Treatment of Mental Health Disorders (Psychiatric/ Mental Health Nursing)

A client who uses a complex ritual says to the nurse, "I feel so guilty. None of this makes any sense. Everyone must really think I'm crazy." What is the most therapeutic response by the nurse? "Your behavior is bizarre, but it serves a useful purpose." "You're concerned about what other people are thinking about you." "I am sure people understand that you can't help this behavior right now." "Guilt serves no useful purpose. It just helps you stay stuck where you are."

"You're concerned about what other people are thinking about you." Rationale Paraphrasing encourages further ventilation of feelings and concerns by the client. Telling the client that the behavior is bizarre but that it serves a useful purpose is a negative response that may increase the client's fears about being "crazy." Saying "I'm sure people understand that you can't help this behavior right now" provides false reassurance and implies that the client is out of control, which may increase the fears. Telling the client that guilt serves no useful purpose and just helps the client stay stuck denies the client's feelings.

An older adult is brought to the clinic by a family member because of increasing confusion over the past week. What can the nurse ask the client to do to assess orientation to place? Explain a proverb. Give the state where the client was born. Identify the name of the clinic's town. Recall what the client ate for breakfast.

Identify the name of the clinic's town. Rationale Orientation to place refers to an individual's awareness of the objective world in its relation to the self; orientation to time, place, and person is part of the assessment of cerebral functioning. Asking the client the name of the town the clinic is in assesses this. Explaining a proverb requires abstract thinking, which involves a higher integrative function than does orientation to place. Having the client state where the client was born helps the nurse assess remote memory, not orientation. Having the client recall what was eaten for breakfast helps assess recent memory, not orientation.

What should the nurse include in the plan of care for a client with dementia of the Alzheimer type, stage 2 (moderate dementia)? Discuss recent current events. Teach the client new social skills. Maintain a daily routine of living. Encourage the client to talk about past experiences.

Maintain a daily routine of living. Rationale The client with this disorder will be most comfortable with a familiar and repetitive daily routine because it will produce less anxiety. Cognitive changes probably make a discussion of current events unrealistic. It probably is beyond the client's capability to develop new social skills. Memory impairment may make talking about past events impossible.

A client who was hospitalized with severe anxiety is ready to be discharged. What priority outcome has been met? Follows rules of the milieu Maintains anxiety at a manageable level Verbalizes positive aspects about the self Recognizes that hallucinations can be controlled

Maintains anxiety at a manageable level Rationale Maintenance of anxiety at a manageable level results from teaching the client to recognize situations that provoke anxiety and how to institute measures to control its development. Following the rules of the milieu and verbalizing positive aspects about the self are not priorities; the client has probably had little difficulty in these areas. No evidence was presented to indicate that the client is hallucinating.

A nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client? Reward healthy behaviors. Explain the treatment plan. Identify various means of coping. Encourage participation in community meetings.

Reward healthy behaviors. Rationale By realistically rewarding the healthy behaviors, the nurse provides secondary gains and encourages the continued use of healthy behaviors. Explaining the treatment plan, identifying various means of coping, and encouraging participation in community meetings are important but will do little to increase the client's self-esteem.

Two 14-year-old girls are best friends and always eat lunch together at school. One of the girls eats rapidly and then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do? Confront her friend with her suspicions. Talk to the school nurse about her concerns. Inform the girl's mother about her daughter's behavior. Watch a while longer before doing anything that might ruin the friendship.

Talk to the school nurse about her concerns. Rationale The adolescent is exhibiting signs of bulimia nervosa. The school nurse is an appropriate resource for the friend and has the responsibility for intervening, because purging can lead to malnutrition and electrolyte imbalances, which are life threatening. The friend does not have the expertise to intervene. Waiting any longer may jeopardize the health of her friend.

One morning a nurse on the psychiatric unit finds a client curled up in the fetal position in the corner of the dayroom. What is an appropriate initial inference for the nurse to make about the client? The client is feeling more anxious today. The client is trying to hide from the staff. The client is tired and probably did not sleep well last night. The client is physically ill and experiencing abdominal discomfort.

The client is feeling more anxious today Rationale The fetal position represents regressive behavior; regression is a way of responding to overwhelming anxiety. No data are available to indicate that the client is trying to hide, is tired, or is physically ill; further assessment would be necessary to support these other interpretations.

How should a nurse intervene when a confused and anxious client voids on the floor in the sitting room of the mental health unit? Make the client mop the floor. Restrict the client's fluids for the rest of the day. Toilet the client more frequently with supervision. Withhold the client's privileges each time the client voids on the floor.

Toilet the client more frequently with supervision. Rationale The client is voiding on the floor not to express hostility but because of confusion. Taking the client to the toilet frequently reduces the risk of voiding in inappropriate places. Making the client mop the floor is a form of punishment for something the client cannot control. Restricting the client's fluids for the rest of the day is not realistic; it will have no effect on the problem and may lead to physiologic problems. If the client were doing this to express hostility, withholding privileges might be effective, but not when the client is unable to control the behavior.

A mother calls the emergency department and speaks to a nurse. Her 16-year-old daughter has just been found in her bedroom cutting her wrists. The mother says, "They're just superficial cuts; the old ones have healed just fine." The mother states that the daughter has had three previous psychiatric admissions for suicide attempts and says that "this situation is pretty much like the other times. I'm not sure whether I should bring her in tonight or tell her primary healthcare provider about what happened at her next appointment, later this week." What is the best reply by the nurse? "You should call 911 now and let them know that your daughter has made a suicide attempt and needs help." "You should let your daughter's primary healthcare provider know about this occurrence in the morning and see whether the provider wants you to make an appointment for her tomorrow." "It sounds like you're very experienced with this situation. You can probably talk to her at home and see whether she'll tell you why she decided to cut herself." "Call her primary healthcare provider in the morning and let the provider know what has happened. Don't have any further conversations about suicide, because you don't want to give her any more ideas about hurting herself."

"You should call 911 now and let them know that your daughter has made a suicide attempt and needs help." Rationale No matter how irritated a family member may be or how trivial the suicide attempt might seem, the attempt must be taken seriously. The daughter is communicating that she is unable to find a way out of a desperate situation or state of mind. The primary healthcare provider should be made aware of the situation, but the daughter still requires immediate attention and evaluation by trained medical personnel.

What clinical manifestation best indicates to the nurse that the mental status of a client with the diagnosis of schizophrenia, paranoid type, is improving? Absence of mild to moderate anxiety Development of insight into the problem Decreased need to use defense mechanisms Ability to function effectively in activities of daily living

Ability to function effectively in activities of daily living Rationale A person who can handle the activities of daily living and function in society is considered mentally stable. Some anxiety is necessary and unavoidable; anxiety causes problems when it is overwhelming for an extended period. Insight into one's problems is of no use if one is unable to function in society. Everyone uses defense mechanisms; the extent to which they are used helps determine mental health.

A client with an obsessive-compulsive disorder continually walks up and down the hall, touching every other chair. When unable to do this, the client becomes upset. What should the nurse do? Distract the client, which will help the client forget about touching the chairs Encourage the client to continue touching the chairs as long as the client wants until fatigue sets in Remove chairs from the hall, thereby relieving the client of the necessity of touching every other one Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed

Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed Rationale It is important to set limits on the behavior, but it is also important to involve the client in the decision-making. Distracting the client, which will help the client forget about touching the chairs, is nontherapeutic; rarely can a client be distracted from a ritual when anxiety is high. Encouraging the client to continue touching the chairs for as long he desires until fatigue sets in is a nontherapeutic approach; some limits must be set by the client and nurse together. Removing chairs from the hall, thereby relieving the client of the necessity of touching every other one, will increase the client's anxiety because the client uses the ritual as a defense against anxiety.

A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client? Double bind Ambivalence Loose association Inappropriate affect

Ambivalence Rationale Ambivalence is the existence of two conflicting emotions, impulses, or desires. Double bind is two conflicting messages, not emotions, in a single communication. Loose associations are not two conflicting emotions but instead the loosening of connections between thoughts. Inappropriate affect is the inappropriate expression of emotions.

A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce this physiological response to stress? Limiting discussions about the problem Providing information regarding medical care Teaching the client how to eliminate stress at home Assisting the client in developing new coping mechanisms

Assisting the client in developing new coping mechanisms Rationale Until the client learns new ways of coping with stress and anxiety, this pattern of behavior will continue. Learning new ways of coping with stress will help break this physiological pattern. Limiting discussion will avoid the problem. Providing information about medical care will reinforce the sick role. A certain amount of stress is present in everyday family situations; the elimination of stress is impossible.

A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention? Encouraging the client to try to walk Explaining to the client that there is nothing wrong Avoiding focusing on the client's physical symptoms Helping the client follow through with the physical therapy plan

Avoiding focusing on the client's physical symptoms Rationale The physical symptoms are not the client's major problem and therefore should not be the focus of care. This is a psychological problem, and the focus should be in this domain. Encouraging the client to try to walk is focusing on the physical symptom of the conflict; the client is not ready to give up the symptom. The disorder operates on an unconscious level but is very real to the client; saying there is nothing wrong denies feelings. Psychotherapy, not physical therapy, is needed at this time.

When talking with the nurse, a client with a mood disorder says, "I feel rotten. I feel useless. I can't think straight. I feel overwhelmed by everything. I don't know if I can go on." What should the nurse document when describing this encounter? Client stated, "I can't think straight," and is not able to cope with current problems. Client appeared to be very depressed for most of the morning and has little interest in self or the environment. Client expressed suicidal thoughts about not being able to go on and exhibits diminished ability to think clearly. Client stated, "I feel rotten. I feel useless. I can't think straight. I feel overwhelmed by everything. I don't know if I can go on."

Client stated, "I feel rotten. I feel useless. I can't think straight. I feel overwhelmed by everything. I don't know if I can go on." Rationale Directly quoting the client, with no added value judgments, is an objective documentation of what happened. Writing down part of what the client said ("I can't think straight") and then concluding that the client can't cope reflects a subjective judgment and an interpretation of what the client actually said. Noting that the client appeared very depressed for most of the morning and showed little interest in self or the environment is a subjective judgment and an interpretation of what the client actually said. Documenting that the client expressed suicidal thoughts about not being able to go on and has a decreased ability to think clearly is a subjective judgment and an interpretation of what the client actually said.

A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate? Loss of appetite Postural hypotension Total memory loss Confusion immediately after the treatment

Confusion immediately after the treatment Rationale The electrical energy passing through the cerebral cortex during ECT results in a temporary state of confusion after treatment. Loss of appetite, postural hypotension, and total memory loss are not usual or expected side effects. Memory loss is usually restored after a few months of treatment.

A depressed, withdrawn client exhibits sadness through nonverbal behavior. What should the nurse plan to help the client to do? Increase structured physical activity. Cope with painful feelings by sharing them. Decide which unit activities the client can perform. Improve the ability to communicate with significant others.

Cope with painful feelings by sharing them. Rationale Sharing painful feelings reduces the isolation and sense of uniqueness that these feelings can cause; sharing of these feelings usually decreases depression. Increasing structured physical activity will do little to decrease the client's sadness and does not consider the client's low level of energy. Improving the client's ability to communicate with significant others may be important for the future, if a problem exists, but the sharing of painful feelings is more important than improving communication.

A client is experiencing feelings of sadness and is having difficulty concentrating and sleeping. What are additional common signs and symptoms of depression that the nurse should expect when performing an assessment of this client? Rigidity and a narrowing of perception Alternating episodes of fatigue and high energy Diminished pleasure in activities and alteration in appetite Excessive socialization and interest in activities of daily living

Diminished pleasure in activities and alteration in appetite Rationale Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. There is a loss of interest in socialization and little participation in activities of daily living.

A client is admitted to the mental health unit because of a progressively increasing depression over the past month. What clinical finding does a nurse expect during the initial assessment of the client? Elated affect related to reaction formation Loose associations related to thought disorder Physical exhaustion resulting from decreased physical activity Diminished verbal expression caused by a slowed thought process

Diminished verbal expression caused by a slowed thought process Rationale As depression increases, the thought process becomes slower and verbal expression decreases. The affect of the depressed person is usually one of sadness, or it may be blank. Loose associations are characteristic of clients with schizophrenia, not depressed clients. Decreased physical activity does not produce physical exhaustion.

To further assess a client's suicidal potential, the nurse should be especially alert to the client's expression of what? Anger and resentment Loneliness and anxiety Frustration and fear of death Helplessness and hopelessness

Helplessness and hopelessness Rationale The expression of helplessness and hopelessness may indicate that this client is unable to continue the struggle of life. Anger and resentment are not indications of potential suicide; the client is still responding to the world, not attempting to leave it. Loneliness and anxiety are usually not sufficient to precipitate a suicide attempt. The client attempting suicide usually sees death as a release.

A client with moderate dementia often assaults nursing staff, and the staff members decide to develop a plan to minimize this behavior. What should the plan include? Limiting the time staff and the client spend together An outline of the consequences for uncooperative behavior The client's preferences for use as a reward or a punishment Identification of nursing staff members whom the client prefers

Identification of nursing staff members whom the client prefers Rationale The type of care needed by the client requires trust in the caregiver, which develops more rapidly when there is a cooperative relationship and client input is accepted. Limiting staff time may place the client in jeopardy. The staff should not be put in the position of punishing the client; the client with dementia cannot be held responsible for uncooperative behavior. Clients with moderate dementia will not remember and learn from a reward system.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. Dementia Multiple losses Declines in health A milestone birthday An injury requiring hospitalization

Multiple losses Declines in health Rationale Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

A male client with a history of schizophrenia comes to the emergency department, accompanied by his wife. What is the emergency department nurse's priority intervention? Observing and evaluating his behavior Writing a plan of care for the mental health team Obtaining a copy of the client's past medical records Meeting separately with his wife and exploring why he came to the hospital

Observing and evaluating his behavior Rationale The client and his needs are the priority, and assessment is the first step of the nursing process. Writing a plan of care for the mental health team is done after a thorough assessment is completed. The nurse must deal with the present, not the past. Although meeting separately with the wife should be done, it is not the priority.

A client exhibiting manic behavior is admitted to the psychiatric hospital. In which room should the nurse manager place the client? One that has basic simple furnishings One that will provide a variety of stimuli One with another client who is very quiet One with another client exhibiting similar behavior

One that has basic simple furnishings Rationale Overactive individuals are stimulated by environmental factors. One responsibility of the nurse is to simplify their surroundings as much as possible. During this phase the client needs a decrease in stimuli. The quiet client may become the target of this client's overactivity. Placing two overactive clients together may produce excessive stimulation.

A nurse is planning care for a client admitted to the unit with a diagnosis of bipolar disorder, manic phase. In which type of room should the nurse tell the admissions clerk to place this client? Private Isolation Semi-private Negative-airflow

Private Rationale The client who is manic needs a nonstimulating environment. A person who is bipolar is not contagious and does not require an isolation room. The presence of another person in the room is considered stimulating and may interfere with the rest and sleep of both clients. A client who is bipolar does not need a negative-airflow room. This type of room is appropriate for a client with a communicable disease, such as tuberculosis, that requires airborne precautions.

A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory? Subtract serial sevens from 100. Copy one simple geometric figure. State three random words mentioned earlier in the exam. Name two common objects when the nurse points to them.

Rationale Stating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. Copying one simple geometric figure is a test of visual comprehension. Naming two common objects when the nurse points to them is a test of verbal skills to identify aphasia.

A client is found to have generalized anxiety disorder. For what behavior should the nurse assess the client to determine the effectiveness of therapy? Participating in activities Learning how to avoid anxiety Taking medications as prescribed Recognizing when anxiety is developing

Recognizing when anxiety is developing Rationale Recognition of anxiety or symptoms of increasing anxiety is an indication that the client is improving. Avoidance of anxiety is not a good indication of improvement; there is no guarantee that anxiety can always be avoided. Participating in activities and taking medications as prescribed do not indicate improvement or recognition of feelings; the client may be doing what others expect.

A nurse is working in the orientation phase of a therapeutic relationship with a client who has borderline personality disorder. What will be most difficult for the client at this stage of the relationship? Controlling anxiety Terminating the session on time Accepting the psychiatric diagnosis Setting mutual goals for the relationship

Setting mutual goals for the relationship Rationale Clients with borderline personality disorder frequently demonstrate a pattern of unstable interpersonal relationships, impulsiveness, affective instability, and frantic efforts to avoid abandonment; these behaviors usually create great difficulty in establishing mutual goals. Although the client with a borderline personality disorder may have difficulty in the areas of controlling anxiety, ending sessions on time, and accepting the diagnosis, none is the most significant issue.

What is a therapeutic nursing action in the care of a depressed client? Playing a game of chess with the client Allowing the client to make personal decisions Sitting down next to the client at frequent intervals Providing the client with frequent periods of time for reflection

Sitting down next to the client at frequent intervals Rationale Sitting down next to the client at frequent intervals gives the client the nonverbal message that someone cares and views the client as being worthy of attention and concern. The concentration required for chess is too much for the client at this time. The client is incapable of making decisions at this time. Depressed clients often have too much thinking time.

On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be? Ignoring the client at this time Stating that this behavior is unacceptable Moving him to his room for a short time-out Telling the client to come to the office later to discuss the behavior

Stating that this behavior is unacceptable Rationale When clients enter a new milieu, limits should be set on unacceptable behavior and acceptable behavior should be reinforced. Neither clients nor unacceptable behavior should ever be ignored. Moving the client to his room for a short time-out is punishment. Unacceptable attention-getting behavior must be addressed immediately; also, the focus should be on appropriate behavior.

A client scheduled to begin electroconvulsive therapy (ECT) to treat severe depression that has not responded to any of the antidepressant medications tells the nurse, "I'm scared that I'll lose my memory forever after the treatment." What is the most therapeutic response by the nurse? "Your memory loss may be permanent, but usually it's just temporary." "You won't experience a permanent memory loss, so there's no need to be frightened." "You'll experience a temporary loss of memory, and feeling frightened about it is expected." "Your memory loss will be temporary, and it will help block out many of your painful past experiences."

"You'll experience a temporary loss of memory, and feeling frightened about it is expected." Rationale Giving the client simple facts and assuring the client that being frightened is expected may help ease the client's fears. Memory loss affects recently learned information such as the ECT experience; the response that it may be permanent may unnecessarily worry the client. Although it is a true statement that memory loss is not permanent and there is no need to worry, this response negates the client's feelings. ECT does not selectively block out painful experiences.

A nurse enters a depressed client's room on the evening of admission and observes the client sitting in a chair crying. What is the most therapeutic response by the nurse? "You're crying. Let's talk about it." "Let me get a cup of coffee; then we can talk." "Visitors will be here soon; you'd better get ready." "You'll feel better soon. Come to the sitting room with me."

"You're crying. Let's talk about it." Rationale Noting that the client is crying and suggesting that the nurse and client talk about it addresses the behavior observed, and the offer by the nurse to spend time to help the client implies that the client is worthy. With "Let me get a cup of coffee; then we can talk" the nurse offers to help but places the client second by stating the desire to get coffee first. The nurse denies the client's feelings by focusing on getting ready for visitors. Assuring the client that the client will feel better soon and asking the client to come to the sitting room constitutes false reassurance. The nurse first recognizes the client's feelings and then moves away from discussing them.

A 10-year-old child in whom autism was diagnosed at the age of 3 years attends a school for developmentally disabled children and lives with parents. The child has frequent episodes of self-biting and head-banging and needs help with feeding and toileting. What is the priority nursing goal for this child? Controlling repetitive behaviors Being able to feed independently Remaining safe from self-inflicted injury Developing control of urinary elimination

Remaining safe from self-inflicted injury Rationale The priority is safety; the child must be protected from self-harm. Repetitive behaviors are comforting, and unless they are harmful their limitation is not a priority. Although feeding independently is a basic need that may be achieved, it is not the priority. Children who need help with toileting are not necessarily incontinent, and it is not the priority.

A nurse is discharging a client from the mental health unit who has been treated for major depression. Which statement is most therapeutic at this time? "I'm going to miss you; we've become good friends." "I know that you're going to be all right when you go home." "Call the contact number we gave you if you have an emergency." "This is my phone number; call and let me know how you're doing."

"Call the contact number we gave you if you have an emergency." Rationale Instructing the client to call the contact number that was provided in case of emergency demonstrates an understanding that the newly discharged client needs to have a support system. Clients need to feel that in a crisis there will be someone there for them. The role of the nurse is not to become a good friend but instead to help the client become a functioning being again. The statement "I know you're going to be all right when you go home" provides false reassurance; the nurse does not know this. Saying "This is my phone number; call and let me know how you're doing" is unprofessional and blurs the roles of nurse and client.

A client with a history of obsessive-compulsive behaviors is attending a mental health day treatment center. Improvement is obvious, and the client applies for a part-time job. On the day of a job interview the client begins displaying compulsive behavior. How should the nurse respond? "Going for your interview must be upsetting you. Describe what you're feeling now." "It's important for you to overcome your anxiety. You should keep that appointment." "Your actions indicate that you want to delay the interview. Do you really want the job?" "Going to the interview seems to upset you. Do you think you should look for another kind of job?"

"Going for your interview must be upsetting you. Describe what you're feeling now." Rationale The client's behaviors are a defense against anxiety resulting from decision-making, which triggers old fears; the client needs support. Noting that it is important for the client to overcome the anxiety and encouraging the client to keep the appointment denies the client's overwhelming anxiety and shows a lack of realistic support. Asking whether the client really wants the job is judgmental; an increase in anxiety does not necessarily mean that the client does not want to attain the goal. The client should be encouraged to work through symptoms, not to avoid risk.

A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped and I don't want to be bothered." What is the best response by the nurse? "You won't feel better unless you make the effort to get up and get dressed." "I know you'll feel better again if you just make an attempt to help yourself." "Everyone feels this way in the beginning as they confront their feelings." "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started."

"I know you don't feel like getting up, but you might feel better if you did. Let me help you get started." Rationale The statement, "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started," acknowledges the client's feelings, offers hope, and helps the client to a higher level of function. The statement, "You won't feel better unless you make the effort to get up and get dressed," ignores the client's feelings and may not be true. The statement, "I know you'll feel better again if you just make an attempt to help yourself," denies the client's feelings and feeling better cannot be guaranteed. The statement, "Everyone feels this way in the beginning as they confront their feelings," minimizes the client's feelings; also the client is not interested in how others feel.

A client tells the nurse, "I'm a terrible, evil person. The voices are telling me that God needs to punish me." What is the most therapeutic initial response by the nurse? "God is loving and won't punish you." "Those voices you're hearing are a fantasy." "Tell me what you're thinking about yourself." "You aren't wicked—both God and I love you."

"Tell me what you're thinking about yourself." Rationale Encouraging the client to focus on the self will facilitate communication and foster self-perception. Stating that God will not punish the client denies the client's feelings and provides false reassurance. Stating that the voices are fantasy denies the client's experience. Stating that the client is not wicked denies the client's feelings and provides false reassurance.

A client confides to the nurse that she enjoys engaging in sex with multiple male adult sex partners simultaneously. What is the most appropriate response by the nurse? "I recommend that you seek counseling for this problem." "Don't you think that having sex with multiple partners is immoral?" "These men are abusing you, and you should go to the police to report them." "What are you using for birth control and protection from sexually transmitted infections?"

"What are you using for birth control and protection from sexually transmitted infections?" Rationale Adults may have consensual sex as desired, but the nurse should encourage the use of birth control and protection from sexually transmitted infections. The nurse is interjecting personal values by stating that the client should seek counseling for this behavior or that the client's behavior is immoral. If the sex is consensual, it is not abusive.

A nurse is preparing a teaching plan to educate a relative of a client with schizophrenia about the early signs of relapse. What signs should the nurse plan to include? Select all that apply. Appearing disheveled Socializing with peers Staying alone in the house Joining a local church singing group Exhibiting indifference to family activities

Appearing disheveled Staying alone in the house Exhibiting indifference to family activities Rationale Appearing disheveled, a negative sign, may indicate schizophrenic relapse, because the individual does not have the interest or energy to complete the activities of daily living. Staying at home alone can be a sign of mental illness relapse, because the individual is becoming isolated and not socializing. Indifference to family activities may indicate mental illness relapse, because it may reflect feelings of apathy or a lack of emotional energy to become involved with others. Socializing with peers is a sign of mental health, because the individual is interacting with others; humans are highly social beings. Joining a church singing group indicates mental health, because the individual is interacting with others and is interested in an activity.

An older adult is being admitted to a nursing home with the diagnosis of dementia. The history reveals confusion, difficulty recognizing family members, and nighttime wandering. What should the nurse include in the client's plan of care? Ordering a vest restraint for the client to be applied at night Obtaining a prescription for a sedative so the client will sleep better at night Requesting that the family provide a companion to stay with the client at night Assigning the client to a room near the nurses' station for closer supervision at night

Assigning the client to a room near the nurses' station for closer supervision at night Rationale It is the nurse's responsibility to ensure the safety of clients; close supervision can help ensure that the client does not wander. Restraints should not be used without a primary healthcare provider's order; a restraint is too excessive an intervention to prevent wandering. The issue is not that the client does not sleep; the issue is that the client wanders. It is the responsibility of the facility, specifically the nurse, to meet the needs of and ensure the safety of clients.

An older client with the diagnosis of dementia of the Alzheimer type is admitted to a long-term care facility. What should the nurse keep in mind regarding confusion when planning care for this client? Confusion occurs with a transfer to new surroundings. Confusion will be unchanged despite reality orientation. Confusion is a common finding and is expected with aging. Confusion results from brain changes that make interventions futile.

Confusion occurs with a transfer to new surroundings. Rationale A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with dementia-type disorders; with appropriate intervention, including frequent reorientation, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. The assertions that reality orientation is ineffective, that confusion is an expected finding in aging, and that brain changes in dementia make interventions futile are all untrue.

What is the most appropriate nursing intervention when a client is seen openly masturbating in the recreation room? Restraining the client's hands Putting the client in seclusion Escorting the client from the room Teaching the client acceptable behavior

Escorting the client from the room Rationale Escorting the client from the room accepts the client but rejects the behavior. The nurse should set limits on this behavior when it is not performed in a private area. Restraining the client's hands is unrealistic and violates the client's rights. Putting the client in seclusion is a punishment rather than a setting of limits. The client may be too anxious at this time to understand a conversation about acceptable and unacceptable behavior. The nurse has a responsibility to the other clients to limit the behavior.

he nursing staff is discussing the best way to develop a relationship with a new client who has antisocial personality disorder. What characteristic of clients with antisocial personality should the nurses consider when planning care? Engages in many rituals Independence of others Exhibits lack of empathy for others Possesses limited communication skills

Exhibits lack of empathy for others Rationale Self-motivation and self-satisfaction are of paramount concern to people with antisocial personality disorder, and they have little or no concern for others. Clients with obsessive-compulsive disorder, not antisocial personality disorder, engage in rituals. Individuals with antisocial personality disorder are extremely dependent on others; they count on others to extricate them from their problems. They are usually charming on the surface and can easily con people into doing what they want.

The night nurse reports that a young client with paranoid schizophrenia has been awake for several nights. The day nurse reviews the client's record and finds that this client did not have an interrupted sleep pattern disorder before transfer from a private room to a four-bed room 3 days ago. What factor should the nurse identify as most likely related to the client's sleeplessness? Fear of the other clients Concern about family at home Watching for an opportunity to escape Trying to work out emotional problems

Fear of the other clients Rationale Because the client has paranoid feelings that other people are out to do harm, assignment to a four-bed room may be threatening. Concern about family at home seems unlikely, because the disruption appears to have started with the transfer to a four-bed room. Watching for an opportunity to escape is possible but unlikely; planning an escape is usually not part of a schizophrenic pattern of behavior. Trying to work out emotional problems is possible but not likely; clients with schizophrenia have difficulty solving problems.

Nurses working with clients who have a diagnosis of dementia should adopt a common approach of care, because these clients have a need to do what? Relate in a consistent manner to staff Learn that the staff cannot be manipulated Accept controls that are concrete and fairly applied Have sameness and consistency in their environment

Have sameness and consistency in their environment Rationale A consistent approach and consistent communication from all members of the health team help the client who has dementia remain more reality oriented. It is the staff members who need to be consistent. Clients who have this disorder do not attempt to manipulate the staff. Acceptance of controls that are concrete and fairly applied is not needed when working with clients who have this disorder; consistency is most important.

A nurse is preparing to care for a client who engages in ritualistic behavior. What is the most appropriate intervention to include in the plan of care? Redirecting the client's energy into activities to help others Teaching the client that the behavior is not serving a realistic purpose Administering antianxiety medications that block out the memory of internal fears Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety

Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety Rationale Helping clients understand that a behavior is being used to control anxiety usually makes them more amenable to psychotherapy. Treatment includes activities to help the client, not others. The client usually understands already that the behavior is not serving a realistic purpose. Administering antianxiety medications that block out the memory of internal fears will only mask symptoms and will not get at the root of what is bothering the client.

Because a severely depressed client has not responded to any of the antidepressant medications, the primary healthcare provider decides to try electroconvulsive therapy (ECT). What should the nurse do before the treatment? Have the client speak with other clients undergoing ECT. Give a detailed explanation of what to expect after the procedure. Limit the client's intake to a light breakfast on the days of the treatment. Provide emotional support while presenting a simple explanation of the ECT procedure.

Provide emotional support while presenting a simple explanation of the ECT procedure. Rationale The nurse should offer support and use clear, simple terms to allay the client's anxiety. Having the client talk to ECT recipients may be too frightening or confusing to the client, and the nurse is responsible for educating the client. Severely depressed clients cannot retain long explanations. The client generally is kept on nothing-by-mouth status before ECT to prevent aspiration during the procedure.

What should the nurse include when developing a plan of care for an older client with a diagnosis of dementia? Explain to the client the details of the regimen Demonstrate interest in the client's various likes and dislikes Be firm when dealing with the client's attitudes and behaviors Provide consistency in carrying out nursing activities for the client

Provide consistency in carrying out nursing activities for the client Rationale Familiarity with situations and continuity add to the client's sense of security and foster trust in the relationship. Detailed explanations will be forgotten; instructions should be simple and to the point and given when needed. Although demonstrating interest in the client's likes and dislikes helps individualize care, continuity is the priority. Some degree of flexibility by the nurse helps individualize care.

A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history? Evaluating the client's adjustment to the unit Providing the client with a sense of security and safety Exploring the client's memory loss and fear of going out Assessing the client's perception of reasons for the hospitalization

Providing the client with a sense of security and safety Rationale The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. Unless the client is provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.

An older client's family tells the nurse that the client has suffered some memory loss in the past few years leading to a diagnosis of dementia with Lewy bodies (DLB). When attempting to increase the client's self-esteem, the nurse should try to avoid discussing events that require memory of what part of the client's life? Married life Work years Recent days Young adulthood

Recent days Rationale Dementia with Lewy bodies (DLB) is characterized with short-term memory loss, unpredictable cognitive shifts, and sleep disturbances. Memory of remote events (e.g., married life, working years, young adulthood) usually remains fairly intact.

What characteristic of an environment should the nurse consider important for a confused older adult with socially aggressive behavior? Sets limits Has variety Is group oriented Allows freedom of expression

Sets limits Rationale Because they have poor control, these individuals cannot set limits for themselves and require an environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others, because the client may be unable to control impulses.

A client has just been admitted to the psychiatric unit on involuntary admission status. During the admission assessment the client tells the nurse, "I am the second son of God and need to say a prayer." What is the best response by the nurse? Interrupting the client and continuing the assessment Joining the client in the prayer and then refocusing on the assessment Quietly leaving the client and coming back later to complete the assessment Waiting until the client finishes the prayer and then completing the assessment

Waiting until the client finishes the prayer and then completing the assessment Rationale During the initial assessment it is important for the nurse to learn as much as possible about a client and to establish baseline data; therefore both direct and indirect assessment data are important. Interrupting the client may interfere with the nurse-client relationship and increase the client's anxiety; also, it may interfere with obtaining valuable information about the client. Joining the client in the prayer and then refocusing on the assessment is not therapeutic and may reinforce the client's delusional thinking. Quietly leaving the client and returning later to complete the assessment is not therapeutic and will not meet standards of care; it may precipitate feelings of abandonment.

While watching television in the dayroom, a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse? Walking to the end of the hallway where the client is standing Accepting the action as the impulsive behavior of a sick person Asking another client in the dayroom why the client acted in this way Documenting the incident in the client's record while the memory is fresh

Walking to the end of the hallway where the client is standing Rationale Walking to the end of the hallway where the client is standing lets the client know that the nurse is available. It also demonstrates an acceptance of the client. Accepting the action as the impulsive behavior of a sick person is an avoidance technique; it shows a lack of acceptance of the client as a person. Another client's perception of the incident may or may not be valid. Although it is important to document the incident in the client's record, this does not take precedence over letting the client know the nurse is available if needed.

The husband of a young mother who has attempted suicide tells the nurse that he told his wife he would bring their 26-month-old daughter to visit his wife and asks if that would be possible. What is the best response by the nurse? "Probably so, but you'd better check with her primary healthcare provider first." "Of course! Children of all ages are welcome to visit relatives." "It could be very upsetting for your child to see her mother so depressed." "Tell me what your wife said when you offered to bring your child for a visit."

"Tell me what your wife said when you offered to bring your child for a visit." Rationale The nurse should determine whether the spouse has discussed the child visiting with the client before commenting further. The responses "Probably so, but you'd better check with her primary healthcare provider first" and "Of course! Children of all ages are welcome to visit relatives" assume that the client has consented to the visit; this assumption may be incorrect. The response "It may be very upsetting for your child to see her mother so depressed" makes an assumption that requires more data and discussion to validate.

A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? Telling the other clients to disregard what the client is saying Ignoring the client's disruptive behavior and waiting for it to subside Restricting the client's contact with other clients until the disruptive behavior ceases Accepting that the client is unable to control this behavior and setting appropriate limits

Accepting that the client is unable to control this behavior and setting appropriate limits Rationale Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs? Allow the client to undress when ready to help maintain identity. Provide two outfits and help the client decide which one to wear. Explain that clean clothes will look more attractive and increase self-esteem. Get assistance and remove the clothing to meet the client's basic hygiene needs.

Allow the client to undress when ready to help maintain identity. Rationale Any approach other than allowing the client to undress when ready will probably be seen as threatening, increase anxiety, and result in a physical confrontation. Providing two outfits and helping the client make a simple decision will increase anxiety, not foster decision-making. Explaining that clean clothes will look more attractive and increase self-esteem will increase anxiety, not increase self-esteem. Getting assistance and removing the clothing to meet the client's basic hygiene needs will increase the client's anxiety and will probably result in a physical confrontation.

A client remains depressed even after an 8-week trial on several antidepressant medications. A decision to initiate electroconvulsive therapy (ECT) is being considered by the treatment team. Which condition is a contraindication to ECT? Brain tumor Type 1 diabetes Hypothyroid disorder Urinary tract infection

Brain tumor Rationale ECT is contraindicated in the presence of a brain tumor, because the treatment causes an increase in intracranial pressure. ECT is not contraindicated in the presence of diabetes, hypothyroid, or urinary tract infection.

After a client on the mental health unit with a known history of opioid addiction has a visit from several friends, a nurse finds the client in a deep sleep and unresponsive to attempts at arousal. The nurse assesses the client's vital signs and determines that an overdose of an opioid has occurred. Which findings support this conclusion? Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Blood pressure of 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths/min Blood pressure of 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths/min Blood pressure of 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths/min

Blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths/min Rationale Opioids cause central nervous system depression, resulting in severe respiratory depression, hypotension, tachycardia, and unconsciousness. The other findings, particularly the respirations, are not indicative of an overdose of an opioid.

The nurse is caring for a newly admitted male client with the diagnosis of bipolar disorder who has a history of hyperactivity and combativeness. Later in the evening, a commotion is heard and the new client is found beating another client. What is the legal interpretation of this situation? The client should have been placed in restraints on admission. A client who is known to have been combative should have been kept sedated. A client with bipolar disorder who is in contact with reality does not require supervision. Because it was known that the client was frequently combative, close observation by the nursing staff was indicated.

Because it was known that the client was frequently combative, close observation by the nursing staff was indicated. Rationale The nurse, knowing that the client has been combative, was negligent in not providing close supervision; a reasonable, prudent nurse should have observed the client closely to protect against self-imposed injury and to protect others. A client may be placed in restraints only because of current unsafe behaviors, not because of past history. It is unrealistic to keep a client sedated at all times. All clients should be supervised, especially those who have a history of combativeness.

An adolescent with a long history of drug abuse, stealing, refusal to comply with rules, and inability to get along in any setting is admitted to an adolescent psychiatric unit for evaluation. What should the nurse include in the plan of care for this adolescent? Providing activities that ensure immediate gratification and social stimulation Allowing as much freedom as possible, setting few rules and minimal structure Serving as a role model for mature behavior while providing a structured setting Behaving in a punitive manner toward the adolescent when rules are not followed

Behaving in a punitive manner toward the adolescent when rules are not followed Rationale The client is unable to control impulses at this time, so control must be provided for the client; the nurse's behavior provides a role model. Providing activities that ensure immediate gratification and social stimulation will probably provoke even more acting-out behavior. The client is not able to set self-controls; freedom may prove frightening to a client who is not in control. Behaving in a punitive manner toward the adolescent when rules are not followed could provoke even more acting-out behavior.

A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors? Bipolar disorder, manic phase Antisocial personality disorder Obsessive-compulsive disorder Chronic undifferentiated schizophrenia

Bipolar disorder, manic phase Rationale This kind of hyperactive behavior is typical of the manic flight into reality associated with mood disorders. The behaviors are more indicative of a mood disorder than a personality disorder. Ritualistic, not manic, behavior is indicative of obsessive-compulsive disorder. A flat affect and apathy are more indicative of a schizophrenic disorder.

What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion? Touch the client's arm gently to convey concern. Maintain eye contact when talking with the client. Attempt to disprove the client's delusional thoughts. Speak softly when talking with others near the client.

Maintain eye contact when talking with the client. Rationale Eye contact focuses the client's attention on the nurse; it also conveys caring and tells the client that the nurse considers the client important. The nurse should respect the client's personal space; touching the client, particularly without warning, may reinforce suspicious thoughts or precipitate agitation. Attempting to disprove the client's delusional thoughts is useless, because a delusion is real to the client. Whispering or laughing in the presence of a paranoid delusional client may reinforce the delusional state and further agitate the client.

What is the school nurse's most important action when monitoring an adolescent who has just returned to high school after a suicide attempt? Observing the adolescent with frequent summonses to the health office Requesting that teachers and friends report any changes in the client's behavior Speaking with the adolescent regarding feelings about returning to school Telling the teachers what happened and having them ask whether there are any problems

Speaking with the adolescent regarding feelings about returning to school Rationale Speaking with the adolescent regarding feelings about returning to school shows the adolescent that the nurse is available and is interested and concerned. Observing the adolescent with frequent summonses to the health office will draw too much attention to the adolescent; also, it is demeaning. Requesting that teachers and friends report any changes in behavior will place responsibility on others and may interfere with the adolescent's relationship with them. Also, it violates the adolescent's right to privacy. Telling the teachers what happened and having them ask whether there are any problems violates the adolescent's right to privacy.

What is the priority when a nurse is formulating a plan of care for a client with a diagnosis of dementia of the Alzheimer type? Implementing remotivational therapy Structuring the environment for safety Arranging for long-term custodial care Stimulating thinking with new experiences

Structuring the environment for safety Rationale Structuring the environment for safety supports the client's ability to function in a protected, safe milieu. Attempting to remotivate the client is not the priority; also, it is not always possible to remotivate a client with organic brain damage. There are no data to indicate the client needs long-term care at this time. Structure and routines will decrease anxiety and increase performance of activities of daily living. Cognitive maintenance should be part of the focus of care.

A client who was recently admitted to the psychiatric unit with the diagnosis of an obsessive-compulsive disorder engages in a handwashing ritual. When the nurse interrupts the ritual, the client becomes angry and acts out. What is the most probable cause for this behavior? The client is feeling overwhelmed in this situation. The client resents the nurse's authoritarian manner. The client's personality is clashing with the nurse's. The client's response reflects an aggressive personality.

The client is feeling overwhelmed in this situation. Rationale The ritual reduces anxiety; when not permitted to complete the ritual, a client with an obsessive-compulsive disorder will experience increased anxiety, frustration, and anger and may act out. The client is experiencing anxiety not related to a personality clash, the nurse's manner, or an aggressive personality.

A nurse sits with a depressed client twice a day, but there is little verbal communication. One afternoon the client asks, "Do you think they'll ever let me out of here?" What is the best reply by the nurse? "We should ask your primary healthcare provider." "Everyone says you're doing fine." "Do you think you're ready to leave?" "How do you feel about leaving here?"

"Do you think you're ready to leave?" Rationale The nurse's response asking about the client's feelings about leaving urges the client to reflect on feelings and encourages communication. Saying "We should ask your primary healthcare provider" shifts responsibility from the nurse to the primary healthcare provider; it is an evasive response. Responding "Everyone says you're doing fine" does not address what the client is asking the nurse; it closes the door to further communication. Asking "Do you think you're ready to leave?" may elicit a yes or no answer; it does not encourage communication.

What statement by a male client during a yearly physical examination indicates to a nurse that the client may have a sexual arousal disorder? "I have no interest in sex." "I don't get hard during sex anymore." "I climax almost before we even get started." "It takes forever before I finally have an orgasm."

"I don't get hard during sex anymore." Rationale The statement "I don't get hard during sex anymore" indicates a sexual arousal disorder, which is a partial or complete failure to achieve a physiologic or psychological response to sexual activity. The statement "I have no interest in sex" may indicate a sexual desire disorder in which the individual has deficient or absent interest in, or extreme aversion to and avoidance of, sexual activity. "I climax almost before we even get started" and "It takes forever before I finally have an orgasm" are both indicative of an orgasmic disorder, which is a delay in or absence of an orgasm or premature ejaculation.

A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped and I don't want to be bothered." What is the best response by the nurse? "You won't feel better unless you make the effort to get up and get dressed." "I know you'll feel better again if you just make an attempt to help yourself." "Everyone feels this way in the beginning as they confront their feelings." "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started."

"I know you don't feel like getting up, but you might feel better if you did. Let me help you get started." Rationale The statement, "I know you don't feel like getting up, but you might feel better if you did. Let me help you get started," acknowledges the client's feelings, offers hope, and helps the client to a higher level of function. The statement, "You won't feel better unless you make the effort to get up and get dressed," ignores the client's feelings and may not be true. The statement, "I know you'll feel better again if you just make an attempt to help yourself," denies the client's feelings and feeling better cannot be guaranteed. The statement, "Everyone feels this way in the beginning as they confront their feelings," minimizes the client's feelings; also the client is not interested in how others feel.

A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse? "Tell me whether the voices are male or female and how many there are." "Don't worry—I've locked the door to your room and won't let anyone in." "I understand that these voices are real to you, but I want you to know that I don't hear them." "You should leave this room. Your mind needs to be occupied so the voices don't bother you."

"I understand that these voices are real to you, but I want you to know that I don't hear them." Rationale The statement "I understand that these voices are real to you, but I want you to know that I don't hear them" demonstrates recognition and acceptance of the client's feelings; it also points out reality. Encouraging the client to focus on a hallucination tends to strengthen and confirm the hallucination. The response "Don't worry—I've locked the door to your room and won't let anyone in" is false reassurance; the client has no reason to trust that the nurse can provide protection. Telling the client to leave this room and observing that the client's mind needs to be occupied so the voices don't aren't bothersome is nontherapeutic; it denies the client's feelings and may increase anxiety.

A nursing team holds a conference to develop goals for the care of a withdrawn, shy male client with low self-esteem who is afraid to talk to members of the opposite sex. Which objective should be given priority and documented in the client's plan of care? "The client will increase his self-esteem." "The client will understand his sexual disorder." "The client will examine his feelings toward women." "The client will increase his knowledge of sexual function."

"The client will increase his self-esteem." Rationale If the goal to increase the client's self-esteem is met, the client's relationship with others should improve in all aspects, including sexual. Increasing insight may be helpful but should not receive priority. The client may or may not have a sexual disorder. Examining his feelings toward women is not appropriate at this time; examining these feelings is nonproductive until the client's self-esteem improves. Increasing the client's knowledge of sexual function may be done, but improvement of self-esteem should receive priority.

A school nurse knows that school-aged children often use defense mechanisms to cope with situations that might negatively affect their self-esteem. The nurse hears a child who was not invited to a sleepover say, "I don't have time to go to that sleepover. I have better things to do." The nurse concludes that the student is using which defense mechanism? Denial Projection Regression Rationalization

Rationalization Rationale Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation. Projection is blaming others for one's shortcomings. Regression is returning to an earlier more familiar mode of behavior.

During a period of hyperactivity a client on the psychiatric unit demands to be allowed to go downtown to shop. The client does not currently have privileges. How should the nurse respond? "You can't leave the unit, because you're too sick." "You'll have to ask your primary healthcare provider for permission to go." "You'll have to wait, because no staff member is available to go with you." "You don't have privileges to leave, but we can look through this new catalog."

"You don't have privileges to leave, but we can look through this new catalog." Rationale Clients who are hyperactive are easily diverted. It is best to use distraction rather than precipitate a confrontation. Telling the client that leaving will not be allowed ignores the client's wishes and offers no alternative behavior. Telling the client that the primary healthcare provider will have to be called shifts responsibility to the primary healthcare provider; the nurse should know that a shopping trip is unrealistic at this time. Telling the client that no one is available to accompany the client does not deal with reality and only postpones the need to address the problem directly.

A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse? "At your age sex isn't that important." "Sex isn't everything it's cracked up to be." "You sound upset about not being able to have an erection." "Maybe it's time for you to speak to your primary healthcare provider about this."

"You sound upset about not being able to have an erection." Rationale When a client reveals something, it is important for the nurse to gather more information. The response "You sound upset about not being able to have an erection" promotes further communication. Assessment is the first step of the nursing process. "At your age sex isn't that important" is a subjective, judgmental response that reflects the nurse's view of sexuality in older adults. "Sex isn't everything it's cracked up to be" interjects the nurse's view and violates the concept of neutrality when counseling clients. Having the client speak to his primary healthcare provider may be indicated eventually, but first the nurse must obtain more information.

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs? Allow the client to undress when ready to help maintain identity. Provide two outfits and help the client decide which one to wear. Explain that clean clothes will look more attractive and increase self-esteem. Get assistance and remove the clothing to meet the client's basic hygiene needs.

Allow the client to undress when ready to help maintain identity. Rationale Any approach other than allowing the client to undress when ready will probably be seen as threatening, increase anxiety, and result in a physical confrontation. Providing two outfits and helping the client make a simple decision will increase anxiety, not foster decision-making. Explaining that clean clothes will look more attractive and increase self-esteem will increase anxiety, not increase self-esteem. Getting assistance and removing the clothing to meet the client's basic hygiene needs will increase the client's anxiety and will probably result in a physical confrontation.

How can a nurse minimize agitation in a disturbed client? By ensuring constant staff contact By increasing environmental sensory stimulation By limiting unnecessary interactions with the client By discussing the reasons for the client's suspicions

By limiting unnecessary interactions with the client Rationale Limiting unnecessary interactions will decrease stimulation and therefore agitation. Constant client and staff contact increases stimulation and agitation. Increasing environmental sensory stimulation bombards the client's sensorium and increases agitation. Not all disturbed clients are suspicious. This client is unlikely to benefit from this discussion at this time.

A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? Seclusion room Four-point restraints Constant one-on-one supervision Removal of unsafe objects from the environment

Constant one-on-one supervision Rationale A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.

What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation? Electroconvulsive therapy Short-term psychoanalysis Nondirective psychotherapy High doses of anxiolytic drugs

Electroconvulsive therapy Rationale Electroconvulsive therapy, which interrupts established patterns of behavior, helps relieve symptoms and limits suicide attempts in clients with severe, intractable depression that does not respond to antidepressant medication. The client's depressed mood limits participation in psychotherapy; feelings precipitated by therapy may lead to suicidal acting out. Psychotherapy is directed toward helping the person learn new coping mechanisms and better ways of coping with problems; the depressed client needs direction to accomplish this. Antianxiety medications are usually not prescribed for clients with depression.

An older client is transferred to a nursing home from a hospital with a diagnosis of dementia. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse sees that the client has laid out several outfits on the bed but is still wearing nightclothes. What should the nurse do? Help the client dress and explain when residents are expected at the activity. Prompt the client to dress more quickly to avoid delaying the other residents. Help the client select appropriate attire and offer to help the client get dressed. Allow the client time to dress but explain that the client has missed the opportunity to attend the activity.

Help the client select appropriate attire and offer to help the client get dressed. Rationale Helping the client select appropriate attire and offering help in getting dressed aids the client in decision-making; new situations may be stressful and may lead to ambivalent feelings. Helping the client dress and explaining when residents are expected at the activity is not sharing decision-making; the client may not remember this explanation in the future. Reminding the client to dress more quickly to avoid delaying the other residents may make the client feel guilty and may increase anxiety. The client may perceive being told that the opportunity to attend the activity has been missed as punishment.

A college student is brought to the mental health clinic by parents with a diagnosis of borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply. Impulsiveness Lability of mood Ritualistic behavior Psychomotor retardation Self-destructive behavior

Impulsiveness Lability of mood Self-destructive behavior Rationale Clients with borderline personality disorder often lead complex, chaotic lives because of their inability to control or limit impulses. Extremes of emotions, ranging from apathy and boredom to anger, may be displayed within short periods. Impulsive self-destructive acts such as reckless driving, spending money, and engaging in unsafe sex often result in negative consequences. Ritualistic behavior is associated with obsessive-compulsive disorders. Psychomotor retardation is associated with mood disorders such as depression.

An adult client with schizophrenia is involuntarily admitted to the psychiatric unit. While off the unit for needed testing, the client runs away. Legally, who should the nurse notify immediately? Probate judge Client's family Client's psychiatrist Law enforcement officer

Law enforcement officer Rationale Legally it is the responsibility of the staff to notify law enforcement officers so the client can be apprehended. A judge may be involved later in a nonemergency situation. Although the family and psychiatrist will be notified eventually, neither is the priority.

At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation? Shutting the client's door during the night Applying a vest restraint when the client is in bed Leaving a dim light on in the client's room at night Administering the client's prescribed as-needed sedative medication

Leaving a dim light on in the client's room at night Rationale A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.

What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion? Touch the client's arm gently to convey concern. Maintain eye contact when talking with the client. Attempt to disprove the client's delusional thoughts. Speak softly when talking with others near the client.

Maintain eye contact when talking with the client. Rationale Eye contact focuses the client's attention on the nurse; it also conveys caring and tells the client that the nurse considers the client important. The nurse should respect the client's personal space; touching the client, particularly without warning, may reinforce suspicious thoughts or precipitate agitation. Attempting to disprove the client's delusional thoughts is useless, because a delusion is real to the client. Whispering or laughing in the presence of a paranoid delusional client may reinforce the delusional state and further agitate the client.

What is the most appropriate nursing intervention for clients who exhibit mild cognitive impairment? Reality orientation Behavioral confrontation Reflective communication Reminiscence group therapy

Reality orientation Rationale Reality orientation is generally helpful for clients exhibiting mild cognitive impairment; these clients are aware of their impairment, and orientation then reduces anxiety. Behavioral confrontation is not therapeutic because it may cause frustration and increase psychomotor agitation in a client with cognitive impairment. Reflective communication is a technique in which the nurse restates or repeats the client's statements; it can be used to clarify thoughts but may also lead to frustration when the approach is overdone. Reminiscence group therapy is helpful with severely confused, disorganized clients because it reinforces identity, acknowledges what was significant, and often compensates for the dullness of the present.

A client is found to have generalized anxiety disorder. For what behavior should the nurse assess the client to determine the effectiveness of therapy? Participating in activities Learning how to avoid anxiety Taking medications as prescribed Recognizing when anxiety is developing

Recognizing when anxiety is developing Rationale Recognition of anxiety or symptoms of increasing anxiety is an indication that the client is improving. Avoidance of anxiety is not a good indication of improvement; there is no guarantee that anxiety can always be avoided. Participating in activities and taking medications as prescribed do not indicate improvement or recognition of feelings; the client may be doing what others expect.

What should the nurse include when developing a plan of care for a client in the manic phase of bipolar disorder? Focusing the client's interest in reality Encouraging the client to talk as much as needed Persuading the client to complete any task that has been started Redirecting the client's excess energy to more constructive activities

Redirecting the client's excess energy to more constructive activities Rationale The hyperactive client usually is easily distracted, so excess energy can be redirected into constructive channels. There is nothing to indicate that the client is not in touch with reality. The client will talk a great deal with no encouragement. The client will not be able to focus long enough on one task to finish it.

While walking to the examination room with the nurse, a toddler with autism suddenly runs to the wall and starts banging the head on it. What should the nurse's initial action be? Allowing the toddler to act out feelings Asking the toddler to stop this behavior Restraining the toddler to prevent head injury Telling the toddler that the behavior is unacceptable

Restraining the toddler to prevent head injury Rationale The child with autism needs protection from self-injury. Permitting the child to act out is possible only if the acting out does not place the child in jeopardy. The child with autism has difficulty following directions, especially when out of control. The child with autism cannot separate self from behavior; a punitive approach will decrease the child's self-esteem.

A nurse is caring for a client with an antisocial personality disorder. What consistent approach should the nurse use with this client? Warm and firm without being punitive Indifferent and detached but nonjudgmental Conditionally acquiescent to client demands Clearly communicative of personal disapproval

Warm and firm without being punitive Rationale The client needs positive relationships with other adults, but clear, consistent limits must be presented to minimize attempts at manipulation. Acting indifferent and detached but nonjudgmental is not a therapeutic approach. Being indifferent and detached gives the impression that the nurse does not care. Being conditionally acquiescent to client demands is not a therapeutic approach because clear, consistent limits are necessary to prevent manipulation. Being clearly communicative of personal disapproval is a judgmental attitude that should be avoided.

A nurse is caring for a female client during the manic phase of bipolar disorder. What should the nurse do to help the client with personal hygiene? Suggest that she wear hospital clothing. Guide her to dress appropriately in her own clothing. Allow her to apply makeup in whatever manner she chooses. Keep makeup away from her because she will apply it too freely.

Guide her to dress appropriately in her own clothing. Rationale Having clients who are experiencing the manic phase of bipolar disorder wear personal clothing helps keep them more in touch with reality. The client may need direction to dress appropriately. Suggesting that she wear hospital clothing does not help the client learn new ways to cope with problem situations. Allowing her to apply makeup in whatever manner she chooses may set up the client as a target of ridicule by other clients. The client may use makeup but with supervision.

A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child? Keeping the child from inflicting any self-injury Helping the child improve communication skills Helping the child formulate realistic ego boundaries Providing the child with opportunities to discharge energy

Keeping the child from inflicting any self-injury Rationale All nursing care should be directed toward preventing injury, particularly with a self-destructive child. Although improved communication skills, formulation of realistic ego boundaries, and opportunities to discharge energy are all important, prevention of injury is the priority.

A client who has been attending a day treatment facility for 1 month with the diagnosis of major depression is to be discharged in a week. Because the nurse and the client are aware of this, what is the most appropriate comment by the nurse? "We have just a few sessions left. I'm really pleased at your progress." "Your discharge date has been set for next week. That's wonderful news." "We have five sessions remaining. We need to start making plans to end our sessions." "I understand that your discharge is set for next week. I'm wondering how you feel about that."

"I understand that your discharge is set for next week. I'm wondering how you feel about that." Rationale Plans for termination that take emotional needs into account are best made after exploration of the client's thoughts and feelings about discharge. Noting that there are just a few sessions left and expressing pleasure at the client's progress acknowledges the future termination but focuses on the nurse's, not the client's, feelings. Noting that the client's discharge date has been set for next week and calling this wonderful news acknowledges the future termination but suggests that the client should feel wonderful about the discharge, which may or may not be true. Although noting that the client and nurse have five sessions remaining and that the two need to start making plans to end the sessions acknowledges the future termination, plans for termination should be made after a discussion of the client's emotional response to the pending discharge.

An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention? Instructing the client to be quiet Allowing the client to act out until fatigue sets in Guiding the client from the room by gently holding the client's arm Giving the client one simple direction at a time in a firm, low-pitched voice

Giving the client one simple direction at a time in a firm, low-pitched voice Rationale Clients who are out of control are seeking control and typically respond to simple directions stated in a firm voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client's arm is done only after an attempt at calming the client has failed.

A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of what? Guilt Grandeur Worthlessness Self-deprecation

Grandeur Rationale During a manic episode a client has an inflated self-esteem that replaces feelings with which the client cannot cope. Feelings of guilt, worthlessness, and self-deprecation are not associated with bipolar disorder, manic episode.

A 16-year-old high school student who has anorexia nervosa tells the school nurse that she thinks she is pregnant even though she has had intercourse only once, more than a year ago. What is the most appropriate inference for the nurse to make about the student? Using magical thinking Submitting to peer pressure Lying about the last time she had intercourse Lacking knowledge that anorexia can cause amenorrhea

Lacking knowledge that anorexia can cause amenorrhea Rationale The loss of body fat from anorexia can cause amenorrhea; the client needs information. No data are available to support the fact that the client is using magical thinking, which is characterized by the belief that thinking or wishing something can cause it to occur; in light of the client's diagnosis of anorexia, this is not the first conclusion. Submitting to peer pressure is not related to this type of concern. Although the nurse should question the timeline again, the client's nutritional status should be explored first.

A client with the diagnosis of obsessive-compulsive disorder who has a need to wash his hands 50 to 60 times a day tearfully tells the nurse, "I know that my hands aren't dirty, but I just can't stop washing them." What is the best response by the nurse? "Let's talk about why you feel that you have to wash your hands." "I think you're getting better; you're beginning to understand your problem." "Don't worry about it; these actions are part of your illness, and the feelings will pass." "I understand that—maybe we can work together to limit the number of times you wash them."

"I understand that—maybe we can work together to limit the number of times you wash them." Rationale The nurse shows an understanding of the client's needs by not totally restricting the handwashing and by working with the client to set limits on the behavior. At this time the client is still too anxious to be capable of coping with the reasons for handwashing. Continued handwashing does not reveal an understanding of the underlying problem, nor is it a sign of progress. Telling the client not to worry denies the client's feelings and may close off communication.

A client with a borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client? Provide an unstructured environment to promote self-expression. Be firm, consistent, and understanding and focus on specific target behaviors. Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. Record but ignore marked shifts in mood, suicidal threats, and temper displays, because these last only a few hours.

Be firm, consistent, and understanding and focus on specific target behaviors. Rationale Consistency, limit-setting, and supportive confrontation are essential nursing interventions designed to provide a secure, therapeutic environment for clients with borderline personality disorder. To be therapeutic, the environment needs structure, and the staff must help the client set short-term goals for behavioral changes. The use of an authoritarian approach will increase anxiety in this type of client, resulting in feelings of rejection and withdrawal. Ignoring the client's behavior is nontherapeutic and may reinforce underlying fears of abandonment.

A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention? Focusing on the present Identifying past stressors Discussing a referral for psychotherapy Exploring the client's history of mental health problems

Focusing on the present Rationale Crisis intervention deals with the here and now; the past is not important except in building on client strengths. The client is anxious and uncomfortable because of the current situation; the focus is on the present, not the past. Psychotherapy is not appropriate for crisis intervention; psychotherapy focuses on the causes of current feelings and behavior and may be provided long term. Exploring the client's history of mental health problems is not significant to crisis intervention.

The nurse is caring for a client with Alzheimer disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, what instructions will the nurse give the staff to monitor the client? At meals to help prevent choking For the presence of mouth ulcers To prevent injury caused by hot foods For attempts at eating inedible objects

For attempts at eating inedible objects Rationale Hyperorality is the compulsive need to taste and chew inedible objects. Hyperorality is not related to choking, a tendency to mouth ulcers, or the inability to perceive temperature properly.

What should the nurse consider when caring for clients who are at risk for suicide? A client who fails in a suicide attempt will probably not try again. Formal suicide plans increase the likelihood that a client will attempt suicide. It is best not to talk to clients about suicide, because it may give them the idea. Clients who talk about suicide are not planning it; they are using the threat to gain attention.

Formal suicide plans increase the likelihood that a client will attempt suicide. Rationale A formal plan demonstrates determination, concentration, and effort, with conclusions already thought out. Failure to successfully complete the suicidal act can add to feelings of worthlessness and stimulate further acts. Verbalizing feelings may help reduce the client's need to act out. Many clients verbalize their suicidal thoughts as they are working on their decision and plan of action; a suicide attempt is not necessarily just to receive attention.

A nurse is counseling a client who is experiencing substance abuse delirium. What communication strategies should be used by the nurse when working with this client? Encouraging the client to practice self-control Using humor when communicating with the client Offering an introduction to the client at each meeting Approaching the client from the side rather than the front

Offering an introduction to the client at each meeting Rationale Clients with delirium have short-term memory loss; therefore it is necessary to reinforce information. A client experiencing delirium is unable to participate in a discussion about self-control. Humor is inappropriate and may cause the client to feel uncomfortable. Approaching the client from the side rather than the front may initiate a startle response, causing the client to become fearful.

A client with major depression that includes psychotic features tells the nurse, "All of my relatives have been killed because I've been sinful and need to be punished." What is the primary focus of nursing interventions? Protecting the client against any suicidal impulses Supporting the client's interest in the outside world Helping the client manage the concern for family members Reassuring the client that past behaviors are not being punished

Protecting the client against any suicidal impulses Rationale Suicidal impulses take priority, and the client must be stopped from acting on them while treatment is in progress; the client's safety is the focus of nursing interventions. Supporting the client's interest in the outside world is of very low priority. The client is focusing on the current personal situation, not the outside world. Helping the client manage the concern for family members is a secondary concern. Reassurance will not change the client's belief.

The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? Dietary practices Concept of space Immigration status Role within the family

Role within the family Rationale If an Asian-American client adheres to traditional Asian practices, the nurse must recognize that the family is the central and most important social force acting on the individual. Dietary practices, concept of space, and immigration status are not as significant as family dynamics.

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care? Physical contact will increase dependency needs. Routines provide stability for clients with dementia. Regressive behavior should be interrupted immediately. Procedures do not have to be explained to clients with dementia.

Routines provide stability for clients with dementia. Rationale Rituals and routines in activities of daily living provide a framework and structure for clients with dementia, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood.

The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain what? Safety within the environment Psychological faculties Participation in educational activities Face-to-face contact with other clients

Safety within the environment Clients with cognitive disorders need an environment that will keep them safe, because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other cognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. People with dementia, delirium, and other cognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.