Unit 1

A client with a history of schizophrenia who responds poorly to medication is now being treated for acute depression. In light of the information elicited from the medication list and laboratory results, which information would the nurse provide? Chart/Lab Results HGB 13.5 HCT 45 RBC 48 PLT 150,000 WBC 3,500 Neutrophils 100 MEDICATIONS: Cloazapin & Fluoxetine 1 "Come in for weekly blood tests to monitor for medication-induced agranulocytosis." 2 "Report incidents of unusual bleeding or easy bruising while taking fluoxetine." 3 "Expect to be prescribed only 1 week's supply of fluoxetine at a time." 4 "Consume a high-protein diet to offset the risk of anemia while taking clozapine."

1. "Come in for weekly blood tests to monitor for medication-induced agranulocytosis." The antipsychotic medication clozapine poses a risk for the development of agranulocytosis, especially when combined with a selective serotonin reuptake inhibitor such as fluoxetine. The client's neutrophil and white blood cell counts (WBCs) are borderline and therefore suggestive of the disorder. Weekly blood testing to monitor these blood values is required. The client's platelet count is in the low-normal range, but fluoxetine is not generally considered a factor in bleeding disorders. Clozapine, not fluoxetine, would likely be prescribed on a week-by-week basis to both help manage side effects and encourage weekly visits for lab work. Clozapine is not generally considered a factor in the development of anemia.

***Which assessment question would the nurse ask before administering a monoamine oxidase inhibitor (MAOI) to a client with depression? Select all that apply. One, some, or all responses may be correct. 1 "Do you eat bananas?" 2 "Do you use any illegal drugs?" 3 "Do you take any allergy medications?" 4 "Do you eat dairy products like cheese and sour cream?" 5 "How many alcoholic beverages do you consume each week?" 6 "How many caffeinated beverages do you drink on a daily basis?

1. "Do you eat bananas?" 2. "Do you use any illegal drugs?" 3. "Do you take any allergy medications?" 4. "Do you eat dairy products like cheese and sour cream?" 5. "How many alcoholic beverages do you consume each week?" 6. "How many caffeinated beverages do you drink on a daily basis? Serious drug interactions can occur with MAOIs including hypertensive crisis, CNS depression, and anticholinergic reactions. Clients taking MAOIs must adhere to dietary and medication restrictions to avoid unwanted side effects. Bananas, strong or aged cheeses, alcoholic beverages, pickles, smoked meats, and caffeinated foods all contain tyramine, an amino acid that increases blood pressure. If a client taking an MAOI eats high-tyramine foods, tyramine can quickly reach dangerous levels and cause a serious spike in blood pressure. MAOIs should not be combined with any other psychoactive substances including those found in illegal drugs. MAOIs may increase the effect of antihistamines used for allergies.

Which statement by the nurse reflects understanding of therapeutic communication with a client experiencing domestic violence? Select all that apply. One, some, or all responses may be correct. 1 "Tell me about your struggles." 2 "Everything is going to be okay." 3 "Get out of the house right away." 4 "You'll feel better after you leave." 5 "Why do you stay when he hits you?" 6 "Why did you return to him after the abuse?"

1. "Tell me about your struggles." "Tell me about your struggles," is therapeutic communication, as it encourages a client to describe their perception. Talking about feelings can help clients clarify their thoughts. "Everything is going to be okay" is falsely reassuring and underrates the client's feelings; it would be better to clarify the client's message. "Get out of the house right away" gives premature advice and assumes that the nurse knows best; it would be better to encourage the client to problem-solve. "You'll feel better after you leave" minimizes the client's feelings and indicates that the nurse is unable to empathize; the nurse would attempt to empathize and explore. "Why do you stay when he hits you?" is a value judgment that prevents problem-solving. The nurse would instead make observations. "Why did you return to him after the abuse?" implies criticism and may make the client defensive. The nurse would ask open-ended questions to avoid this.

***Which response would the nurse make to a client with alcohol use disorder who says, "I can't go to the hospital's Alcoholics Anonymous meeting today because I'm expecting an important phone call"? 1 "You are expected to go to the meeting." 2 "Phone calls are not that important now." 3 "You can go to another meeting later in the day." 4 "Go to the meeting after you take the phone call."

1. "You are expected to go to the meeting." The response "You are expected to go to the meeting" helps the client recognize and adhere to established limits and goals. The response "Phone calls are not that important now" may be seen as degrading and focuses on external events rather than the client's behavior and compliance. The responses "You can go to another meeting later in the day" and "Go to the meeting after you take the phone call" reinforce the client's pattern of manipulation and do not help the client take responsibility.

Which vital sign findings would alert the nurse to a client's opioid overdose? 1 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths per minute 2 180/100 mm Hg, tachycardia, and respiratory rate of 18 breaths per minute 3 120/80 mm Hg, regular pulse, and respiratory rate of 20 breaths per minute 4 140/90 mm Hg, irregular pulse, and respiratory rate of 28 breaths per minute

1. 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths per minute A blood pressure of 70/40 mm Hg, weak pulse, and respiratory rate of 10 breaths per minute would alert the nurse to an opioid overdose. 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.

A client with a diagnosis of obsessive-compulsive disorder is often late for appointments because it takes so much time each day to complete a ritualistic hand-washing routine. Which is the most therapeutic nursing intervention? 1 Accepting the client's ritual in a matter-of-fact manner without criticism 2 Encouraging the client to speed up the ritual so appointments can be met on time 3 Discouraging the client from washing the hands so frequently to prevent skin breakdown 4 Letting the client know how angry others become when the hand washing holds up activities

1. Accepting the client's ritual in a matter-of-fact manner without criticism Responding to behavior in a matter-of-fact way prevents reinforcing the behavior. Allowing time for the ritual will help keep the client's anxiety from increasing; attempts to speed up ritualistic behavior will probably increase the client's anxiety. Attempts to discourage ritualistic behavior often increase anxiety. Disparaging the client may decrease self-esteem and increase anxiety and guilt, thereby intensifying the hand-washing routine.

For Alcoholics Anonymous, which goal is the priority? 1 Acknowledging and changing destructive behavior 2 Developing functional social and family relationships 3 Identifying how people present themselves to others 4 Understanding interactional patterns within the group

1. Acknowledging and changing destructive behavior The purpose of a self-help group is for individuals to develop their strengths and new, constructive patterns of coping. Developing functional relationships, identifying how people present themselves to others, and understanding patterns of interaction within the group are also desirable outcomes of group therapy.

***The nurse suspects that an adolescent has anorexia nervosa. Which characteristics may have been observed in the adolescent? Select all that apply. One, some, or all responses may be correct. 1 Denying illness 2 Dismissing food 3 Seeking intimacy 4 Being extroverted 5 Maintaining rigid body control

1. Denying illness 2. Dismissing food 5. Maintaining rigid body control Anorexia nervosa is a complex disorder that can result in morbidity and mortality. Denying the illness, dismissing food, and maintaining rigid control of the body are characteristics observed in adolescents with anorexia nervosa. Seeking intimacy and being extroverted are characteristics of bulimia nervosa.

***The nurse is teaching a client about tricyclic antidepressants. Which potential side effects would the nurse include? Select all that apply. One, some, or all responses may be correct. 1 Dry mouth 2 Drowsiness 3 Constipation 4 Severe hypertension 5 Orthostatic hypotension

1. Dry mouth 2. Drowsiness 3. Constipation 5. Orthostatic hypotension Dry mouth is a common anticholinergic side effect of tricyclic antidepressants. Drowsiness can be a common side effect but usually decreases with continued treatment. Constipation is a common side effect that usually can be managed with stool softeners and a high-fiber diet. Orthostatic hypotension is a common side effect of tricyclic antidepressants; the client should be instructed to rise slowly from a sitting to a standing position. Hypertension of any type is not a side effect of tricyclic antidepressants.

To help a client with bipolar disorder who is aggressive and disruptive in group and social settings develop social skills, which initial approach would the nurse take? 1 Facilitating one-on-one interactions 2 Encouraging self-care with support 3 Developing guidelines for behavior 4 Helping the client decrease activity level

1. Facilitating one-on-one interactions The nurse would facilitate one-on-one interactions. The client who is aggressive in groups must begin socialization in one-on-one interactions that are less stimulating and distracting. Promoting self-care avoids addressing behaviors in group and social situations. The client may not be interested in or able to develop guidelines for appropriate behavior at this time. The client may not be able to decrease activity at this time, and it must be channeled appropriately.

Which approach would the nurse take for a client who was involved in a near-fatal automobile collision and arrives at the crisis center with reports of anxiety and flashbacks? 1 Focusing on the present 2 Identifying past stressors 3 Discussing a referral for psychotherapy 4 Exploring the client's history of mental health problems

1. Focusing on the present The approach would be focusing on the present because the client is in a crisis. 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.

Which side effects would the client expect after undergoing electroconvulsive therapy? Select all that apply. One, some, or all responses may be correct. 1 Headache 2 Confusion 3 Memory loss 4 Loss of appetite 5 Postural hypotension

1. Headache 2. Confusion 3. Memory loss The electrical energy passing through the cerebral cortex during electroconvulsive therapy (ECT) results in a headache after treatment, a temporary state of confusion, and temporary memory loss. Loss of appetite and postural hypotension are not usual or expected side effects.

***Which clinical manifestations would the nurse observe in a client with opioid withdrawal? Select all that apply. One, some, or all responses may be correct. 1 Muscle twitching 2 Runny nose 3 Tachycardia 4 Flulike symptoms 5 Pinpoint pupils

1. Muscle twitching 2. Runny nose 3. Tachycardia 4. Flulike symptoms The nurse would observe the following: muscle twitching, runny nose, tachycardia, and flulike symptoms. When opioids, which are central nervous system depressants, are withdrawn initially, the client will experience muscle twitching, a runny nose (rhinorrhea), tearing (lacrimation), diaphoresis, yawning, and tachycardia. Flulike symptoms, such as nausea, vomiting, and diarrhea, also occur. Pinpoint pupils occur with intoxication or overdose, not during withdrawal.

Which priority concern would the nurse monitor for while working with clients withdrawing from cocaine? 1 Risk for self-injury 2 Potential for seizure 3 Danger of dehydration 4 Probability of injuring others

1. Risk for self-injury The priority concern the nurse would monitor for is risk for self-injury. Safety of the client is always a priority. Although potential for seizure is important, the potential for seizure is increased while a person is under the influence of cocaine, not during withdrawal. Although dehydration may occur during cocaine use and withdrawal, it is not the priority concern. Although clients in cocaine withdrawal may be irritable with others, they are more apt to hurt themselves than others, making risk for self-injury the priority.

**A client on antidepressant therapy develops hyperthermia, seizures, and a heart rate of 200 beats per minute. Which medication would the nurse suspect is responsible for the condition? 1 Sertraline 2 Asenapine 3 Risperidone 4 Fluphenazine

1. Sertraline A heart rate of 200 beats per minute indicates cardiac dysrhythmias. Hyperthermia, seizures, and cardiac dysrhythmias in a client on antidepressant therapy indicate serotonin syndrome. Serotonin syndrome is an adverse effect of selective serotonin reuptake inhibitors such as sertraline. Asenapine, risperidone, and fluphenazine are antipsychotics that may cause drowsiness, neuroleptic malignant syndrome, extrapyramidal symptoms, and tardive dyskinesia as adverse effects.

Which action would the nurse take for a client with panic disorder who jumps when spoken to, reports feeling uneasy, and says, "It's as though something bad is going to happen"? 1 Stay with the client to be a calming presence. 2 Encourage the client to communicate with the staff. 3 Allow the client to set the parameters for the interaction. 4 Help the client understand the cause of the feelings described.

1. Stay with the client to be a calming presence. The nurse would stay with the client to be a calming presence. Fear can be overwhelming; the nurse's presence provides protection from possible escalating anxiety. The client's anxiety level is interfering with the ability to communicate; anxiety must be reduced first before the nurse would encourage the client to communicate with the staff. The client's anxiety level is so high that sufficient emotional energy to set parameters is not available. Helping the client understand the cause of the feelings he or she describes may increase the client's anxiety at this time.

***Which action would the nurse take when caring for a client having an acute episode of anxiety? Select all that apply. One, some, or all responses may be correct. 1 Staying with the client 2 Giving brief directions 3 Using short, simple sentences 4 Linking the client's behavior to feelings 5 Teaching a cognitive therapy principle 6 Having the client write an assessment of strengths

1. Staying with the client 2. Giving brief directions 3. Using short, simple sentences 4. Linking the client's behavior to feelings 5. Teaching a cognitive therapy principle 6. Having the client write an assessment of strengths Staying with the client conveys acceptance and the ability to give help. Giving brief directions reduces indecision. Using short, simple sentences promotes comprehension. Linking the client's behavior to feelings promotes self-awareness. Cognitive therapy principles provide a basis for behavioral change. Writing an assessment of strengths increases self-acceptance.

***A health care provider prescribes lithium carbonate for a client with bipolar disorder, depressive episode. Which instructions will the nurse include when teaching the client about lithium? Select all that apply. One, some, or all responses may be correct. 1 Take the medication with food. 2 Adjust the dosage if your mood improves. 3 Have a snack with milk before going to bed. 4 It may take several weeks for beneficial results to occur. 5 Restriction of sodium intake is unnecessary.

1. Take the medication with food. 4. It may take several weeks for beneficial results to occur. 5. Restriction of sodium intake is unnecessary. Lithium should be taken with food to prevent gastric irritation. It will take 1 to 3 weeks before beneficial results occur. Lithium decreases sodium resorption by the renal tubules. If sodium intake is decreased, sodium depletion may occur. In addition, lithium retention is increased when sodium intake is decreased; restricted sodium intake can lead to lithium toxicity. The dosage should not be adjusted without health care provider supervision. It is not necessary to have a snack with milk when the client goes to bed.

***Which characteristics would the nurse anticipate in the infant of a suspected or known opioid abuser? Select all that apply. One, some, or all responses may be correct. 1 Tremors 2 Dehydration 3 Hyperactivity 4 Muscle hypotonicity 5 Prolonged sleep periods

1. Tremors 3. Hyperactivity Opioid dependence in the newborn is physiologic; as the drug is cleared from the body, signs of drug withdrawal become evident. Tremors and hyperactivity are typical signs of cerebral irritability. Dehydration is a result of inadequate feeding, not a direct result of opioid withdrawal. Muscle hypertonicity, not hypotonicity, occurs with opioid withdrawal. Signs of opioid withdrawal include excessive activity and sleep disturbances.

***Place these interventions in priority order, from the least to the most restrictive, when dealing with a bipolar manic client who is threatening staff and clients. 1. Seclusion 2. Restraints 3. Limit-setting 4. Diversional activities 5. Medication administration

1.Diversional activities 2.Limitsetting 4.Medication administration 3.Seclusion 5.Restraints From least to most restrictive interventions: diversional activities, limit-setting, medication administration, seclusion, and restraints. Diversional activities should be the first intervention attempted because they do not involve any restriction on client activities and manic clients are easily distracted. Limit-setting should be the next intervention attempted because it is minimally restrictive. Medication administration, although considered a chemical restraint, is less restrictive than physical restraints or seclusion. Seclusion is more restrictive than medication but less restrictive than restraints. Restraints are the most restrictive intervention in psychiatric nursing.

Which response would the nurse make when trying to help a client with schizophrenia take a shower? 1 "Would you like a shower?" 2 "I'll help you take your shower now." 3 "When do you want your shower, now or later?" 4 "You'll feel so much better if you have a shower."

2. "I'll help you take your shower now." The nurse would say, "I'll help you take your shower now." Stating the intention of helping the client shower is direct, does not require the client to make a decision, provides help, and meets the client's physiological and psychological needs. The schizophrenic client may or may not be capable of making a decision; if the client says no, the nurse will be confronted with a dilemma: Meeting the client's physiological needs will contradict the client's wish not to bathe. Therefore, "Would you like a shower" is inappropriate. The client with schizophrenia may not be able to tell the nurse when the shower is desired (now or later), because the client may be incapable of making a decision. "You'll feel so much better if you have a shower" may be false reassurance; the client with schizophrenia may not be able to process cause and effect.

Which response would the nurse expect from a client with antisocial personality disorder? 1 "I need a lot of help with my troubles." 2 "Society makes people follow rules that don't apply to me." 3 "This might help me straighten out my life." 4 "I don't like to be around other people for long periods of time."

2. "Society makes people follow rules that don't apply to me." The antisocial client is incapable of accepting responsibility for self-created problems and blames society for the behavior. An admission that the client needs a lot of help or that the therapy may help the client straighten out demonstrates insight, and these individuals rarely develop insight into their problems. An antisocial personality disorder does not mean the client doesn't like being around other people; it means the client does not like society's rules and laws (antisocial) and these rules and laws do not apply to him or her.

Which findings would alert the nurse that a client with schizophrenia is experiencing positive symptoms? Select all that apply. One, some, or all responses may be correct. 1 Poverty of speech 2 Agitated behavior 3 Lack of motivation 4 Delusions of grandeur 5 Auditory hallucinations

2. Agitated behavior 4. Delusions of grandeur 5. Auditory hallucinations Positive symptoms include agitated behavior, delusions of grandeur, and auditory hallucinations. Agitated and restless behaviors are positive symptoms of schizophrenia. A delusion is a fixed false belief that is resistant to reasoning; when a person believes that he or she is a famous, historical or fictional omnipotent character, this is called a delusion of grandeur. A delusion is a positive symptom associated with schizophrenia. An auditory hallucination is a sensory perception involving the sense of hearing that occurs in the absence of an external stimulus and is a positive symptom associated with schizophrenia. Decreased verbalization, including a sudden stoppage in the flow of speech (blocking) and lack of inflection, is a negative symptom associated with schizophrenia. Lack of motivation (avolition) and apathy are negative symptoms associated with schizophrenia.

Which finding would the nurse observe in a client with conversion disorder who is unable to move the right arm? 1 Feeling depressed 2 Appearing composed 3 Demonstrating free-floating anxiety 4 Exhibiting tension when discussing symptoms

2. Appearing composed The client would appear composed. The client with a conversion disorder literally converts the anxiety to the symptom. Once the symptom develops, it serves as a defense against the anxiety and the client is diagnostically almost anxiety free. In a conversion disorder, the reactions the nurse would expect to encounter are not in proportion to the disability; therefore, the affected client is usually not depressed. The conflict is resolved by the paralysis of the arm; therefore, the anxiety is under control and the client would not demonstrate free-floating anxiety. These clients usually are calm and composed, not tense, when discussing symptoms.

Which action would the nurse take for a client with borderline personality disorder? 1 Provide an unstructured environment to promote self-expression. 2 Be firm, consistent, and understanding while focusing on specific target behaviors. 3 Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. 4 Record but ignore marked shifts in mood, suicidal threats, and temper displays because these are attention-seeking behaviors.

2. Be firm, consistent, and understanding while focusing on specific target behaviors. The nurse would be firm, consistent, and understanding while focusing on specific target behaviors. 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.

***Chart/Exhibit 1 Client 1--Fatigue Client 2-- Insomnia Client 3-- Chronic Pain Client 4--Sexual Dysfunction Four clients are admitted to a hospital with different symptoms associated with depression. The nurse identifies which client as benefiting mostfrom mirtazapine? 1 Client 1 2 Client 2 3 Client 3 4 Client 4

2. Client 2 Mirtazapine causes substantial sedation. Client 2 would benefit from mirtazapine. Client 1 requires a central nervous system stimulant such as fluoxetine. Client 3 would benefit from duloxetine, a medication that relieves chronic pain. Client 4 would benefit from bupropion, which enhances a person's libido.

During electroconvulsive therapy (ECT), the health care provider administers an electrical shock, and the seizure duration is 60 seconds. Place in priority order the nursing actions that would be taken after the seizure ends. 1. Checking vital signs 2. Ensuring an open airway 3. Assessing the client for the presence of short-term memory loss 4. Providing nourishment because the client has been on nothing-by-mouth (NPO) status 5. Orienting the client to place and time

2. Ensuring an open airway 1. Checking vital signs 5. Orienting the client to place and time 3. Assessing the client for the presence of short-term memory loss 4. Providing nourishment because the client has been on nothing-by-mouth (NPO) status During the seizure the client is not breathing or swallowing, and mucous secretions collect in the oral cavity, so ensuring a patent airway is the priority. ECT and anesthesia can cause significant temporary physiological changes. Check the vital signs to quickly identify and address complications. Orient the client to place and time as the anesthesia wears off to ease the client's anxiety. As the client becomes more alert, ask memory questions to determine the level of short-term memory loss. This is a common side effect of ECT, and presence or absence should be documented. Food and fluids are offered after the client is completely awake, oriented, and stable.

While interviewing the parents of an injured child who is brought to the emergency department, the nurse begins to suspect child abuse. Which parental behaviors might support this conclusion? Select all that apply. One, some, or all responses may be correct. 1 Demonstrating concern for the injured child 2 Focusing on the child's role in sustaining the injury 3 Changing the story of how the child sustained the injury 4 Asking questions about the injury and the child's prognosis 5 Giving an explanation of how the injury occurred that is not consistent with the injury

2. Focusing on the child's role in sustaining the injury 3. Changing the story of how the child sustained the injury 5. Giving an explanation of how the injury occurred that is not consistent with the injury The child is often the scapegoat in the situation; the parents blame the child because they have unrealistic expectations of the child. Discrepancies or inconsistencies between the parents' explanation of the child's injuries and the physical findings are common because the reports are not based in fact. Abusive parents usually do not ask questions about the injury or prognosis and demonstrate little or no interest in their child's well-being.

***Which action would the nurse implement for a client with somatic symptoms? Select all that apply. One, some, or all responses may be correct. 1 Scheduling office visits once a year 2 Having the client direct all requests to the case manager 3 Reminding the client who is in charge of their care 4 Conducting a physical examination only when necessary 5 Explaining to the client that the symptoms are not real 6 Taking vital signs each time client complains of symptoms

2. Having the client direct all requests to the case manager Clients with somatic symptoms would be instructed to direct all requests to the case manager to reduce manipulation. Frequent, brief, and regular office visits are recommended for clients with somatic symptoms. It would be counterproductive to remind the client who is in charge of their care, as power struggles are not helpful. A physical examination would always be conducted. The nurse would never imply that a client's symptoms are not real; rather, the nurse would acknowledge that the psychogenic symptoms are real to the client. After physical complaints have been investigated, the nurse would avoid taking vital signs for each complaint because this further reinforces the somatization.

A client who has schizophrenia sees a group of visitors sitting together and says, "I know they're talking about me." Which altered thought process is the client demonstrating? 1 Flight of ideas 2 Ideas of reference 3 Grandiose delusion 4 Thought broadcasting

2. Ideas of reference In ideas of reference, the client has a delusional belief that she or he is the focus of ordinary events. Flight of ideas is the rapid thinking and speaking seen in clients in a manic state. Grandiose delusions are irrational beliefs that overestimate one's ability or worth. Thought broadcasting is the delusional belief that others can read one's thoughts.

*A client with schizophrenia says to the nurse, "I've been here 5 days. There are five players on a basketball team. I like to play the piano." Which cognitive disorder would the nurse chart the client is experiencing? 1 Word salad 2 Loose association 3 Thought blocking 4 Delusional thinking

2. Loose association The nurse would chart the client is experiencing loose association. These ideas are not well connected, and there is no clear train of thought. This is an example of loose association. Word salad is incoherent expressions containing jumbled words. This client's thoughts are coherent but not connected. Thought blocking occurs when the client loses the train of thinking and ideas are not completed. Each of the client's thoughts is complete but not linked to the next thought. These statements are reality based and not reflective of delusional thinking.

Which outcome would indicate a client who was hospitalized with severe anxiety is ready to be discharged? 1 Follows rules of the milieu 2 Maintains anxiety at a manageable level 3 Verbalizes positive aspects about the self 4 Recognizes that hallucinations can be controlled

2. Maintains anxiety at a manageable level Maintaining anxiety at a manageable level would indicate the client is ready to be discharged. 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 priority outcomes for discharge; the client has probably had little difficulty in these areas. No evidence was presented in the scenario to indicate that the client is hallucinating.

Which priority parameter would the nurse monitor in a young adult client with schizophrenia who says, "The voices in heaven are telling me to come home to God"? 1 Disturbed self-esteem 2 Potential for self-harm 3 Dysfunctional verbal communication 4 Impaired perception of environmental stimuli

2. Potential for self-harm The nurse would monitor the potential for self-harm. Client safety always is a priority, and command hallucinations increase the risk of injury. Although promoting self-esteem is important, this is not a priority at this time. There are no data to support the need to focus on the client's ability to verbally communicate. Verbal hallucinations occur within the individual; they are not precipitated by an environmental stimulus. Illusions are precipitated by an environmental stimulus.

Which nursing intervention would be essential for a client with antisocial personality disorder who is admitted to the mental health hospital? 1 Encouraging interactions with others 2 Presenting a united, consistent staff approach 3 Assuming a nurturing, forgiving tone in disputes 4 Using seclusion when manipulative behaviors are exhibited

2. Presenting a united, consistent staff approach The essential nursing intervention is to present a united, consistent staff approach. Clients with an antisocial personality disorder are experts in manipulation and exploitation; they may ignore rules and divide staff members. These clients do not need to be encouraged to interact with other people, because they are forward in their approach to others. A nurturing, forgiving tone will foster and worsen manipulation, not decrease it. Seclusion is an overreaction to manipulative behaviors; it implies punishment, which is not productive. Seclusion is used only when the client may injure the self or others.

Which characteristic distinguishes post-traumatic stress disorders from other anxiety disorders? 1 Lack of interest in family and others 2 Reliving the trauma in dreams and flashbacks 3 Avoidance of situations that resemble the stress 4 Blunted affect when discussing the traumatic situation

2. Reliving the trauma in dreams and flashbacks Experiencing the actual trauma in dreams or flashbacks is the major symptom that distinguishes post-traumatic stress disorders from other anxiety disorders. Lack of interest in family and others is usually not associated with anxiety disorders. Avoidance of situations that resemble the stress is more common with phobic disorders. Blunted affect that occurs during discussion of a traumatic situation is more characteristic of acute stress disorder.

Which is the professional nurse's legal responsibility regarding child abuse? 1 Honor the request of the parents not to report the suspected abuse. 2 Report any suspected abuse to local law enforcement authorities. 3 Return the child to the legal parent even if he or she is suspected of abuse. 4 Provide the parents with a copy of the child's medical record.

2. Report any suspected abuse to local law enforcement authorities. Nurses and primary health care providers are legally responsible for reporting suspected or actual abuse. Child protective services may obtain a court order to grant temporary guardianship if it is found that the child is in immediate danger. The other answer options do not fulfil the nurse's duty to report suspected child abuse.

Which response would the nurse make when administering an oral medication to an agitated and angry client with schizophrenia who shouts, "Get out of here"? 1 Stating, "You must take your medicine now." 2 Saying, "I'll be back in a few minutes so we can talk." 3 Explaining why it is necessary to take the medication 4 Withholding the medication before notifying the primary health care provider

2. Saying, "I'll be back in a few minutes so we can talk." Saying, "I'll be back in a few minutes so we can talk" allows the angry client time to regain self-control; announcing a plan to return will ease fears of abandonment or retribution. Staying and insisting that the client take the medication may provoke increased anger and further loss of control. Clients will not accept or listen to logical explanations when angry. Thus explaining why it is necessary to take the medication would be ineffective at this time. Alternative nursing interventions should be attempted before withholding the medication and notifying the primary health care provider, although these may become necessary.

For a female sexual assault victim, which information is the most important to document? 1 Observations about the client's reaction to male staff members 2 Statements by the client about the sexual assault and the rapist 3 Information about the client's previous knowledge of the rapist 4 Summary of the client's description of the assault and the rapist

2. Statements by the client about the sexual assault and the rapist Statements by the client about the sexual assault and the rapist eliminate the nurse's subjectivity from the report. Observations about the client's reaction to male staff members is unrelated to the sexual assault itself and are subjective. Eliciting information about the client's previous knowledge of the rapist is not the responsibility of the nurse. Summary of the client's description increases the possibility of nurse subjectivity.

***A client with a new diagnosis of bipolar disorder is prescribed lithium carbonate. Which teaching(s) would the nurse provide to the client after reviewing the information below? Select all that apply. One, some, or all responses may be correct. HGB 14.5 HCT 45% RBC 48 PLT 160,000 WBC 6,600 Neutrophils 140 Na 132 Ca 9 TSH 10 milli-international units/L 1 Lithium can affect white blood cell (WBC) production and increase the client's risk for infection. 2 The client's thyroid function will require frequent assessments while taking lithium. 3 Hyponatremia could lead to lithium toxicity, so the primary health care provider must be notified of the level. 4 Because of the platelet count, neutropenic precautions will be initiated once the client starts lithium therapy. 5 The current hemoglobin and hematocrit levels require regular monitoring once the lithium level stabilizes.

2. The client's thyroid function will require frequent assessments while taking lithium. 3. Hyponatremia could lead to lithium toxicity, so the primary health care provider must be notified of the level. Lithium carbonate therapy can affect thyroid function negatively; the client's current thyroid-stimulating hormone (TSH) is at a high normal level, so frequent checks are appropriate. Low serum sodium levels would result in the kidneys reabsorbing the lithium; this situation would lead to lithium toxicity. The primary health care provider must be notified of the laboratory result. Lithium is not known to have a negative effect on WBC, platelet, or red blood cell (RBC) production.

***Dystonia develops in a client receiving injections of fluphenazine decanoate for schizophrenia. Which clinical manifestations would the nurse document during the assessment? Select all that apply. One, some, or all responses may be correct. 1 Akathisia 2 Torticollis 3 Shuffling gait 4 Masklike facies 5 Oculogyric crisis

2. Torticollis 5. Oculogyric crisis Impaired or distorted muscle tone (dystonia) is a side effect of fluphenazine decanoate; spasms of the neck that pull the head to the side (torticollis) are typical of dystonia. Deviation and fixation of the eyes (oculogyric crisis) are typical of dystonia. The feeling of restlessness and an urgent need for movement (akathisia) is not related to dystonia. Shuffling gait is a symptom of pseudoparkinsonism. A masklike facies is also found in pseudoparkinsonism.

Which short-term client outcome would be priority for a client who has attempted suicide? 1 Strengthening coping skills 2 Establishing a no-suicide contract 3 Learning problem-solving techniques 4 Recognizing why suicide was attempted

2.Establishing a no-suicide contract The priority goal is to establish a no-suicide contract. The primary goal is to keep the client safe. A no-suicide contract secures the client's agreement not to attempt suicide for a specified period and to seek help when suicidal ideas occur. Improving the client's coping skills is part of the treatment plan after the immediate crisis has been controlled. Teaching problem-solving is part of the long-range treatment plan after the immediate crisis is controlled. Recognizing why suicide was attempted is not the primary objective, safety is the primary objective.

***A primary health care provider writes a prescription of "Restraints PRN (as needed)" for a client who has a history of violent behavior. Which action would the nurse take? 1 Ask the health care provider to specify the type of restraint in the prescription. 2 Notify the provider that PRN prescriptions for restraints are unacceptable. 3 Implement the restraint prescription when the client begins to act out. 4 Ensure that the entire staff is aware of the prescription for the restraints.

2.Notify the provider that PRN prescriptions for restraints are unacceptable. A new prescription must be written each time a client requires restraints. When a client acts out, the nurse will use the least restrictive measures, which may progress to seclusion or restraints, and then obtain the necessary prescription that specifies the type of restraint. The entire staff should be aware of the history of violence and be watching for behavioral signs to prevent escalation and the need for restraints.

Which explanation would the nurse include about systematic desensitization for a client who has a phobia about dogs? 1 "You'll be immediately exposed to dogs until you no longer feel anxious." 2 "Rewards will be given when you don't become anxious around dogs." 3 "Your contact with dogs will be increased, and we'll teach you relaxation techniques." 4 "We'll be engaging in detailed discussions to help you identify what caused your phobia."

3. "Your contact with dogs will be increased, and we'll teach you relaxation techniques." The nurse would say, "Your contact with dogs will be increased, and we'll teach you relaxation techniques." Increased contact with the object of the phobia or the situation that causes phobia, accompanied by the use of relaxation techniques, is an accurate description of the behavioral therapy method of systematic desensitization. Immediate exposure to the object or situation that inspires fear until the anxiety is gone is a different behavioral approach called flooding. Giving rewards when the client is no longer made anxious by a fear-inspiring object or situation is a different behavioral approach called operant conditioning. Detailed discussions of the reason for the phobia constitute a type of psychoanalytical therapy rather than a behavioral approach, like systematic desensitization.

***Which behavior would the nurse expect from a client with borderline personality disorder? 1 Act out to intimidate others. 2 Cooperate with the staff to gain praise. 3 Divide the staff into opposing factions to gain self-esteem. 4 Remain removed from others to avoid interacting with them.

3. Divide the staff into opposing factions to gain self-esteem. The nurse would expect the client to divide the staff into opposing factions to gain self-esteem. Attempts at dividing the staff are expected, because the resulting effect creates a feeling of power and control. These individuals usually act out to discharge anxiety rather than to intimidate others. Usually they comply or cooperate to prevent a feeling of abandonment rather than to gain praise. Although these clients may occasionally withdraw from others, they cannot remain removed from others because of their impulsiveness and manipulation. They like the intense interactions.

Which health problem is the most serious complication associated with intractable anorexia nervosa? 1 Endocrine imbalance resulting in amenorrhea 2 Decreased metabolism causing cold intolerance 3 Electrolyte imbalance causing cardiac dysrhythmias 4 Hypoalbuminemia resulting in peripheral edema

3. Electrolyte imbalance causing cardiac dysrhythmias These clients have severely depleted levels of potassium and sodium because of the starvation diet and energy expenditure; these electrolytes are necessary for adequate cardiac function. Although amenorrhea, slowed metabolism, cold intolerance, and hypoalbuminemia may occur, they are less serious.

***The care plan for a client with bulimia nervosa includes "observe client after meals"; however, the client managed to purge four times in the past week. Which action would the nurse use first? 1 Tell the client that all privileges are revoked until the purging stops. 2 Confine the client to his or her bedroom with one-on-one observation. 3 Evaluate the factors that are affecting the success of the intervention. 4 Talk to the staff members who failed to prevent the purging.

3. Evaluate the factors that are affecting the success of the intervention. Observing the client after meals is the only way to ascertain that the client does not engage in purging; however, when a straightforward intervention is not working, the nurse must evaluate factors that are interfering (e.g., staff shortage, client manipulating staff, design of environment prevents observation). Once the constraints are identified, the plan can be revised. Revoking privileges, one-on-one observation, or talking to staff members may be actions that the nurse uses after evaluating the barriers.

Which client finding would indicate that the therapy is beginning to be effective in a client with anorexia nervosa? 1 Hides food in clothes pockets 2 States that the hospitalization has been helpful 3 Has gained 6 lb (2.7 kg) since admission 3 weeks ago 4 Remains in the dining room eating for 1 hour after others have left

3. Has gained 6 lb (2.7 kg) since admission 3 weeks ago Gaining weight is a sign of improvement in a client with anorexia nervosa. Weight gain of 6 lb (2.7 kg) since admission 3 weeks ago is objective proof that the client's eating behaviors have improved. "Stashing" of food is a characteristic of an eating disorder, not a sign of improvement. The statement that the hospitalization has been helpful is subjective information and may be manipulative. "Marathon meals" with little actual food ingestion are common in people with anorexia. Remaining in the dining room eating for 1 hour after others have left is not improvement.

Which action would the nurse anticipate taking when a client with anxiety begins hyperventilating and reports feeling dizzy? 1 Administering oxygen 2 Offering an incentive spirometer 3 Having the client breathe in and out of a paper bag 4 Administering intravenous sodium bicarbonate

3. Having the client breathe in and out of a paper bag The client's dizziness is likely caused by respiratory alkalosis secondary to hyperventilation. Breathing in and out of a paper bag leads to rebreathing exhaled carbon dioxide and resolves the respiratory alkalosis. Administering oxygen is not necessary because there is no evidence of hypoxia. There is no evidence that the client needs an incentive spirometer to prevent atelectasis. The client is already alkalotic; bicarbonate ions will increase the problem.

***Which behavior is most typical for clients with borderline personality disorder? 1 Arrogant 2 Eccentric 3 Impulsive 4 Dependent

3. Impulsive Impulsive, potentially self-damaging behaviors are typical of clients with this personality disorder. Arrogance is associated with a narcissistic personality disorder. Eccentric behavior is more typical of the client with a schizotypal personality disorder. Dependent behavior is associated with dependent personality disorder.

A client with a history of alcoholism develops Wernicke encephalopathy associated with Korsakoff syndrome. Which medication therapy is indicated for management of this condition? 1 Traditional phenothiazines 2 Judicious use of antipsychotics 3 Intramuscular injections of thiamine 4 Oral administration of chlorpromazine

3. Intramuscular injections of thiamine Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs. A traditional phenothiazine is a neuroleptic antipsychotic that should not be prescribed because it is hepatotoxic. Antipsychotics must be avoided; their use has a higher risk of toxic side effects in older or debilitated persons. Chlorpromazine, a neuroleptic, cannot be used because it is severely toxic to the liver.

The nurse is caring for a client who was brought to the emergency department after binge drinking at a party. Which interventions would the nurse include in the plan of care to prevent a suicide attempt? Select all that apply. One, some, or all responses may be correct. 1 Keep door closed for privacy. 2 Allow phone and charger in room. 3 Require sitter in room at all times. 4 Verify medications are swallowed. 5 Use plastic utensils and paper cups.

3. Require sitter in room at all times. 4. Verify medications are swallowed. 5. Use plastic utensils and paper cups. Suicide precautions that should be part of the plan of care for a client on suicide precautions include the use of a safety sitter to stay in the client's room 24 hours a day to provide direct observation at all times. The nurse would verify the client has swallowed all medications administered to prevent hoarding. Clients who plan suicide may attempt to pocket all medications and take them all at once to carry out the plan. The use of plastic utensils and paper cups prevent self-harm from regular utensils and glass cups. The door should remain open at all times for direct observation. The nurse would not permit the client to have the phone charger in the room because the client can use the cord for self-harm.

In which situation would the nurse anticipate naltrexone to be administered? 1 To treat opioid overdose 2 To block the systemic effects of cocaine 3 To decrease the recovering alcoholic's desire to drink 4 To prevent severe withdrawal symptoms from antianxiety agents

3. To decrease the recovering alcoholic's desire to drink Naltrexone is effective in reducing the risk of relapse among recovering alcoholics in conjunction with other types of therapy. Naloxone, not naltrexone, is used for opioid overdose. Naltrexone is not used to treat the effects of cocaine. It is an opioid antagonist. It is not used for antianxiety agent withdrawal.

A client is admitted for severe manic clinical manifestations and is prescribed 200 mg of liquid valproic acid three times a day. Valproic acid is available as 250 mg/5 mL. How many milliliters would the nurse administer? Record your answer as a whole number. ___ mL

4 Solve the problem with the use of the "desire over have" formula of ratio and proportion.

The client with antisocial personality disorder says, "I didn't do much. I watched TV and read a little," when asked how things went yesterday. Which response would be an appropriate confrontational response by the nurse? 1. "It seems that you're expecting us to wave a magic wand that will cure you." 2 "That's not much for someone who wants to get out of the hospital so badly." 3 "Please tell me why you seem to be having difficulty facing up to your part in your problems." 4 "It doesn't sound to me like you've been doing much work on the problems that brought you into the hospital."

4. "It doesn't sound to me like you've been doing much work on the problems that brought you into the hospital." The response, "It doesn't sound to me like you've been doing much work on the problems that brought you into the hospital," is the most appropriate confrontational response. It confronts the client with the fact that the client has not been working on personal problems. The response, "It seems that you're expecting us to wave a magic wand that will cure you," is not confrontational; it is sarcastic, judgmental, and hostile; this will put the client on the defensive. The response, "That's not much for someone to do who wants to get out of the hospital so badly," is not confrontational; it is sarcastic, judgmental, and hostile; this will put the client on the defensive. The response, "Please tell me why you seem to be having difficulty facing up to your part in your problems," requires insight from the client; insight is uncommon in clients with an antisocial personality. This response asks for exploration of an issue rather than confronting a behavior and uses the word why, which is nontherapeutic.

***A client is receiving carbamazepine for the treatment of a manic episode of bipolar disorder. Which information would the nurse include when planning client teaching about this medication? Select all that apply. One, some, or all responses may be correct. 1 "You have to eat a low-sodium diet every day." 2 "You'll have to take a diuretic with this medication." 3 "You'll have to take this medication for the rest of your life." 4 "You may want to suck on sugar-free hard candy when you get a dry mouth." 5 "We'll need to test your blood often during the first few weeks of therapy."

4. "You may want to suck on sugar-free hard candy when you get a dry mouth." 5. "We'll need to test your blood often during the first few weeks of therapy." Sucking on hard candy or frequent rinsing may relieve a dry mouth, a side effect of carbamazepine. It can cause severe bone marrow depression in the early phase of therapy. Also, the medication level needs to be checked frequently to ensure a therapeutic level. A low-sodium diet is not required, nor is a diuretic. The client may or may not have to take the medication for life.

Which action would the nurse take for a client with an obsessive-compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted? 1 Distract the client, which will help the client forget about touching the chairs. 2 Encourage the client to continue touching the chairs as long as the client wants until fatigue sets in. 3 Remove chairs from the hall, thereby relieving the client of the necessity of touching every other one. 4 Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed.

4. Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed. The nurse would allow the behavior to continue for a specified time, letting the client help set the time limits. 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 the client 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.

Which initial action should the nurse take for a client with schizophrenia who sits rocking in a corner for long periods and responds to voices with words that the staff cannot understand? 1 Include the client in a discussion group on the unit. 2 Encourage the client to talk to other clients during the day. 3 Allow the client to be alone while observing from a distance. 4 Arrange the client's day to allow for short periods to be spent with the nurse.

4. Arrange the client's day to allow for short periods to be spent with the nurse. The nurse would initially arrange the client's day to allow for short periods to be spent with the nurse. Clients with schizophrenia manifest psychotic signs and symptoms that preclude interaction with others for more than just short periods. Initially, clients with schizophrenia cannot function in a discussion group. Psychotic manifestations such as fragmented delusions, vague hallucinations, disorientation, and incoherence prevent these clients from interacting with others. Therefore, encouraging the client to talk to others will be unproductive in the beginning stages of hospitalization. Clients with schizophrenia have problems with interpersonal relations because their behavior is often bizarre and disorganized. Allowing the client to be alone will not relieve anxiety; instead, it will foster further withdrawal.

Which action would the nurse take for an adolescent who has been admitted to the psychiatric hospital with a diagnosis of anorexia nervosa? 1 Schedule an endocrinology consult because of amenorrhea. 2 Confront those behaviors that reflect an inflated self-importance. 3 Arrange for psychotherapy sessions to help develop a desire to accommodate others. 4 Develop a contract to achieve a weekly weight gain, with consequences for nonachievement.

4. Develop a contract to achieve a weekly weight gain, with consequences for nonachievement. Treatment usually includes a contract for weight gain, signed by the client, whereby privileges are revoked if the weight is not gained (consequences for nonachievement); the diet and the amount of food eaten are not the focus of care. Menstruation usually ceases because of severe malnutrition, not because of a pathological endocrine condition. These clients have a low self-esteem and do not have an inflated self-importance. Psychotherapy for anorexia nervosa will not focus on a desire to accommodate others but will focus on the control issues and low self-esteem.

A 45-year-old client who recently completed alcohol detoxification reports plans to begin using disulfirams as part of the alcoholism treatment regimen. Which client teaching would the nurse share regarding this medication? 1 Voluntary compliance with the disulfiram regimen is very high. 2 A single dose of oral disulfiram will be effective for up to 72 hours. 3 Disulfiram may be taken intramuscularly and will be effective for as long as 7 days. 4 Foods, medications, and any topical preparation containing alcohol should be avoided.

4. Foods, medications, and any topical preparation containing alcohol should be avoided. Disulfiram causes unpleasant physical effects when mixed with alcohol. Any substance that contains alcohol may trigger an adverse reaction. Voluntary compliance with the use of disulfiram is often very low because of the negative physical effects experienced by the individual if alcohol is ingested. For disulfiram to be effective, it must be taken orally every day. Disulfiram is not administered intramuscularly.

A client in the hyperactive phase of bipolar disorder is receiving lithium. The nurse sees that the client's lithium blood level is 1.8 mEq/L (1.8 mmol/L). Which action would the nurse take? 1 Continuing the usual dose of lithium and noting any adverse reactions 2 Discontinuing the medication until the lithium serum level drops to 0.5 mEq/L (0.5 mmol/L) 3 Asking the health care provider to increase the dose of lithium, because the blood lithium level is too low 4 Holding the medication and notifying the health care provider immediately, because the blood lithium level may be toxic

4. Holding the medication and notifying the health care provider immediately, because the blood lithium level may be toxic The lithium level should be maintained between 0.5 and 1.5 mEq/L (0.5-1.5 mmol/L). The lithium level is currently unsafe but does not need to drop to 0.5 mEq/L (0.5 mmol/L) before being resumed. Continuing the medication and asking the primary health care provider to prescribe a higher dosage are both unsafe options.

***Which action would the nurse take to help a client participate in an activity whose depression is beginning to lift but remains aloof from the other clients on the mental health unit? 1 Find solitary pursuits that the client can enjoy. 2 Speak to the client about the importance of entering into activities. 3 Ask the primary health care provider to speak to the client about participating. 4 Invite another client to take part in a joint activity with the nurse and the client.

4. Invite another client to take part in a joint activity with the nurse and the client. The nurse would invite another client to take part in a joint activity with the nurse and the client. Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time, it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations about the importance of entering into activities will not necessarily change behavior. Asking the primary health care provider to speak to the client about participating transfers the nurse's responsibility to the primary health care provider.

To determine the effectiveness of therapy, which behavior would the nurse assess for in a client with generalized anxiety disorder? 1. Participating in activities 2. Learning how to avoid anxiety 3 Taking medications as prescribed 4 Recognizing when anxiety is developing

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

***Which intervention related to restraint use is appropriate to delegate to nursing assistive personnel (NAP)? Select all that apply. One, some, or all responses may be correct. 1 Appropriate use of restraints 2 Determination of the need for restraints 3 Assessment of the client's behavior 4 Routine checks of the client while in restraints 5 Orientation of the client to the environment

4. Routine checks of the client while in restraints NAP can perform routine checks of the client in restraints. Determination of appropriate use of restraints and the need for restraints; assessment of a client's behavior; and orientation of the client to the environment are not tasks that can be delegated to NAP.

A client with obsessive-compulsive disorder (OCD) begins to perform a ritual that involves several complex hand motions, but it is time for the client to go to group therapy. Which intervention is the best choice? 1 Tell the client to stop going to group until the ritual is controlled. 2 Instruct the client to perform the hand motions for the group. 3 Delay the start of the group session until after the ritual is finished. 4 Tell the client to join the group as soon as the ritual is completed.

4. Tell the client to join the group as soon as the ritual is completed. The purpose of the ritual is to decrease anxiety, so the best choice is to tell the client to join the group as soon as she or he can. This is not ideal; the group norms usually include punctuality. For subsequent sessions the nurse and client would negotiate time for the ritual that did not overlap with the group time. The nurse would not discontinue a therapy without consulting the health care provider and other members of the health care team. Performing the hand motions during the group would be disruptive and distracting to the other group members, and it is likely to increase embarrassment for the client with OCD. Delaying the start of the group is not fair or therapeutic for the other group members.

Which short-term outcome would the nurse use for a client with bulimia nervosa who at times feels helpless in regard to the eating disorder? 1 Practices effective socialization skills 2 Perceives the body shape as acceptable 3 Decreases preoccupation with delusional thoughts 4 Verbalizes the desire to increase control over stressful situations

4. Verbalizes the desire to increase control over stressful situations The short-term goal is to verbalize the desire to increase control over stressful situations. The client needs to learn to cope with stressful life situations effectively rather than resorting to binge-purge behaviors. The first step toward achieving control is expressing a desire to do so. Most clients with bulimia nervosa are socially adept and do not need to focus on improvement in socialization skills. Perception of one's body shape is acceptable as a long-term, not short-term, outcome for a client with bulimia nervosa. Clients with bulimia nervosa do not tend to experience delusional thoughts.