Unit 4 dynamic

A nurse is caring for a client who has borderline personality disorder. The client has previously identified another nurse as his favorite, stating, "He's the best nurse ever." When that nurse calls in sick, which of the following statements indicates that the client is using splitting as a method of coping? A."He's the worst nurse that's ever taken care of me." B."You're just lying to me. He's not really sick." C."He's my favorite nurse, and I'm really worried about him." D."If anyone else tries to take care of me, I'm going to get really upset."

A."He's the worst nurse that's ever taken care of me." The client is using splitting when he relates to others as if they are all good or all bad, rather than as integrated individuals who have both positive and negative attributes.

A nurse is caring for a client who has bipolar disorder. The client states, "My family wants me to come home for a visit. What do you think I should do?" Which of the following responses should the nurse offer? A."Tell me how you are feeling about their request." B."I think it's important for you to spend some time with your family." C."Maybe you shouldn't go if you're not sure about the visit." D."What does your social worker think you should do?"

A."Tell me how you are feeling about their request."

A nurse is reviewing the laboratory report of a client who has been taking lithium carbonate for several months. Which of the following should the nurse recognize as a therapeutic lithium level? A.1.2 mEq/L B.1.6 mEq/L C.2.0 mEq/L D.2.5 mEq/L

A.1.2 mEq/L A lithium level of 1.2 mEq/L is within the expected reference range. Clients taking lithium should drink 6 to 8 glasses of water a day to maintain a normal state of hydration. Clients should also consume an adequate amount of sodium to prevent lithium toxicity.

A nurse on an inpatient mental health unit is attending an interdisciplinary treatment team meeting for a client who has bipolar disorder with rapid cycling. The client is being prepared for discharge following his fourth admission in the last year. Which of the following referrals should the nurse make for the client first? A.Assertive community treatment B.Support group C.Private counseling D.Vocational rehabilitation services

A.Assertive community treatment An ACT program should be most beneficial for this client who has bipolar disorder with rapid cycling, as professional help will be available to the client 24 hours a day for crisis management.

A nurse is caring for a client who has schizophrenia. The client spends a great deal of time repeating rhyming syllables such as, "Me, see, bee, tree." The nurse recognizes that the client is demonstrating which of the following positive manifestations of schizophrenia? A.Clang association B.Echolalia C.Magical thinking D.Word salad

A.Clang association Stringing and repeating words together because of their rhyming sounds is called clang association. Clang association is a positive manifestation of schizophrenia

A nurse is performing an admission assessment on a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect the client to report? (Select all that apply.) A.Difficulty sleeping for several weeks B.Inability to concentrate on simple tasks C.Desire for sexual activity with multiple partners D.Absence of bathing for several days E.Lack of enjoyment from a long-time hobby of gardening

A.Difficulty sleeping for several weeks B.Inability to concentrate on simple tasks D.Absence of bathing for several days E.Lack of enjoyment from a long-time hobby of gardening

A nurse on an acute care unit is providing postoperative care to an older adult client who develops delirium. Which of the following actions should the nurse take? A.Request a prescription for an antianxiety medication B.Provide the client with a stimulating activity prior to bedtime C.Dim the lights in the client's room at night D.Encourage the client to make decisions about her daily routine

A.Request a prescription for an antianxiety medication

A nurse in a community mental health facility is caring for 4 clients. Which of the following clients should the nurse identify as experiencing an adventitious crisis? A.A client who has a new diagnosis of severe bipolar disorder B.A client who is depressed following a devastating fire in her home C.A client who is experiencing acute grief following his father's death D.A client who is experiencing postpartum depression following the birth of her first child

B.A client who is depressed following a devastating fire in her home The nurse should identify that a client who is experiencing depression following a house fire is experiencing an adventitious crisis. An adventitious crisis is unplanned and not a part of everyday life. The crisis can result from a natural disaster, a national disaster, or a crime of violence.

A nurse is caring for a client who has schizophrenia and started taking a first-generation antipsychotic medication 3 weeks ago. The client reports a feeling of inner restlessness, rocks back and forth when sitting down, and paces frequently. The nurse should identify that the client is experiencing which of the following adverse effects of antipsychotic medications? A.Neuroleptic malignant syndrome B.Akathisia C.Anticholinergic toxicity D.Opisthotonos

B.Akathisia Akathisia is an extrapyramidal adverse effect that can occur in a client within the first 2 months of beginning a first-generation antipsychotic medication. The client might be unable to rest due to a feeling of inner restlessness. Rocking back and forth and pacing the floor can also be manifestations of akathisia.

A nurse is admitting a client who has antisocial personality disorder to an acute care unit. The client is admitted under a court order following the theft and destruction of a car. Which of the following behaviors should the nurse expect the client to display? A.Relief about finally receiving care B.Anger with the nursing staff for hospitalizing him against his will C.Withdrawal from others due to shame over his recent actions D.Remorse for stealing and destroying the car

B.Anger with the nursing staff for hospitalizing him against his will A client who has antisocial personality disorder exhibits a low frustration level and can quickly become angry and aggressive when the situation does not meet his or her will or desires.

A nurse is caring for a client with bipolar disorder who is experiencing mania. Which of the following actions is the nurse's priority? A.Offer the client finger foods every 2 hours B.Determine if the client is a danger to herself C.Monitor the client's vital signs every 2 hours D.Move the client to a quiet area

B.Determine if the client is a danger to herself

A nurse is updating the plan of care for a client who has major depression and a new prescription for amitriptyline. The nurse should plan to monitor the client for which of the following adverse effects? A.Hypertension B.Drowsiness C.Panic attacks D.Diarrhea

B.Drowsiness

A nurse is planning care for a client who has bipolar disorder and has acute mania. Which of the following interventions should the nurse include in the plan? A.Provide the client with a low-calorie, low-fat diet B.Encourage the client to have frequent rest periods C.Escort the client to daily group therapy D.Limit the client's intake of caffeinated beverages to 12 oz per day

B.Encourage the client to have frequent rest periods The nurse should encourage the client to have frequent rest periods throughout the day to decrease the client's risk of exhaustion. Because of the constant activity associated with acute mania, the nurse should encourage brief rest periods each hour.

A nurse is assessing a client who has major depressive disorder. Which of the following questions should the nurse prioritize when speaking with the client? A."Do you have any close friends?" B. "Can you describe how you feel about what's happening?" C."Have you thought about hurting yourself?" D."How are you dealing with being away from your family?"

C."Have you thought about hurting yourself?"

A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates that the client is displaying cognitive symptoms? A."I just feel so hopeless." B."The government has been watching my house." C."I am unable to remember to brush my teeth." D."I no longer enjoy the activities I used to love."

C."I am unable to remember to brush my teeth." The nurse should recognize that memory impairment is a cognitive symptom of schizophrenia. Other cognitive symptoms include impaired concentration, judgment, and problem-solving.

A nurse on a mental health unit is observing a client who has schizophrenia. Which of the following client statements should the nurse recognize as clang association? A."Her mannerologies are poor." B."My dog blank a boat to supreme heights." C."I can play the flute while wearing a suit. You are cute." D."My joints ache. My friend is in the joint."

C."I can play the flute while wearing a suit. You are cute."

A nurse is caring for a client who has antisocial personality disorder. The client uses manipulation to gain access to a smoking area from which his access has been limited as a behavioral intervention. Which of the following statements should the nurse make? A."You know you shouldn't use the smoking area." B."You know that manipulation is not the right thing to do." C."Let's review the consequences of your actions." D."I can talk with the provider about reducing your smoking restriction."

C."Let's review the consequences of your actions." When communicating with a client who has antisocial personality disorder, the nurse should set clear and realistic limits on behavior that all staff members adhere to, identify the client's undesirable behavior, and communicate the consequences of that behavior.

A nurse is caring for a client who has bipolar disorder and has been prescribed lithium. The client's adult child states, "I'm upset that my father is taking this medication." Which of the following responses should the nurse make? A."It will be alright because your father's provider knows what to do." B."You should be more concerned about your father's mania, which puts him at risk for injury." C."Tell me what worries you have about your father taking this medication." D."This is an important medication to treat your father's condition."

C."Tell me what worries you have about your father taking this medication."

A nurse is performing an admission assessment for a client who has schizophrenia. The client suddenly stops talking and begins staring intently at a chair in the corner of the room. Which of the following responses should the nurse make? A."Please try to focus on our conversation." B."There is nothing over there except a chair." C."Tell me what you are seeing by that chair." D."Whatever you are seeing by that chair is not real."

C."Tell me what you are seeing by that chair."

A nurse is caring for a client who reports that the television set in the room is really a 2-way radio and states, "Voices are coming from the TV, and everything we say in this room is being recorded." Which of the following responses should the nurse offer? A."What we say is not being recorded." B."Let's ignore the voices and talk about something else." C."That must be very frightening." D."Why do you think the TV is a 2-way radio?"

C."That must be very frightening." The nurse should respond to the client's delusion in a calm and empathetic manner. By acknowledging to the client that the delusion must be frightening, the nurse promotes the nurse-client relationship.

A nurse is caring for a client who has schizophrenia. Which of the following client statements should the nurse identify as a persecutory delusion? A."A tornado is going to wipe us out in 9 days." B."My brain is dead, and my body is slowly rotting away." C."The government is after me because I know top-secret information." D."The TV is purposely playing commercials for products I don't like."

C."The government is after me because I know top-secret information."

A nurse is assessing a newly admitted client who has schizophrenia. The client suddenly looks at an empty chair and appears to be listening to something. Which of the following responses should the nurse make? A."I thought I heard something too." B."Is someone telling you something?" C."What are you hearing?" D."There is nobody in that chair for you to listen to."

C."What are you hearing?"

A nurse is planning to administer a dose of lithium carbonate to a client who has bipolar disorder. The laboratory report indicates the client's current lithium level is 1.0 mEq/L. Which of the following actions should the nurse take? A.Contact the provider for a dosage increase B.Request a repeat of the lithium level C.Administer the medication D.Prepare the client for gastric lavage

C.Administer the medication The nurse should administer the medication because the client's lithium level is within the expected reference range.

A nurse is caring for a client who has schizophrenia. The nurse notices that the client is pacing up and down the hall rapidly and muttering in an angry manner. Which of the following actions should the nurse perform first? A.Apply mechanical restraints to the client B.Administer PRN haloperidol IM to the client C.Approach the client in a non-threatening manner D.Place the client in seclusion

C.Approach the client in a non-threatening manner

A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client? A.Spaghetti with meatballs, a salad, and apple pie B.Beef and vegetable stew, rice, and vanilla pudding C.Chicken nuggets, crackers with cheese sticks, and a cookie D.Broiled fish fillets, stewed tomatoes, and ice cream

C.Chicken nuggets, crackers with cheese sticks, and a cookie A client who is in the manic phase of bipolar disorder should receive high-calorie finger foods that can be carried and are relatively easy to manipulate. This meal is a good choice for a client who is hyperactive, has a short attention span, and might not sit down to eat.

A nurse is caring for a client with borderline personality disorder (BPD) who exhibits a pattern of behavior of playing a staff member against another. Which of the following actions should the nurse take? A.Have the same staff members work with the client on a long-term basis B.Sit down and listen to the client's feelings about other staff members C.Explore with the client his use of clinging and distancing behaviors D.Arrange for the client to share complaints regarding staff members with the nursing supervisor

C.Explore with the client his use of clinging and distancing behaviors Splitting is a common defense mechanism demonstrated by clients who have BPD in which the client plays one staff member against another. First, the client expresses feelings of attachment toward a certain staff member and then abruptly begins issuing complaints about this person to other staff members.

A nurse is caring for a client who has bipolar disorder. Which of the following manifestations is the priority finding for the nurse to identify? A.Inability to concentrate B.Poor hygiene C.Hyperactivity D.Pressured speech

C.Hyperactivity

A nurse is performing an admission assessment for a client who has schizophrenia. The nurse notices that the client's appearance is unkempt, and he appears to be actively hallucinating. Which of the following should be the nurse's priority assessment? A.Perception of reality B.Ability to follow directions C.Physical needs D.Mental status

C.Physical needs These levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential while problem-solving and coping with life situations.

A nurse in an acute mental health facility is caring for a client who is experiencing an acute manic episode. Which of the following actions is the nurse's priority? A.Maintain the client's contact with her family. B.Discourage the client's use of vulgar language. C.Protect the client from impulsive behavior. D.Redirect the client's excessive energy to creative tasks.

C.Protect the client from impulsive behavior.

A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior? A.Confront the client for breaking the rules B.Stand near the client to offer comfort and support C.Speak to the client with clear, calm, caring statements D.Escort the client to the nurses' station

C.Speak to the client with clear, calm, caring statements To remain in control of the situation, the nurse should use clear, calm statements that are non-threatening to the client. The nurse should also set limits for clients who exhibit potentially violent behavior.

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. Which of the following medications may be administered safely while the client is taking lithium? A.Ibuprofen B.Haloperidol C.Valproic acid D.Hydrochlorothiazide

C.Valproic acid Valproic acid and lithium are both indicated for the treatment of bipolar disorder. The nurse may safely administer both of these medications to the client.

A nurse is caring for a client who has schizophrenia. Which of the following client statements indicates clang associations? A."I am the king, and everyone should bow to me." B."I'm feeling schmoolizious today." C."Option, contrary, moose, allergic." D."Basketball in the hall very tall."

D."Basketball in the hall very tall." A client who speaks using clang associations is choosing words based on their sound rather than meaning. The words often rhyme.

A nurse is evaluating teaching for a client who has bipolar disorder and a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching? A."I should take lithium on an empty stomach." B."I can take ibuprofen for headaches while taking lithium." C."I need to limit my salt intake while taking lithium." D."I am likely to gain weight while taking lithium."

D."I am likely to gain weight while taking lithium." The nurse should instruct the client to eat a low-calorie diet while taking lithium because this medication can cause weight gain.

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? A."Can you tell me why you do not want to participate in the planned group activity?" B."Do you understand that psychotropic medications cause weight gain?" C."The aerobics class will be more effective at burning calories than walking." D."It sounds like you have come up with an alternative exercise that works for you."

D."It sounds like you have come up with an alternative exercise that works for you."

A nurse is providing teaching to the family of a client who has schizophrenia. Which of the following statements by a family member indicates an understanding of the teaching? A."We will not set time limits for discussing her delusions." B."We will avoid reacting to her command hallucinations." C."She might lose weight due to her medications." D."She might be having a relapse if she stops attending social events."

D."She might be having a relapse if she stops attending social events." The family of a client who has schizophrenia should be taught the signs of relapse, including avoiding other people, sleep disturbances, difficulty concentrating, and being unable to tell reality from nonreality.

A nurse is caring for a client who has schizophrenia. The client states, "Aliens came into my room last night and took a sample of my blood." Which of the following responses should the nurse make? A."Aliens do not exist." B."Has your daughter had her baby?" C."Do you mean to say a laboratory technician drew your blood last night?" D."That does not sound real."

D."That does not sound real."

A nurse is caring for a client who has schizophrenia and is admitted to the mental health unit. The client has a history of aggression and is observed continually pacing the hallway in an agitated manner over the past hour. Which of the following responses should the nurse make? A."It's a beautiful day outside. Let's take a walk together." B."Sit down and we'll try out a relaxation exercise." C."Would you like your anti-anxiety medication now?" D."You are pacing back and forth. Can you tell me what you are feeling?"

D."You are pacing back and forth. Can you tell me what you are feeling?"

A nurse at an acute mental health facility is caring for a client who has acute mania due to bipolar disorder. At 0300, the client runs to the nurse's station and demands to see the provider immediately. Which of the following responses should the nurse offer? A."Your request is unreasonable. We cannot call your provider at 3:00 in the morning." B."If you can calm down for 5 min, then I will call your provider for you." C."Calm down, go back to your room, and come back in 15 min so we can talk about how you're feeling." D."You must be very upset about something to want to see your provider in the middle of the night."

D."You must be very upset about something to want to see your provider in the middle of the night."

A nurse is providing teaching to a client who is scheduled to start taking valproic acid. Which of the following instructions should the nurse include? A."You should expect the provider to decrease your dosage of valproic acid gradually." B."You should take aspirin for pain while taking valproic acid." C."You should undergo thyroid function tests every 6 months while taking valproic acid." D."You should have your liver function levels monitored regularly while taking valproic acid."

D."You should have your liver function levels monitored regularly while taking valproic acid."

A nurse is collecting data from a client with schizophrenia who was recently admitted to acute care. Which of the following findings should the nurse expect? A.Seductive behaviors B.Obsession with rituals C.Uncontrolled appetite D.Associative looseness

D.Associative looseness The nurse should recognize associative looseness (speech that reveals thought patterns that shift rapidly from one topic to another) as a common finding for a client who has schizophrenia. Other findings include the presence of delusions, hallucinations, and altered speech patterns, such as echolalia.

A nurse is admitting a client who has schizophrenia. During the initial interview, which of the following behaviors should the nurse identify as a positive manifestation of schizophrenia? A.Anhedonia B.Avolition C.Flat affect D.Hallucinations

D.Hallucinations Positive manifestations of schizophrenia are behaviors or thought patterns that are not usually present. Positive manifestations include hallucinations, religiosity, delusions, paranoia, and disorganized speech.

A nurse is assessing a client who has schizophrenia. The client states, "I need to get my gummamoshu from by my house." The nurse recognizes this statement as an example of which of the following? A.Flight of ideas B.Echolalia C.Perseveration D.Neologism

D.Neologism The nurse should recognize the client's response as a neologism, an invented word which has no meaning to others.

A nurse in a mental health clinic is assessing a client who has a history of mania. Which of the following findings indicates that the client is experiencing a relapse? A.Weight gain B.Ritualistic behavior C.Anhedonia D.Pressured speech

D.Pressured speech Pressured speech is an indication of a relapse in a client who has mania.

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan? A.Discourage the client from taking naps during the day. B.Allow the client to choose which items of clothing to wear each day. C.Encourage the client to participate in group therapy. D.Provide the client frequently with high-calorie finger-foods.

D.Provide the client frequently with high-calorie finger-foods.

A nurse is working with a client who exhibits extreme superstition, elaborate speech patterns, and eccentric behavior. The nurse should identify these features as which of the following personality disorders? A.Paranoid B.Histrionic C.Antisocial D.Schizotypal

D.Schizotypal Findings of schizotypal personality disorder include a pattern of social impairments and cognitive alterations, including superstitious actions that are not congruent with the client's cultural norms and speech changes (e.g. an increase in the use of metaphors and other elaborate speech patterns).

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. Which of the following manifestations should the nurse expect? A.Hallucinations B.Impaired memory C.Dysphoria D.Social discomfort

D.Social discomfort The absence of something that should be present is considered a negative symptom of schizophrenia.

A nurse is providing discharge teaching to the guardians of an adolescent who has bipolar disorder. Which of the following manifestations should the nurse identify as an indication of acute mania? (Select all that apply.) A.Completes school projects B.Naps during the daytime C.Eats large amounts D.Spends excessive amounts of money E.Speaks crassly using a loud voice

D.Spends excessive amounts of money E.Speaks crassly using a loud voice The nurse should identify that a client who has acute mania is impulsive and at risk for spending excessive amounts of money despite financial status.