10, 15, 16,12,17,24,32,11,18,23 varacolis
a kindergartner is disruptive in class. This child is unable to sit for expected lengths of time, inattentive to teacher, screams while the teacher is talking, and is aggressive toward other children. The nurse plans interventions designed to achieve what?
loneliness and increase self-esteem
a client experiences a sudden episode of severe anxiety. of these medications in the clients medical record, which is most appropriate to give as a prn anxiolytic
lorazepam
a nurse wants to teach alternative coping strategies to a client experiencing severe anxiety. Which action should the nurse perform first
lower the clients current anxiety
a client insistently states, "i can decipher codes of DNA just by looking at someone." Which problem is evident
magical thinking
a client diagnosed with schizophrenia anxiously says, "I can see the left side of my body merging with the wall, then my face appears and disappears in the mirror" while listening, the nurse should engage in what behavior?
maintain a normal social interaction distance from client
a nurse will prepare teaching materials for parents of a child newly diagnosed with ADHD. Infomation will focus on which medication will be prescribed
methylphenidate
the adult child of a client diagnosed with major depressive disorder asks, "do you think depression and physical illness are connected? since my father's death, my mother has had shingles and the flu, but she's usually not the one who gets sick"
negative emotions and prolonged stress interfere with the body's ability to protect itself and can increase likelihood of illness
a client receiving risperidone reports severe muscle stiffness at 1030. By 12:00, the client has difficulty swallowing and is drooling. By 1600, vital signs are 102.8; pulse 110, respirations 26; 150/90. the client is diaphoresis. What is the nurse's best analysis and action?
neuroleptic malignant syndrome; notify health care provider stat
a client diagnosed with schizophrenia has taken a conventional antipsychotic medication for a year. Hallucinations are less intrusive, but the client continues to have apathy, poverty of thought, and social isolation. The nurse would expect a change to which medication?
olanzapine
a client diagnosed with schizophrenia says, "contagious bacteria are everywhere. When they get in your body, you will be locked up with other infected people." Which problem is evident
paranoia
a newly admitted client diagnosed with schizophrenia is hyper vigilant and constantly scans the environment. The client stats, "I saw two doctors talking in the hall. They were plotting to kill me" The nurse may correctly asses this behavior using which term
paranoia
a client diagnosed with schizophrenia demonstrates little spontaneous movement and has catatonia. The clients activities of daily living are severely compromised. What will be an appropriate outcome for this client.
performs self-care activities with coaching by the end of day 3
a client says," one result of my chronic stress is that I feel so tired. I usually sleep from 11:00 PM to 6:30 Am. I started setting my alarm to give me an extra 30 minutes of sleep each morning, but I don't feel any better and I'm rushed for work
perhaps going to bed a half-hour earlier would work better than sleeping later
a client diagnosed with schizophrenia exhibits little spontaneous movement and demonstrates catatonia. Which client needs are of priority importance?
physiological
when group therapy is prescribed as a treatment modality, the nurse would suggest placement of a 9 year old in a group that uses what strategy
play and talk about a play activity
the nurse assesses a client diagnosed with schizophrenia. Which assessment finding would the nurse regard as a negative symptom of schizophrenia.
poor personal hygiene
which finding constitutes a negative symptom associated with schizophrenia
poverty of thought
which client focused scenario best demonstrates an example of eustress
prepares to take a vacation to a tropical island with a group of cross friends
a client preparing for surgery has moderate anxiety and is unable to understand preoperative information. which nursing intervention is most appropriate
present the information again in a calm manner using simple language
two staff nurses applied for a charge nurse position. After the promotion was announced, the nurse who was not promoted said, "the nurse manager had a headache the day I was interviewed:" which defense mechanism is evident
projection
a client fearfully runs form chair to chair crying. "they're coming. they're coming." the client does not follow the staffs directions or respond to verbal interventions. What is the initial nursing intervention of highest priority
providing for the client's safety
a client diagnosed with schizophrenia has taken fluphenazine 5 mg p.o. bid for 3 weeks. The nurse now observes a shuffling propulsive gait, a mask-like face, and drooling. Which term applies to these symptoms
pseudoparkinsonism
the family of a client diagnosed with schizophrenia is unfamiliar with the illness and family's role in recovery. Which type of therapy should the nurse recommend
psycho educational
a client tells a nurse, " My best friend is the perfect person. she is kind, considerate, good looking, and successful with every task. I could have been like her If i had the opportunities, luck and money she had: This client is demonstrating
rationalization
an individual experiences sexual dysfunction and blames it on a partner by calling the person unattractive and unromantic.
rationalization
a person speaking about a rival for a significant other's affection says in an emotion , syrupy voice, "what a lovely person. that's someone I adore" what is the defense mechanism
reaction formation
a client diagnosed with schizophrenia has been stable for a years however, the family now reports the client is tense, sleeps 3 to 4 hours per night, and has difficulty concentrating. The client says, "my computer is sending out infected radiation beams." The nurse can correctly assess this information as an indiction of what?
relapse
a parent diagnosed with schizophrenia and 13 year old child live in a homeless shelter. The child formed a trusting relationship with a shelter volunteer. The child says, "my three friends and I got an A on our school science project." The nurse can assess that the child is demonstrating
resiliency
when a client diagnosed with schizophrenia was discharged 6 months ago, haloperidol was prescribed. The client now says, "I stopped taking those pills. They made me feel like a robot." what are common side effects the nurse should validate with the client
sedation and muscle stiffness
a person has minor physical injuries after an auto accident. The person is unable to focus and says, "I feel like something awful is going to happen" This person have nausea, dizziness, tachycardia, and hyperventilation. What is the person's level of anxiety. What is the persons level of anxiety
severe
when a 5 year old is disruptive, the nurse says, "you must take a time-out" the expectation is that the child will do what?
sit on the edge of the activity until able to regain self-control
what is the nurse's priority focused assessment for side effects in a child taking metadate for ADHD
sleep disturbances and weight loss
soon after parents announced they were divorcing, a child stopped participating in sports, sat alone at lunch, and avoided former friends. The child told the school nurse, "if my parents loved me, they would work out their problems" Which diagnosis has the highest priority
social isolation
a desired outcome for a 12 year old diagnosed with ADHD is to improve relationships with other children. Which treatment modality should the nurse suggest
social skills group
a recent immigrant from honduras comes to the clinic with a family member who has been a U.S. resident for 10 years. The family member says, "the immigration to America has been very difficult." Considering cultural background, which expression of stress by this client would the nurse expect?
somatic complaints
A client newly diagnosed as HIV-positive seeks the nurse's advice on how to reduce risk of infections. The client says, :I went to church tears ago and I was in my best health then. Maybe I should stat going to church again." Which response will the nurse offer?
studies show that spiritual practices can enhance immune system function and coping abilities
a person with a fear of heights drives across a high bridge. Which division of the ANS will be stimulated
sympathetic nervous system
when a 5 year old diagnosed with ADHD bounces out of a chair and runs over and slaps another child, what is the nurse's best action?
take the aggressive child to another room
a nurse educates a client about the antipsychotic medication regime. Afterward, which comment by the client indicates the teaching was effective
taking this medication regularly will reduce the severity of my symptoms
a client diagnosed with schizophrenia has received fluphenazine decanoate twice a month for 3 years. the clinic nurse notes that the client grimaces and constantly smacks both lips. The client's neck and shoulders twist in a slow, snakelike motion. Which problem would the nurse suspect?
tardive dyskinesia
a client tells the nurse, "my primary provider thinks my problems with stress relate to negative way I think about things and suggested I learn new ways of thinking
teach the client to recognize, reconsider, and reframe irrational thoughts
a client reports, "I am overwhelmed by stress." Which question by the nurse would be moist important to use in initial assessment of this client
tell me about the kinds of things you to reduce or cope with your stress
a client says, "facebook has a new tracking capacity. if I use the internet, homeland security will detain me as a terrorist" What is the nurse's best initial response
tell the client, "you are in a safe place where your will be helped"
which assessment finding would cause the nurse to consider a child to be most at risk for developing a mental illness?
the child has been raised by a parent with recurring major depressive disorder
a client who had been experiencing significant stress learned to use progressive muscle relaxation and deep breathing exercises. When the client returns to the clinic 2 weeks later, which findings most clearly shows the client is coping more effectively with stress?
the client's systolic blood pressure has changed from the 140s to the 120s
a nurse asks a client diagnosed with schizophrenia, "What is meant by the old saying, "You cant judge a book by looking at the cover?" which response by the client indicates concrete thinking?
the table of contents tells what a book is about
the parent of a child diagnosed with tourette's disorder says to the nurse, "I think my child is faking the tics because they come and go." Which response is accurate
tics often change frequency or severity. That doesn't mean they arent real
a client diagnosed with schizophrenia begins a new prescription for ziprasidone. The client is 5'6 and currently weighs 204 pounds. The client has dry flaky skin, headaches about 2x a month, and a family history of colon cancer. Which intervention has the highest priority for the nurse to include in the client's plan of care
weight management strategies
a client diagnosed with schizophrenia anxiously tells the nurse, "the voice is telling me to do things" what is the nurse's priority assessment question
what is the voice telling you to do ?
what assessment findings mark the prodromal stage of schizophrenia
withdrawal, misinterpreting, poor concentration, and preoccupation with religion
a newly hospitalized client experiencing psychosis says, "red chair out town board." which term should the nurse use to document this finding
world salad
a nurse assess a 3 year old diagnosed with an autism spectrum disorder. Which finding is most associated with the child's disorder
continuously rocks in place for 30 minutes
which behavior indicates that the treatment plan for a child diagnosed with an autism spectrum disorder was effective
holds the parents and while walking
a person with fear of heights drives across a high bridge. Which structure will stimulate a response from ANS
hypothalamus
a client diagnosed with schizophrenia tells the nurse, "I eat skiller. Tend to end. Easter. It blows away. Get it?" What is the nurse's most therapeutic response
i am having difficulty understanding what are you saying
a newly admitted client diagnosed with schizophrenia says, "the voices are bothering me. They yell and tell me I am bad. I have got to get away from them" Most helpful reply from nurse
ill stay with you. focus on what we're are talking about, not the voices.
which nursing diagnosis is universally applicable for children diagnosed with autism spectrum disorders
impaired social interaction related to difficulty maintaining relationships
a child diagnosed with ADHD shows hyperactivity, aggression, and impaired play. The healthcare provider prescribed amhetamine salts. The nurse should monitor for which desired behavior
improved abilities to participate in cooperative play with children
assessment data for a 7 year old reveals an inability to take turns, blurting out answers to questions before answer is complete and frequently interrupting others' conversations. How should the nurse document these behaviors
impulsivity
a nurse leads a psycho educational group about problem solving with seizures adults diagnosed with schizophrenia. Which teaching strategy is likely to be most effective.
invite participants to come up with solution to getting incorrect change for purchase.
typically antipsychotic drugs often produce sedation and extraoyramidal side effects such as stiffness and gait disturbance, effects the client might describe as making him or her feel like a "robot." The side effects mentioned in other options are usually not associated typical antipsychotic therapy or would not have effect described by the client
"the voices say everyone is trying to kill me"
a nurse sits with a client diagnosed with schizophrenia. The client starts to laugh uncontrollably, although the ruse has not said anything funny. What is the nurse's therapeutic response?
"you're laughing. Tell me what's happening."
which changes reflect short-term physiological responses to stress?
-muscular tension, BP, and triglycerides increase. -epinephrine is released, increasing heart and respiratory rate -corticosteroids release increases stamina and impedes digestion -corticosteroids is released, increasing glucogenesis and reducing fluid loss
the child prescribed an antipsychotic medication to manage violent behavior is one most likely diagnosed with what disorder
ADHD
the parent of a 6 year old says, "my child is in constant motion and talks all the time. My child isn't interested in toys but is out of bed every morning before me" the child's behavior is most consistent with
ADHD
a child diagnosed with ADHD will begin medication therapy. The nurse should prepare a plan to teach the family about which classification of medications
CNS stimulants
a client tells the nurse, " I will never be happy until Im as successful as my older sister" the nurse asks teh client to reassess this statement and reframe it. Which reframed statement by the client is most likely to promote coping
I can find contentment in succeeding at my own job level
a client experiencing moderate anxiety says, "I feel undone.": What would be the appropriate response by the nurse
I'm not sure I understand. give me an example
a client tells the nurse, :I. know that I should reduce the stress in my life, but I have no idea where to start"
Let's talk about what is going on in your life and then look at possible options
A client is brought to the ED after a motorcycle accident. The client is alert, responsive, and diagnosed with a broken leg. The client's vital signs are pulse 72 and RR 16. After being informed surgery is required for broken leg, which vital signs would be expected
PR 80 and RR 20
a client experiencing significant stress associated with a disturbing. new medical diagnosis asks the nurse, "Do you think saying a prayer would help?"
You may find prayer gives you comfort and lowers your stress
which child demonstrates behaviors indicative of neurodevelopmental disorder
a 3 year old who is mute, passive toward adults and twirls while walking
a client diagnosed with schizophrenia begins to talks about "macnabs" hiding in the warehouse at work. The client's use of the word should be documented using what term
a neologism
according to recent life changes question are, which situation would most necessitate a complete assessment of a person's stress status and coping abilities?
a person returning to college after an employer ceased operations
a nurse leads a psycho educational group about first generation antipsychotic medications with six adult men diagnosed with schizophrenia. The nurse will monitor for concerns regarding body image with respect to which potential side effects of these medications
gynecomastia
a nurse works with a child's who is sad and irritable because the child's parents are divorcing. why is establishing a therapeutic alliance with this child a priority?
acceptance and trust convey feelings of security to the child
an acutely violent client diagnosed with schizophrenia recieved doses of haloperidol. Two hours later the nurse notices the client's head rotated to one side in a stiffy fixed position, the lower jaw thrust forward, and drooling. Which intervention by the nurse is indicated?
administer diphenhydramine 50 mg IM from the prn medication administration record
two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had feelings f loss but then became supportive of new manager by helping make the transition smooth and encouraging others. Which best term describes nurse response
altruism
a client diagnosed with schizophrenia is very disturbed and violent. After several doses of haloperidol, the client is calm. Two hours later the nurse sees the client's head rotated to one side in a stiff position, the lower jaw thrust forward, and drooling. Which problem is most likely?
an acute dystonic reaction
a client in the ED shows disorganized behavior and incoherent e after a friend suggested a homosexual encounter. Which room should the nurse place the client?
an interview room furnished with a desk and two chairs
a health care provider considers which antipsychotic medication to prescribe for a client diagnosed with schizophrenia who has auditory hallucinations and poor social functioning client is also overweight and hypertensive. Which drug should the nurse advocate
aripiprazole
a client diagnosed with schizophrenia says, "its beat. Time to eat. No room for the cat." what type of verbalization is evident
associative looseness
a nurse observes a catatonic client standing immobile, facing the wall with one arm extended in a salute. The client remains immobile in this position for 15 minutes, moving only when the nurse gently lowers the arm. What is the name of this phenomenon
catatonia
a woman is 5'7 160 lb wears a size 8 shoe. She says, My feet are so huge. Ive asked 3 orthopedist to surgical reduce my feet." this person tries to buy shoes to make her feet look smaller and in social setting, conceals both feet under a table or chair. Which health problem is likely
body dysmorphic disorder
a client checks and rechecks electrical cords related to an obsessive thought that the house may burn down. The nurse client explore the likelihood of an actual fire. the client states this event is not likely. This counseling demonstrates what appropriate principle of therapy
cognitive restructuring
a person who feels unattractive repeadtly says, "although i'm not beautiful, I am smart: This is an example of what defense mechanism
compensation
a client is experiencing moderate anxiety. The nurse encourages the client to talk about feelings and concerns. What is the rationale for this intervention
concerns stated aloud become less overwhelming and help problem solving begin
a nurse leads a psycho educational group for clients experiencing depression. The nurse plans to implement an exercise regime for each client. What rationale will the nurse use when presenting this plan of treatment team concerning the benefits of exercise?
has been identified as having a diminished effect on cytokines
a client diagnosed with schizophrenia says, "my co-workers are out to get me. I also saw two doctors plotting to kill me." How does this client perceive the environment
dangerous
a client's care plan includes monitoring for auditory hallucinations. Which assessment finding suggest the client may be hallucinating
darting eyes, tilted head, mumbling to self
a client undergoing diagnostic tests says, "nothing is wrong with me expect a stubborn chest cold." The spouse reports the client smokes, cough daily, lost 15 pounds, and easily fatigued. Which defense mechanism is the client using
denial
a client nervously says, "financial problems are stressing my marriage. I've heard rumors about cutbacks at work; I am afraid I might get laid off." the client's pulse is 112/minute; RR 26/minute and BP 166/88. Which nursing intervention will the nurse implement
direct the client in slow and deep breathing using abdominal muscles
when a nurse asks a newly admitted client to describe social supports, the client says, "My parents died last year, and I have no family. I am newly divorced and my former in-laws blame me. I dont have many friends because most people my age just want to go out drinking." Which action will the nurse apply?
discuss how divorce support groups could increase coping and social support
a nurse assesses a client with a tentative diagnosis of generalized anxiety disorder. Which question would be most appropriate for the nurse to ask
do you find it difficult to control your worrying?
a child reports to the school nurse of being verbally bullied by an aggressive classmate. What is the nurse's best first action
encourage the victimized child to share feelings about the experience
a child diagnosed with ADHD had this nursing diagnosis: impaired social interaction related to excessive neuronal activity as evidenced by aggression and demanding behavior with others. Which finding indicates plan of care was effective
engages in cooperative play with other children
a client diagnosed with emphysema has severe shortness of breath and needs portable oxygen when leaving home. Recently the client has reduced activity because of fear that breathing difficulty will occur. A nurse suggest using guided imagery. Which image should the client be encouraged to visualize?
feeling relaxed and taking regular deep breathes when leaving home
a client has had difficulty keeping a job because of arguing with co-workers and accusing them of conspiracy. Today the client shouts, "they're all plotting to destroy me. Isn't that rue?" what is the nurse's most therapeutic response
feeling that people want to destroy you must be very frightening
a 4 year old cries for 5 minutes when the parents leave the child at preschool. The parents asl the nurse, "what should we do?" What is the nurse's best response?
give your child a kiss before you leave the preschool program
