2400- EAQ: Exam 1 Review

Which intervention would the nurse include in the plan of care for a client with posttraumatic stress disorder who verbalizes a desire to have control over personal feelings related to being the only survivor? A. Work on self-forgiveness. B. Explore specific feelings related to survivor guilt. C. Discuss life situations that the client is able to manage. D. Focus on the client's inability to limit escalating anxiety.

C RAT- The nurse would add to the plan of care and discuss life situations that the client is able to manage. Focusing on situations that are manageable will enable the client to experience a sense of personal power. Working on self-forgiveness relates to feelings of self-blame and depression. Talking about survivor guilt will not allow the development of a sense of control over the trauma; instead, the client may focus on being a survivor through luck or chance. Focusing on negative responses (inability to limit escalating anxiety) will not help the client gain a sense of personal control over the feelings related to the trauma.

The health care provider prescribes divalproex sodium 375 mg twice a day by mouth. The divalproex sodium is labeled "250 mg/5 mL." How many milliliters of solution will the nurse administer per dose? Record your answer using one decimal place. A. 1.5 B. 6.5 C. 7..5 D. 2.5

C

Which is the best room assignment for a child admitted with injuries that may be related to abuse? A. In an isolation room B. With a friendly older child C. With a child of the same age D. In a room near the nurses' desk

D RAT- A child who exhibits signs of abuse needs close supervision, especially when members of the family visit. The child requires close monitoring and should not be left alone. There is no indication that this child needs to be placed in an isolation room for the sake of infection control. An older child who exhibits signs of friendliness may be threatening to this child. Placement with a child of the same age may be desirable from a developmental level, but it does not meet the child's safety needs.

For Alcoholics Anonymous, which goal is the priority? A. Acknowledging and changing destructive behavior B. Developing functional social and family relationships C. Identifying how people present themselves to others D. Understanding interactional patterns within the group

A RAT- 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.

Which medication would the nurse instruct a client to avoid while taking alprazolam? Select all that apply. One, some, or all responses may be correct. A. Opioids B. Alcohol C. Barbiturates D. Antidepressants E. First-generation antipsychotics

A, B, C RAT- Respiratory depression can occur if a client combines benzodiazepines with opioids, alcohol, or barbiturates. Antidepressants and first-generation antipsychotics are safe to take with benzodiazepines

Which factors would the nurse find in the client history of a young college student with borderline personality disorder? Select all that apply. One, some, or all responses may be correct. A. Impulsiveness B. Lability of mood C. Ritualistic behavior D. Psychomotor retardation E. Self-destructive behavior

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

A client with obsessive-compulsive disorder has an anxiety level that is approaching a panic level, and the client's ritual is interfering with work and daily living. For which selective serotonin reuptake inhibitor (SSRI) would the nurse anticipate preparing a teaching plan? A. Haloperidol B. Fluvoxamine C. Imipramine D. Benztropine

B RAT- Fluvoxamine inhibits central nervous system neuron uptake of serotonin but not norepinephrine. Haloperidol is not an SSRI; it is an antipsychotic that blocks neurotransmission produced by dopamine at synapses. Imipramine is a tricyclic antidepressant, not an SSRI. Benztropine is an antiparkinsonian agent, not an SSRI.

A primary health care provider diagnoses chronic, low-grade depression in a client. Which medication is indicated for this condition? A. Alprazolam B. Lithium salts C. Amitriptyline D. Clomipramine

C RAT- Dysthymia (chronic low-grade depression) can be treated by the administration of antidepressant medications such as amitriptyline. Alprazolam is the medication of choice for treating anxiety disorders. Lithium salt is prescribed to treat bipolar disorders. Clomipramine is a tricyclic antidepressant medication prescribed for treating obsessive-compulsive 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? A. Traditional phenothiazines B. Judicious use of antipsychotics C. Intramuscular injections of thiamine D. Oral administration of chlorpromazine

C Rat-

A client is scheduled for a 6-week electroconvulsive therapy (ECT) program. Which intervention is important during the course of treatment? A. Provision of tyramine-free meals B. Avoidance of exposure to the sun C. Maintenance of a steady sodium intake D. Elimination of benzodiazepines for nighttime sedation

D RAT- The use of benzodiazepines can raise the seizure threshold, which is counterproductive. A tyramine-free diet is required with monoamine oxidase therapy, not after ECT. Photosensitivity is not a side effect of ECT. A stable sodium level is necessary with lithium therapy, not ECT.

The nurse is assessing a client with a history of depression to determine imminent risk for attempting suicide. Which statement made by the client indicates a need for immediate intervention? A. "I have a strong faith in a higher power." B. "My parents keep firearms in the house." C. "Everyone would be better off if I wasn't here." D. "I grew up in a house where we were often abused."

C RAT- Clients with depression should be assessed for suicidal ideations to determine the risk for committing suicide. The statement, "Everyone would be better off if I wasn't here" is a warning sign that the client is at an immediate risk for suicide. The client with a strong faith in a higher power possesses the ability to adapt to stressors and is less likely to commit suicide. The presence of firearms in the house and living through abuse are risk factors for possible suicide, but do not represent an imminent risk.

In which situation would the nurse anticipate naltrexone to be administered? A. To treat opioid overdose B. To block the systemic effects of cocaine C. To decrease the recovering alcoholic's desire to drink D. To prevent severe withdrawal symptoms from antianxiety agents

C RAT- 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.

When the health care provider examines the genital area of a 5-year-old child in whom sexual abuse is suspected, which nursing action is the most therapeutic? A. Explaining the procedure and remaining with the child during the examination B. Asking the child if she prefers the nurse or the mother to be present for the examination C. Telling the child that the provider wants to see if there is "anything wrong down there" D. Asking the mother to explain the examination in terms that the child will understand

A RAT- Explaining the procedure and remaining with the child during the examination provides reassurance and support for the child. Asking the child to decide whether the mother or nurse will stay is nontherapeutic; the child may fear that choosing the nurse will make the mother angry. "Anything wrong down there" is frightening; this suggests that the nurse and provider think that something is wrong. The mother may be able to explain the examination, but communication patterns between the mother and child are probably not ideal.

A client, diagnosed with borderline personality disorder, declares that the whole staff is "bad" after being disappointed by one staff member. Which defense mechanism is the client using? A. Splitting B. Rationalization C. Undoing D. Reaction formation

A RAT- It is the compartmentalization of opposite-affect states and failure to integrate the positive and negative aspects of self or others. Rationalization is justifying an illogical behavior by creating a plausible explanation. Undoing is making up for an action. Reaction formation is the expression of unacceptable desires by adopting opposite behaviors in an exaggerated way.

Which substance produces sneezing, yawning, and tearing of the eyes as withdrawal occurs? A. Heroin B. Cocaine C. Morphine D. Phenobarbital

A RAT- Research indicates that sneezing, yawning, and tearing are the first physical signs of withdrawal from heroin. Depression and irritability accompany withdrawal from cocaine. Restlessness, shakiness, hallucinations, and sometimes coma accompany withdrawal from morphine. Insomnia, seizures, weakness, sweating, and anxiety accompany withdrawal from phenobarbital.

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. A. Staying with the client B. Giving brief directions C. Using short, simple sentences D. Linking the client's behavior to feelings E. Teaching a cognitive therapy principle F. Having the client write an assessment of strengths

A, B, C, D, E, F RAT- 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.

Which clinical manifestations indicating the beginning of an episode of mania would the nurse include in an educational program for family members of clients with bipolar disorder? Select all that apply. One, some, or all responses may be correct. A. Insomnia B. Irritability C. Excessive eating D. Decreased libido E. Financial irresponsibility

A, B, E During a manic episode, there is a decreased need for sleep and clients do not feel tired, leading to insomnia. At the beginning of a manic episode, the primary mood is irritability; the emotions often fluctuate between euphoria and anger. During a manic episode, impulsivity, impaired judgment, and involvement in pleasurable activities may result in spending sprees that can have negative consequences (financial irresponsibility). During a manic episode, there is a decrease in appetite, not excessive eating. The client's increased activity and inability to sit still interfere with the ability to eat and drink. Hypersexuality, rather than decreased libido, is common during a manic episode.

Which outcome would the nurse add to the plan of care for a client with anorexia nervosa? A. Eat every meal for a week. B. Gain 1 lb (0.5 kg) of weight a week. C. Attend group therapy every day. D. Talk about food for 1 hour a day.

B RAT- An outcome is focused on where the client should be after certain actions are taken; this client needs to gain weight. Eating every meal for a week may set up a struggle between the client and the nurse; the focus of care should not be a struggle for control as that is the major issue in clients with anorexia nervosa. Dietary intake is an aspect of their life they can control. Behavior modification techniques work much better than group therapy; anorexia nervosa clients lack insight and will focus on food. Anorexic clients talk freely about food; this is not therapeutic, nor an appropriate outcome.

A 20-year-old carpenter with a history of substance abuse falls from a roof and sustains fractures of the right femur and left tibia. Which intervention is the most important? A. Confronting the client about substance abuse B. Overlooking the drug problem during hospitalization C. Assessing for amount and time of last substance use D. Advocating for adequate dosage of pain medication

C RAT- Determining the amount and last use of the substance is the priority. Nurses would base their treatment of withdrawal symptoms on the time and amount of last use. Confronting the client is not appropriate; helping the client to deal with substance problem will come later. Ignoring the substance abuse puts the client at risk for withdrawal symptoms or undertreatment of pain. Because of cross-tolerance the client may need larger doses of analgesia for pain relief, but this is not the priority.

Which signs and symptoms would the nurse observe in a client experiencing alcohol withdrawal? Select all that apply. One, some, or all responses may be correct. A. Fatigue B. Anxiety C. Runny nose D. Diaphoresis E. Psychomotor agitation

B, D, E RAT- Anxiety, diaphoresis, and psychomotor agitation all occur with alcohol withdrawal. Anxiety is commonly associated with withdrawal from alcohol. When a person is withdrawing from alcohol, associated autonomic hyperactivity causes an increased heart rate and diaphoresis. The withdrawal of alcohol affects the central nervous system, resulting in excited motor activity (psychomotor agitation). Fatigue is associated with withdrawal from caffeine or stimulants. A runny nose and tearing of the eyes are associated with withdrawal from opioids.

Which intervention would the nurse include when developing a plan of care for a client in the manic phase of bipolar disorder? A. Focus the client's interest in reminiscing. B. Encourage the client to talk as much as needed. C. Persuade the client to complete any task that has been started. D. Redirect the client's excess energy to more constructive activities.

D RAT- The hyperactive client usually is easily distracted, so excess energy can be redirected into constructive channels. The client with bipolar disorder, manic phase, does not need to reminisce. The client in the manic phase will talk a great deal with no encouragement. The client in the manic phase will not be able to focus long enough on one task to finish it.

For a client with the diagnosis of schizophrenia, which clinical findings are positive signs/symptoms? Select all that apply. One, some, or all responses may be correct. A. Anergy B. Flat affect C. Social withdrawal D. Disorganized thoughts E. Auditory hallucinations

D, E Positive symptoms, referred to as florid psychotic symptoms, reflect an excess or distortion of function and include delusions, hallucinations, increased speech production with associations, and bizarre behavior. Disorganized thoughts (e.g., derailment, tangentiality, illogicality, incoherence, and circumstantiality) are positive signs of schizophrenia. Positive symptoms usually respond to antipsychotic medications. Negative symptoms reflect a lessening or loss of normal function. A lack of energy (anergy), a lack of emotional expression (flat affect), and inadequate social skills leading to withdrawal and isolation are considered negative symptoms associated with schizophrenia.

Which personality characteristics are common for an antisocial personality disorder? Select all that apply. One, some, or all responses may be correct. A. Aloof B. Suspicious C. Perfectionist D. Irresponsible E. Manipulative

D, E RAT- People with antisocial personalities are often irresponsible, amoral, dishonest, and do not learn from negative experiences. People with antisocial personalities are often charming and calculating when exploiting others; they show no remorse for hurting others and do not develop insight into predictable consequences. Aloofness is associated with the schizoid personality. Suspiciousness is associated with the paranoid personality. Perfectionism is associated with the obsessive-compulsive personality.

Which characteristics of affect are expected for a client with the diagnosis of somatoform disorder, conversion type? Select all that apply. One, some, or all responses may be correct. A. Calm B. Cheerful C. Depressed D. Frightened E. Matter-of-fact

A, E RAT- Emotional conflicts are transferred to physical symptoms; thus the symptoms reduce anxiety and remove the conflict. The individual demonstrates a lack of concern about the symptoms (la belle indifférence). The individual will not be happy and cheerful, sad and depressed, or frightened.

Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal? A. Infuse intravenous fluids. B. Monitor the level of anxiety. C. Obtain frequent vital signs. D. Administer chlordiazepoxide

D RAT- The nurse would administer chlordiazepoxide to prevent injury because alcohol withdrawal can cause seizures and autonomic hyperactivity. Administering intravenous fluids maintains hydration. Monitoring anxiety levels does not affect client safety. Obtaining frequent vital signs allows the nurse to assess for autonomic hyperactivity but does not directly affect client safety.

See attached chart- A client with a history of schizophrenia has recently begun reporting symptoms of depression and is now prescribed a selective serotonin reuptake inhibitor (SSRI). In light of the information in the client's chart, which action is the nurse's priority? A. Educating both the client and family on how to identify the early signs of extrapyramidal symptoms B. Requesting a gastrointestinal consult to identify the cause of the client's need for frequent antacids C. Stressing the importance of managing the client's diet while taking the prescribed antidepressant D. Discussing the stressors that have developed since the client moved in with the sister and brother-in-law

A RAT- Extrapyramidal symptoms can result from antipsychotic medication therapy, and the risk is increased when the treatment plan includes an SSRI antidepressant. The cause of the frequent use of antacids should be explored but does not take priority in this situation. A well-balanced diet is always important, but the importance of diet management would still exist if the antidepressant were a monoamine oxidase inhibitor (MAOI) and not an SSRI. Identifying and addressing stressors is important, but it does not take priority in this situation.

Which primary gain would an adolescent client with anorexia nervosa achieve from this disorder? A. Reduction of anxiety through control over food B. Separation from parents secondary to hospitalization C. Release from school responsibilities because of illness D. Increased parental attentiveness related to massive weight loss

A RAT- The client decreases anxiety by maintaining a childlike build and by demonstrating mastery/control over food. Families of anorectic persons are usually fused, so separation from parents is not a primary gain. Anorectic persons generally excel in academic areas and receive attention and praise as the perfect child; this is not a primary gain. However, it could be a secondary gain. Reduction of anxiety, not the resulting attentiveness by parents, is the primary gain. The parental attentiveness could be a secondary gain.

A client has been admitted to the pediatric eating disorders unit with a diagnosis of anorexia and is undergoing behavioral therapy. Unit privileges are based on weight gain and have been explained to the client. Which is the most appropriate intervention for the nurse to use when taking the lunch tray to the client's room? A. Setting the tray down and saying nothing B. Reminding the client that eating will be rewarded C. Commenting on the client's thinness and need to gain weight D. Threatening the client that if she doesn't eat she won't gain any privileges

A RAT- The client uses eating and weight gain as a means of controlling the environment. The client has been told the rules of the unit and must make the personal decision to try to win privileges. The nurse needs to take the focus away from eating. The client knows that gaining weight will be rewarded and does not need reminders. The client is used to everyone commenting on her weight. Although the client appears thin to others, the client's self-perception is that she needs to lose a little bit of weight. Threats should not be used in any circumstance.

During the initial assessment phase, which parameter would the nurse focus on for a client with panic disorder and agoraphobia? A. Easing the client's anxiety so further interviewing may be done B. Learning about the client's home life to facilitate the planning of future care C. Suggesting that the client rest for a while before taking the health history D. Helping the client identify the source of anxiety so the source may be avoided

A RAT- The nurse would focus on easing the client's anxiety so further interviewing may be done. The client will be unable to concentrate or focus on the interview if anxiety is not reduced. Learning about the client's home life to facilitate the planning of care is not the priority at this time; anxiety must be reduced and the client's level of comfort increased. The client will not rest until anxiety is reduced. Helping the client identify the source of anxiety so the source can be avoided is not the priority at this time; anxiety must be reduced and the client's level of comfort increased.

Which action would the nurse take for a client with obsessive-compulsive disorder who begins the ritual of changing clothes for the fourth time, 10 minutes before lunch? A. Tell the client to finish changing clothes and say that lunch can be eaten afterward. B. Help the client change clothes quickly so lunch can be eaten at the scheduled time. C. Lead the client to the dining room and explain that the clothes can be changed after lunchtime. D. Inform the client that everyone is required to be in the dining room at a specific time, so there is no time to change clothes.

A RAT- The nurse would tell the client to finish changing clothes and explain that lunch can be eaten afterward. This response sets some limits on the compulsive act; it permits the ritual without reinforcing it but does not increase anxiety by removing the defense. Rushing the completion of the ritual will increase anxiety, because the ritual is being used as a defense. Leading the client to the dining room and explaining that the clothes can be changed after lunch will increase the client's anxiety and reinforce the need for the behavior. Preventing the ritual will increase anxiety, because the ritual is being used as a coping mechanism.

After an episode of binge eating, which feelings will a client with bulimia nervosa experience? Select all that apply. One, some, or all responses may be correct. A. Helplessness B. Sleepiness C. Loneliness D. Hopelessness E. Powerlessness

A, D, E RAT- Clients with bulimia nervosa have a sense of being out of control that accompanies the excessive or compulsive consumption of large amounts of food, resulting in feelings of powerlessness, helplessness, and hopelessness. Sleepiness is not experienced during an episode after binge eating; however, severe electrolyte imbalances caused by binge eating may result in weakness and fatigue. Although people with bulimia nervosa tend to binge alone and in secret, loneliness is not the primary feeling experienced during binge eating.

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. A. Take the medication with food. B. Adjust the dosage if your mood improves. C. Have a snack with milk before going to bed. D. It may take several weeks for beneficial results to occur. E. Restriction of sodium intake is unnecessary.

A, D, E RAT- 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 statement by a client with schizophrenia alerts the nurse that immediate safety precautions would be taken for others? Select all that apply. One, some, or all responses may be correct. A. "The voice told me to punch the guy." B. "I saw the bugs crawling on the walls." C. "God spoke to me; we prayed together." D. "I was speaking to the other person here." E. "There was someone here who told me to leave."

A, E RAT- A command hallucination pushes a person to perform an action. These hallucinations can be dangerous, because they may direct a client to do harm to him- or herself or others. The presence of command hallucinations on assessment requires immediate intervention by the nurse. Seeing bugs crawling on the walls is a visual hallucination. A client with auditory hallucinations may claim to have spoken to God or to a person who is not present in the room.

A client has paralysis of the legs related to somatoform disorder, conversion type. Which explanation must be considered when formulating the plan of care? A. The illness is very real to the client and requires appropriate nursing care. B. Although the client believes that there is an illness, there is no cause for concern. C. There is no physiological basis for the illness; only emotional care is needed. D. Nursing intervention is needed even though the nurse understands that the client is not ill.

A. RAT- Individuals who have somatoform disorders are ill. They have complex physical and psychological interactions that impair functioning. They need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.

Which instructions would the nurse share with a housekeeping staff member who reports that the client with anorexia nervosa has food hidden in the room? A. Point this out to the client and remove the food. B. Report it to the nursing staff if it happens again. C. Disregard this finding because it is a common behavior in clients with anorexia. D. Keep a record of when this happens and report it to the nursing staff weekly.

B RAT- Asking the housekeeping staff to keep the nursing staff informed shows that housekeeping members are part of the health team and their input is valued; this will help keep lines of communication open. Pointing this out to the client and removing the food is not the responsibility of the housekeeping staff. Disregarding input from members of the health care team does not promote collaboration. Client behaviors should never be disregarded. The housekeeping staff should notify a nursing team member if this behavior occurs again. Keeping a record of when this happens and reporting to the nursing staff weekly is not the responsibility of the housekeeping staff.

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

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

B RAT- 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.

Which behavior would indicate a client with antisocial personality disorder who is facing criminal charges for stealing money from work is meeting treatment outcomes? A. Expression of feelings of resentment toward the employer B. Discussion of plans for each of the possible outcomes of a trial C. Expression of resignation about difficult relationships with coworkers D. Discussion of the decision to file a grievance against the employer after discharge from the hospital

B RAT- If the client can realistically examine the possible outcomes of the trial, then some benefit has been gained from the therapy. Expressing resentment toward the employer does not indicate the client is meeting treatment outcomes. Expressing resignation about difficult relationships with coworkers does not show improvement or insight. Deciding to file a grievance indicates unrealistic planning and does not demonstrate the development of insight or the ability to meet treatment outcomes. The client is still blaming other for mistakes and decisions made by the client.

See attached chart: A client's antidepressant medication therapy has recently been modified to substitute a tricyclic antidepressant for the monoamine oxidase inhibitor (MAOI) prescribed 2 years ago. In light of the assessment data collected during the follow-up appointment, which action will the nurse take first? A. Retake the individual's blood pressure. B. Determine exactly when the client began taking the amitriptyline. C. Ask how the client is managing the stress related to the new job and pregnancy. D. Identify what measures the client has implemented to help manage the recurrent headaches.

B RAT- Improper weaning from an MAOI can result in the development of hypertensive crisis. The client's increased blood pressure and chronic headache are possible early warning signs of this serious side effect. Determining exactly when the client began taking the newly prescribed tricyclic medication will help the nurse determine whether the MAOI had sufficient time to be excreted from the body. Reassessing the client's blood pressure, though not inappropriate, does not have the same priority as does gathering new information that could help identify the root of the hypertension and headaches. Stress can be a factor in increased blood pressure and headaches, but in this situation a more serious potential complication must be explored. Identifying the self-treatment the client has implemented for the reported headaches, though appropriate, does not take priority over determining the possible cause of the increased blood pressure and headaches.

Which type of mental health disorder is most likely to include an assessment for presence of secondary gains? A. Bipolar disorder B. Somatic symptom disorder C. Schizophrenia spectrum disorder D. Childhood neurodevelopmental disorder

B RAT- Somatic symptom disorder is characterized by an excessive focus on physical symptoms, and reassurance from the health care provider rarely eliminates the concern. The symptoms and the sick role provide two sources of secondary gain: attention from family, friends, and health care staff and a reason to avoid work or social obligations. Secondary gain can be associated with other physical or mental health disorders but is less likely with bipolar, schizophrenia, or childhood neurodevelopmental disorders.

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? A. Word salad B. Loose association C. Thought blocking D. Delusional thinking

B RAT- 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 response would the nurse make to a client with bipolar I mood disorder, manic episode, who says to the nurse, "I don't know what I'm doing here. I never felt better in my life; I've got the world on a string around my finger"? A. "Have you ever felt this way before?" B. "You're feeling pretty elated right now." C. "You have the whole world on a string." D. "Why do you think you're feeling so good?"

B RAT- The nurse would make the response, "You're feeling pretty elated right now." This response demonstrates empathy; in addition, it focuses on the client's feelings. The question, "Have you ever felt this way before?" will elicit a yes or no answer; an open-ended response allows for more self-expression. The response, "You've got the whole world on a string," reflects only part of the content; it may be the least significant part of the client's statement. "Why" questions should be avoided, because people often do not know why they feel or behave the way they do; this question may cause defensiveness.

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"? A. Disturbed self-esteem B. Potential for self-harm C. Dysfunctional verbal communication D. Impaired perception of environmental stimuli

B RAT- 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 response would the nurse make to a client with an obsessive-compulsive disorder who spends 30 minutes in the bathroom six times a day and says, "It keeps me from getting nervous"? A. "Let's look at the positive because you will have your own bathroom here." B. "Tell me how spending time in the bathroom helps you avoid becoming nervous." C. "Tell me more about what you do in the bathroom during those 30-minute periods." D. "Let's start by cutting down the time you spend in the bathroom to 20 minutes, three times a day."

B RAT- The response, "Tell me how spending time in the bathroom helps you avoid becoming nervous," encourages the client to explore the defenses employed to cope with anxiety. The response "Let's look at the positive because you will have your own bathroom here," is a nontherapeutic response that denies the importance of a problematic area of behavior. The response, "Tell me more about what you do in the bathroom during those 30-minute periods," focuses on tasks rather than feelings; also, it may be perceived as threatening or judgmental. The response, "Let's start by cutting down the time you spend in the bathroom to 20 minutes, three times a day," is a nontherapeutic response because it will increase the client's anxiety. It is too early to start changing the behavior and the nurse is cutting the time in half by going from six times a day to three.

Which short-term goal would be appropriate for a client with phobias about elevators and large crowds who comes to the clinic for help because of feelings of depression related to these fears? A. Ride an elevator without anxiety when accompanied by the nurse. B. Describe the thoughts and feelings experienced in terrifying situations. C. Experience an elevation of mood and relief from feelings of depression. D. Identify the early childhood conflicts that resulted in the development of these fears.

B RAT- The short-term goal is to describe the thoughts and feelings experienced in terrifying situations. This is a realistic essential first step. The problem and related feelings must be explored before solutions can be developed. Riding an elevator without anxiety when accompanied by the nurse is a long-term goal. Experiencing an elevation of mood and relief from feelings of depression is a long-term goal. Identifying the early childhood conflicts leading to the development of the fears is an inappropriate goal; a direct connection to life events is often difficult to find.

Which behavior would a 2-year-old child with a history of physical abuse display? A. Smile readily at anyone who enters the room. B. Be wary of physical contact initiated by anyone. C. Pay little attention to the nurse standing at the bedside. D. Begin to scream when the nurse nears the bedside

B RAT- This child will have difficulties with physical contact, because adult contact often results in pain. This child will not trust or welcome strangers and will be acutely aware of anyone coming near; abused children try to defend themselves by keeping alert to the possibility of attack. Abused children will usually not cry out; they learn not to expect comforting or soothing by others.

Which action must the nurse take first to therapeutically relate to parents who have abused their child? A. Develop a trusting relationship with the child. B. Identify personal feelings about child abusers. C. Recognize the emotional needs of the parents. D. Gather information about the child's home environment.

B RAT- To establish an interpersonal relationship with clients, the nurse must first be aware of personal feelings. This is particularly important when the nurse's personal views are at odds with the clients' behaviors. Although developing a trusting relationship with the child should eventually be done, this does not address the nurse's relationship with the parents. Information about the home environment and assessment of the parents' emotional needs can be obtained after a relationship is established with the parents.

Which action would the nurse take when an adolescent with anorexia nervosa starts to discuss food and eating? A. Listen to the client's list of favorite foods and secure these foods for the client. B. Tell the client gently but firmly to direct the discussion of food to the nutritionist. C. Use the client's current interest in food to encourage an increase in food intake. D. Let the client talk about food as long as the client wants and limit discussion about eating.

B RAT-All food issues should be discussed with the nutritionist, thereby removing a potential source of conflict between the nurse and client. Listening to the client's list of favorite foods and securing these foods will accomplish little, because the client's failure to eat is not based on food likes or dislikes. Using the client's current interest in food to encourage an increased food intake will increase the conflict between the nurse and client. Letting the client talk about food as long as the client wants and limiting discussion about eating may be self-defeating, because a discussion of food will be the major focus of all nurse-client interactions.

Which interventions would the nurse include in the plan of care for a client with depression who is at risk for self-directed violence? Select all that apply. One, some, or all responses may be correct. A. Provide safe outlets for energy. B. Make rounds every 15 minutes. C. Assign a room next to the nurses' station. D. Reduce stimulation by dimming the lights. E. Promote the discussion of negative thoughts.

B, C RAT- Appropriate safety interventions for a client who is at risk for or showing signs of potential intent to self-harm would include making rounds to check on the client every 15 minutes and assigning the client to a room next to the nurses' station to allow nursing staff to check on the client frequently. Agitated clients benefit from being provided a safe outlet for extra energy and minimized stimulation. The nurse would encourage a client who is at risk for other-directed violence, not self-directed violence, to discuss the negative thoughts.

The nurse teaches dietary guidelines to a client who will be receiving tranylcypromine sulfate, a monoamine oxidase inhibitor (MAOI). The client compiles a list of foods to avoid. Which foods included on the list indicate that the teaching has been effective? Select all that apply. One, some, or all responses may be correct. A. French fries B. Pepperoni pizza C. Bologna sandwich D. Hamburger on a bun E. Hash brown potatoes

B, C RAT- Cheese and processed meats contain tyramine, which is contraindicated when MAOIs are taken. Tyramine, a precursor in the synthesis of norepinephrine, taken in the presence of MAOIs can lead to a sharp increase in norepinephrine and a potentially fatal hypertensive crisis. Although bread does not contain tyramine, bologna does; delicatessen meats (e.g., bologna and sausage), meat extracts, and liver are high in tyramine and should be avoided. French-fried potatoes, hamburgers, bread, and hash brown potatoes do not contain tyramine and are not contraindicated when a client is taking an MAOI.

Which actions would the nurse take to assist an aggressive client in deescalating the agitated behavior? Select all that apply. One, some, or all responses may be correct. A. Offer physical touch to show caring. B. Encourage the client to express perceived needs. C. Avoid verbal struggles in an attempt to demonstrate authority. D. Provide the client with clear options to the unacceptable behavior. E. Refer to the client in an authoritarian manner to demonstrate control of the situation. F. Explain the expected outcomes if the client is unable to control the unacceptable behavior.

B, C, D, F RAT- Encouraging the client to express perceived needs provides the client with a sense of being heard and respected. The nurse would avoid verbal struggles because verbal struggling will likely increase the tension and aggressive behavior of the client. Providing options will allow the client to effectively change behaviors if capable of doing so. Explaining outcomes for continued unacceptable behavior allows the client to make a decision to change behaviors if capable of doing so. Touching the client will likely be viewed as aggressive and lead to an increase in the client's agitation. It is important to present a calm, firm persona but avoid being authoritarian, because this will likely lead to a power struggle.

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. A. Akathisia B. Torticollis C. Shuffling gait D. Masklike facies E. Oculogyric crisis

B, E RAT- 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 action would the nurse take for a female client who has just awakened from her first electroconvulsive therapy (ECT) treatment? A. Immediately get the client out of bed and back into the unit's routine. B. Sit the client up and arrange for the dietary staff to deliver a lunch tray. C. Orient the client to time and place and explain that the treatment is over. D. Take the client's pulse and blood pressure every 15 minutes after the client is fully awake.

C RAT- The nurse would orient the client to time and place and explain that the treatment is over. Clients are confused when they awaken after ECT. They have loss of recent memory, so it is important to orient them to time, place, and situation. The nurse would not immediately get the client out of bed; this occurs about 1 to 3 hours after the treatment. Sitting the client up may be done later if the client asks for food. Vital signs are monitored before the client is awake; they may become stable before the client is fully awake.

Which response would the nurse make to a client with depression who is sitting by the window crying? A. "It's okay. No need to cry or worry while you're here. We all feel down now and then." B. "Please don't consider suicide. It really isn't an appropriate way out of your troubles." C. "You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if you would like." D. "Why don't you go into the dayroom and join the card game going on? That'll take your mind off of your problems for a while."

C RAT- The nurse would say, "You seem to be experiencing a sad moment. I'll sit here with you for a while and talk if you would like." The nurse is acknowledging that the client is feeling especially down and offering to be available for discussion or just to provide a presence. Telling the client not to cry and that we all feel down now and then belittles the client's feelings. The response regarding suicide is judgmental and may discourage any effort by the client to initiate a discussion. Suggesting a card game does not acknowledge the client's feelings and appears to trivialize the client's feelings.

Which supervised activity would be therapeutic for a client with bipolar disorder, manic episode, during the early phase of treatment? A. Doing a needlepoint project B. Joining a brief swimming competition C. Walking around the facility with a nurse D. Playing a board game with another client

C RAT- Walking around the facility with a nurse does not involve an element of competition and still allows the client to channel excess energy safely. A needlepoint project requires fine motor skills of a client who is hyperactive and whose attention span is limited. The sense of competition and added stimulation provided by a swimming competition may increase the client's anxiety and acting-out behavior. The client is too hyperactive to play a board game and may respond with distractibility or aggressiveness toward others.

Which outcome criteria would be important to discuss with a female client who has bulimia nervosa? Select all that apply. One, some, or all responses may be correct. A. Resuming menstruation B. Achieving 85% of ideal body weight C. Abstaining from binge-purge behaviors D. Describing a realistic perception of body shape E. Demonstrating three learned skills for managing stress

C, D, E RAT- Abstaining from binge-purge behaviors is an appropriate goal for a client with bulimia nervosa. A realistic perception of body shape is an appropriate goal for clients with bulimia nervosa because they have an obsessive and persistent concern with body shape and weight. Demonstration of three learned skills for managing stress is an appropriate goal for clients with bulimia nervosa because they experience stress and anxiety and have limited impulse control. Although clients with bulimia may have menstrual dysfunction, amenorrhea is not expected. This outcome is appropriate for clients with anorexia nervosa. Clients with bulimia may be slightly overweight or slightly below weight for their height. Achievement of 85% of ideal body weight is not an appropriate goal for clients with bulimia nervosa.

Which nutritional guidelines would the nurse emphasize for an adolescent who has anorexia nervosa? Select all that apply. One, some, or all responses may be correct. A. Increase high-fiber foods. B. Eat just three meals a day. C. Increase food intake gradually. D. Limit mealtime to half an hour. E. Provide privileges for dietary goal achievement.

C, D, E RAT- Food intake should be increased by approximately 200 calories weekly. A gradual increase allows the client to adapt emotionally and physically to the increased volume. Thirty minutes is sufficient time for eating. Extended mealtimes place excessive attention on eating and increase anxiety, conflict, and power struggles. Goals should be set (e.g., gaining 2 lb [0.9 kg] per week and eating 90% of each meal). Behaviors that result in achievement of goals should be rewarded. Goals provide structure, and rewards motivate additional positive behaviors while promoting self-esteem. Consumption of high-fiber foods does not have to be increased. A variety of foods and textures should be eaten. Small, frequent meals should be offered, not just three meals a day.

A client with depression presents with feelings of sadness and is having difficulty sleeping. Which additional signs and symptoms would the nurse monitor for? Select all that apply. One, some, or all responses may be correct. A. Rigidity with a narrowing of perception B. Alternating episodes of fatigue and high energy C. Diminished pleasure in activities D. Excessive socialization E. Alteration in appetite

C, E RAT- Additional signs and symptoms include diminished pleasure in activities and alteration in appetite. Depression is characterized by feelings of hopelessness, helplessness, and despair, leaving little room for any pleasure; alteration in appetite (either decreased or increased) is common in depressed clients. Although there is a narrowing of perception, rigidity is uncommon with depression. Fatigue is continually present and does not alternate with a high energy level. In depression there is a loss of interest in socialization, not excessive socialization.

Which question would the nurse ask the client with conversion disorder who experiences a feeling of weakness and is unable to move the right arm while listening to instructions for a group project? A. "Exactly when did the weakness begin?" B. "Is this similar to what you usually experience?" C. "Would you like to leave the group for a while?" D. "What emotion were you feeling before you felt the weakness?"

D RAT- Asking what emotion the client was feeling before experiencing the weakness focuses the client on the relationship between emotion and physical symptoms in a nonthreatening, accepting manner. The nurse knows when the weakness began, so it is unnecessary to ask. Asking whether this experience is similar to what the client usually experiences does not identify what the person was feeling when the weakness happened and focuses on the symptom rather than the real problem. Asking whether the client would like to leave the group for a while will provide a secondary gain; it implies sympathy and allows the client to avoid an undesired activity or responsibility.

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? A. Voluntary compliance with the disulfiram regimen is very high. B. A single dose of oral disulfiram will be effective for up to 72 hours. C. Disulfiram may be taken intramuscularly and will be effective for as long as 7 days. D. Foods, medications, and any topical preparation containing alcohol should be avoided.

D RAT- 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. F or disulfiram to be effective, it must be taken orally every day. Disulfiram is not administered intramuscularly.

Which approach would the nurse use for a client with major depression who refuses to participate in unit activities, claiming to be "just too tired"? A. Planning 1 rest period during each activity B. Explaining why the staff believes that the activities are therapeutic C. Encouraging the client to express negative feelings about the activities D. Accepting the client's feelings about activities while calmly setting firm limits

D RAT- Fatigue and apathy are symptoms of depression and should be accepted; however, limits would be set to facilitate participation in unit activities. Planning 1 rest period during each activity allows the client to manipulate the environment. Explaining why the staff believes that the activities are therapeutic will not change the client's mind about them, and this response does not show an understanding of the client's needs. Encouraging the client to express negative feelings about the activities will reinforce negative feelings about participating in them and would be counterproductive.

The nurse is caring for a group of clients on the psychiatric unit. Which clinical findings will alert the nurse that serotonin syndrome has developed in one of the clients? A. Continuous involuntary movement of the tongue and jaw B. Extremely high blood pressure with headache and flushing C. Blurred vision, urine retention, dry mouth, and constipation D. Restlessness, tachycardia, fever, diarrhea, and altered mental status

D RAT- Serotonin syndrome, an excessive accumulation of serotonin that can lead to death if not identified and treated quickly. Continuous involuntary movement of the tongue and jaw is related to tardive dyskinesia, which results from long-term use of an antipsychotic medication. Extremely high blood pressure with headache and flushing indicate a possible hypertensive crisis from the intake of tyramine-containing foods by a client receiving a monoamine oxidase inhibitor antidepressant. Blurred vision, urine retention, dry mouth, and constipation are common anticholinergic side effects of tricyclic antidepressants and some antipsychotic medications.

Which response would the nurse make to a client with a borderline personality disorder who cries bitterly and pounds the bed in frustration after a conference with the primary health care provider? A. Leave the client for a short period and wait until the client regains control. B. Pat the client reassuringly on the back and say, "I know that it's hard to bear." C. Ask about the client's troubles and answer, "Other people also have problems." D. Stay with the client and listen attentively if the client wishes to talk about the problem.

D RAT- Sitting with the client indicates acceptance and demonstrates that the nurse believes the client is worthy of the nurse's time. It is better to stay with the client quietly until control is regained; staying prevents the outburst from escalating. Patting the client reassuringly on the back and saying, "I know that it's hard to bear" provides little comfort for the client; touching should be used judiciously in this instance. Asking about the client's troubles and answering, "Other people also have problems" may close off further communication and belittles the client's problems.

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? A. Continuing the usual dose of lithium and noting any adverse reactions B. Discontinuing the medication until the lithium serum level drops to 0.5 mEq/L (0.5 mmol/L) C. Asking the health care provider to increase the dose of lithium, because the blood lithium level is too low D. Holding the medication and notifying the health care provider immediately, because the blood lithium level may be toxic

D RAT- The lithium level should be maintained between 0.5 and 1.5 mEq/L (0.5-1.5 mmol/L). T he 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? A. Find solitary pursuits that the client can enjoy. B. Speak to the client about the importance of entering into activities. C. Ask the primary health care provider to speak to the client about participating. D. Invite another client to take part in a joint activity with the nurse and the client.

D RAT- 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.

Which response would the nurse make to a client with schizophrenia who says, "I'm starting to hear voices"? A. "How do you feel about the voices, and what do they mean to you?" B. "You're the only one hearing the voices. Are you sure you hear them?" C. "The health team members will observe your behavior. We won't leave you alone." D. "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"

D RAT- The nurse would say, "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?" Acknowledging that the client is hearing voices and that the voices are very real to the client validates the presence of the client's hallucinations without agreeing with them, which communicates acceptance and can form a foundation for trust; it may help the client return to reality. The nurse also needs to assess the content of the voices to determine the risk of self-injury or violence against others. The client's contact with reality is too tenuous to explore what the voices mean. Thus, the nurse would not ask, "How do you feel about the voices, and what do they mean to you?" Saying that the client is the only one hearing the voices and asking whether the client is sure the voices are being heard demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe the behavior and that the client won't be left alone is focusing the response on the health care team rather than the client.

See attached chart- The nurse is assessing four clients in the postanesthesia care unit (PCU) who are on opioid treatment. Which client does the nurse expect will benefit from an immediate treatment with naloxone? A. Client A B. Client B C. Client C D. Client D

D RAT- This client, with severe sedation because of opioids, has minimal response to verbal and physical stimulation; this client requires immediate treatment with naloxone to reverse effects of opioids. Client A, with level 3 sedation and respiratory rate of 15 breaths per minute, should take acetaminophen to stabilize the condition. Client B, who is slightly drowsy and easily aroused with a respiratory rate of 24 breaths per minute, has level 2 sedation, which does not require any intervention. Client C, who is awake and alert with a respiratory rate of 32 breaths per minute, is normal.

The nurse is caring for a child admitted with suspicious injuries. Which question would the nurse ask to obtain further information about possible child abuse? A. "What behaviors cause you to get into trouble?" B. "What problems do you have when at school?" C. "What is it about your parents that upsets you the most?" D. "What happens when you do something wrong?"

D RAT- This provides information about punishment and physical and/or verbal abuse that may be taking place. Asking the child what behaviors cause the child to get into trouble allows the child to understand what actions are inappropriate to perform. Problems the child may have at school may reflect poor coping skills or bullying, but not child abuse. Asking the child what upsets him or her the most about their parents may elicit responses about strict rules but not necessarily evidence of child abuse.

Which response is best to give a client who has schizophrenia, when he interjects random and nonsensical sentences that have nothing to do with the main conversational topics? A. "You aren't making any sense; let's talk about something else." B. "Why don't you take a rest? We can talk again later this afternoon." C. "I'd like to understand what you're saying, but you're too confused now." D. "I'd like to understand what you're saying, but I'm having trouble following you."

D RAT- When the nurse conveys a desire to understand, this increases the client's feeling of self-esteem. Nurse also states reality and the reality is that as a listener, the conversation is hard to follow, and the intended meaning is not being received. Clients with schizophrenia have problems with associative links, and these same problems will occur regardless of the topic. The other responses serve to block or stop communication, and they suggest that the nurse doesn't want to speak to the client unless he makes sense.

Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake? A. "Getting angry is wrong; your behavior must stop." B. "Yelling is unacceptable and will only get you placed in seclusion." C. "You have to eat the first tray of food; then I'll get another tray for you." D. "It must be frustrating to get the wrong tray. I'll order another tray for you."

D RAT- When working with clients with borderline personality disorders it is important that nurses empathize with the client's emotions and then offer constructive solutions to issues. Anger is not always wrong; it is how it is expressed that is important. Although yelling is not desirable, it is inappropriate to threaten seclusion. Telling the client that the first tray of food must be eaten before getting another is punitive. Clients have a right to receive the tray they ordered.

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. A. Seclusion B. Restraints C. Limit-setting D. Diversional activities E. Medication administration

D, C, E, A, B RAT- 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.

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. A. "You have to eat a low-sodium diet every day." B. "You'll have to take a diuretic with this medication." C. "You'll have to take this medication for the rest of your life." D. "You may want to suck on sugar-free hard candy when you get a dry mouth." E. "We'll need to test your blood often during the first few weeks of therapy."

D, E RAT- 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.

A woman who is frequently physically abused says, "It's my fault that my husband beats me." Which response would the nurse use? A. "Maybe, but it's likely that your husband is also at fault." B. "I can't agree with that—no one should be beaten." C. "Tell me why you believe that you deserve to be beaten." D. "You say that it was your fault—help me understand that."

D. RAT- Paraphrasing and clarifying are interviewing techniques that promote communication between the nurse and client and help the client hear and explore her words and gain insight into her behavior. A closed declarative statement (husband is also at fault) limits dialogue. Nurse-focused statements (I can't agree) do not empower the client. "Why" questions are generally not therapeutic because most clients cannot respond to these questions with logical explanations.

See attached chart- A client admitted for substance abuse detoxification displayed extreme anger toward his spouse. Based on the client documentation below, which conclusion can be drawn? A. The nurse responded appropriately, because the client expressed his feelings and calmed down. B. The nurse responded inappropriately, because the nurse had to spend 30 minutes with the client. C. The nurse responded appropriately, because communication de-escalated the aggressive behavior. D. The nurse responded inappropriately, because the threat of harm to the wife was unaddressed.

D. RAT- Threatening physical harm requires notification of the appropriate individuals about any viable threat. This documentation reflects the nurse's failure to follow through and report the threat. Expressing feelings and de-escalation are a desirable outcomes, and therapeutic communication is a vital tool in addressing the client's anger, but the major safety issue cannot be left unaddressed. Spending time to de-escalate anger is an appropriate use of the nurse's time.