle of clomipramine. The nurse notes that the medication has not been taken by the client in 2 months. Which behavior observed in the client would validate noncompliance with this medication? 1. Complaints of insomnia 2. Complaints of hunger and fatigue 3. A pulse rate of less than 60 beats per minute 4. Frequent handwashing with hot, soapy water
Answer: 4 Rationale: Clomipramine is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Sedation sometimes occurs. Insomnia seldom is a side effect. Weight gain and tachycardia are side and adverse effects of this medication.
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1. Ask the client to leave the group for this session only. 2. Refer the client to another group that includes other manic clients. 3. Tell the client to stop monopolizing in a firm but compassionate manner. 4. Thank the client for the input, but inform the client that others now need a chance to contribute.
Answer: 4 Rationale: 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 because they are not directed toward helping the client in a therapeutic manner.
On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care, anticipating which client behavior? 1. Fearfulness regarding treatment measures 2. Anger and aggressiveness directed toward others 3. An understanding of the pathology and symptoms of the diagnosis 4. A willingness to participate in the planning of the care and treatment plan
Answer: 4 Rationale: 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 the client is 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 clients understand their mental health problems; it only indicates the client's desire for help.
A client is scheduled for discharge and will be taking phenobarbital for an extended period. The nurse would place highest priority on teaching the client which point that directly relates to client safety? 1. Take the medication only with meals. 2. Take the medication at the same time each day. 3. Use a dose container to help prevent missed doses. 4. Avoid drinking alcohol while taking this medication.
Answer: 4 Rationale: Phenobarbital is an anticonvulsant and hypnotic agent. The client should avoid taking any other central nervous system depressants such as alcohol while taking this medication. The medication may be given without regard to meals. Taking the medication at the same time each day enhances compliance and maintains more stable blood levels of the medication. Using a dose container or "pillbox" may be helpful for some clients.
A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which therapeutic response would the nurse make? 1. "You have everything to live for." 2. "Why do you see yourself as a failure?" 3. "Feeling like this is all part of being depressed." 4. "It sounds as if you've been feeling like a failure for a while."
Answer: 4 Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The remaining options block communication because they minimize the client's experience and do not facilitate exploration of the client's expressed feelings. In addition, use of the word why is nontherapeutic because clients frequently interpret why questions as accusations. Why questions can cause resentment, insecurity and mistrust.
The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction would the nurse provide to the client? 1. Get adequate sunlight. 2. Continue driving as usual. 3. Avoid foods rich in potassium. 4. Get up slowly when changing positions.
Answer: 4 Rationale: Risperidone can cause orthostatic hypotension. Sunlight should be avoided by clients taking this medication. With any psychotropic medication, individuals need to take caution with driving or other activities requiring alertness until they can determine whether their level of alertness is affected. Food interaction is not a concern.
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings would alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations
Answer: 4 Rationale: Symptoms associated with alcohol withdrawal delirium typically include hypertension, tachycardia, nausea and vomiting, tremors (especially in the hand), sweating, anxiety, agitation, tactile disturbances, hallucinations such as auditory or visual disturbances, headache, and disorientation.
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 plan to engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function 2. Exploring the client's potential for self-harm 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4. Inquiring about and examining the client's feelings for any that may block adaptive coping
Answer: 4 Rationale: 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 nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which therapeutic response would the nurse make? 1. "Really?" 2. "Why haven't you been able to sleep?" 3. "Sometimes I have trouble sleeping too." 4. "Tell me more about your sleep over the past few nights."
Answer: 4 Rationale: The correct option uses the therapeutic communication technique of exploring. Exploring is an important technique to use in examining experiences that are important to the client. The remaining options are nontherapeutic responses and are blocks to communication. Additionally, they do not encourage the client to expand on the problem. The response "Really?" can be interpreted by the client that the nurse is doubtful of what the client has expressed. Use of the word why is nontherapeutic because it may be interpreted as accusatory and can cause insecurity and mistrust. Offering personal experiences moves the focus away from the client and onto the nurse.
