Adolescent disorders
The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse? "I didn't hear anyone talking; come with me to your room." "What you heard was in your head; it was your imagination." "Come to the dayroom and watch television; you'll feel better." "God wouldn't tell you to lie there in the hall. God wants you to behave reasonably."
"I didn't hear anyone talking; come with me to your room." The nurse is focusing on reality and trying to distract and refocus the client's attention. "What you heard was in your head; it was your imagination" is too blunt and belittling; this approach rarely is effective. "Come to the dayroom and watch television; you'll feel better" is false reassurance; the nurse does not know that the client will feel better. "God wouldn't tell you to lie in the hall; God wants you to behave reasonably" may be interpreted as belittling or an attempt to convince the client that the behavior is irrational, which is usually ineffective.
A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention? Telling the other clients to disregard what the client is saying Ignoring the client's disruptive behavior and waiting for it to subside Restricting the client's contact with other clients until the disruptive behavior ceases Accepting that the client is unable to control this behavior and setting appropriate limits
Accepting that the client is unable to control this behavior and setting appropriate limits Clients who are out of control need to have limits set for them. The staff must understand that the client is not deliberately trying to disrupt the unit. Telling the other clients to disregard what the client is saying is demeaning the client in the eyes of the other clients and does not address the problem directly. Ignoring the client will not stop the disruptive behavior; also, the nurse has a responsibility to the other clients. Restricting the client's contact with other clients until the disruptive behavior ceases may be done as a last resort, but this approach should not be used until other alternatives have been explored.
When a client who has a bipolar mood disorder is hyperactive, it is difficult to entice her to sit still long enough to eat a complete meal. The plan of care states, "Provide finger foods such as carrots, celery, and cheese sticks at 10 am, 2 pm, and 7 pm." Recent assessment of this client indicates that all of the food provided at mealtimes is being eaten but that snacks have been refused. The nursing staff should: Change the plan, depending on evaluation findings. Ask the client whether the finger foods should still be provided. Continue the current plan so the client's nutritional status will improve. Reassess the client's nutritional status in 1 week so changes can be made.
Change the plan, depending on evaluation findings. Because the plan does not meet the client's needs, it should be changed. The client has already let the staff know that finger foods are not wanted. Continuing the plan will be frustrating for the client and the staff because the client's behavior indicates that snacks are not wanted. When the client's needs are not being met, the plan should be changed immediately.
A client has a diagnosis of schizoid personality disorder. During the assessment the nurse should expect the client's behavior to be: Rigid and controlling Dependent and submissive Detached and socially distant Superstitious and socially anxious
Detached and socially distant Clients with the diagnosis of schizoid personality disorder neither desire nor enjoy close relationships, prefer solitary activities, and demonstrate emotional coldness, detachment, and a flattened affect. Rigid and controlling behavior is typical of clients with the diagnosis of obsessive-compulsive personality disorder. Dependent and submissive behavior is typical of clients with the diagnosis of dependent personality disorder. Superstitious and socially anxious behavior is typical of clients with the diagnosis of schizotypal personality disorder.
A practitioner prescribes divalproex (Depakote) for a client with the diagnosis of bipolar I disorder, manic episode. What side effects of this medication might the client report during a follow-up visit? Dizziness, nausea, and vomiting Photosensitivity, agitation, and restlessness Abdominal cramps, tremor, and muscle weakness Weight gain, drowsiness, and diminished concentration
Dizziness, nausea, and vomiting Divalproex (Depakote), an anticonvulsant, causes gastric irritation and should be taken with food; it is available in an enteric-coated form. It may cause nausea, vomiting, indigestion, hypersalivation, diarrhea or constipation, anorexia or increased appetite, dizziness, headache, and confusion. Photosensitivity, agitation, and restlessness are all common side effects of phenothiazines. Abdominal cramps, tremor, and muscle weakness are signs and symptoms of lithium toxicity. Weight gain, drowsiness, and diminished concentration are common side effects of tricyclic antidepressants.
Risk for assaultive behavior is highest in the mental health client who: Uses profane language Touches people excessively Exhibits a sudden withdrawal Experiences command hallucinations
Experiences command hallucinations Command hallucinations are dangerous because they may influence the client to engage in behaviors that are dangerous to self or others. Although profane language, excessive touching of others, and withdrawn behavior may all be cause for concern, but none is as dangerous as command hallucinations.
A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective? Threats Ideation Gestures Attempts
Gestures A suicidal gesture involves superficial, nonlethal injuries; the client has no intent to die as a result of the injuries. A suicidal threat is a person's verbal statement of intent to commit suicide; there is no action. Suicidal ideation is a person's thoughts regarding suicide; there is no definitive intent or action expressed. A suicide attempt is an actual implementation of a severe self-injurious act; there is an attempt to cause serious self-harm or death.
A nurse is planning activities for a withdrawn client who is hallucinating. What is the most therapeutic activity for this client? Going for a walk with the nurse Watching a movie with other clients Playing a board game with a group of clients Playing a game of cards alone in the dayroom
Going for a walk with the nurse Walking with the nurse facilitates one-on-one interaction and the development of a trusting relationship. Watching a movie will allow the client to withdraw further. Playing a game with others is beyond the client's ability at this time. Playing cards alone will allow the client to withdraw further.
A depressed client frequently expresses doubts about living and admits thinking about suicide while denying that he has developed a plan. During this period it is essential that the nurse: Have a staff member stay with the client continuously Plan to involve the client in activities that foster independence Explain in detail to the client how the staff will protect him against self-harm Make frequent unobtrusive observations of the client's moods and his activities
Make frequent unobtrusive observations of the client's moods and his activities It is necessary to assess behavior changes that indicate impending suicidal acting out. Because there is no overt acting out and there is no plan, continuous observation is not necessary. The depressed client has little energy and has difficulty making decisions. Activities that are more structured are needed. Detailed explanations are inappropriate and overwhelming for a depressed client.
A nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client? Reward healthy behaviors. Explain the treatment plan. Identify various means of coping. Encourage participation in community meetings.
Reward healthy behaviors. By realistically rewarding the healthy behaviors, the nurse provides secondary gains and encourages the continued use of healthy behaviors. Explaining the treatment plan, identifying various means of coping, and encouraging participation in community meetings are important but will do little to increase the client's self-esteem.
Personality disorders are identified in the DSM-V in clusters. How should the nurse describe the behaviors of an individual with a cluster A personality disorder? Odd and eccentric Anxious and fearful Dramatic and erratic Hostile and impulsive
Odd and eccentric Cluster A includes paranoid, schizoid, and schizotypal personality disorders. These clients are odd and eccentric and use strange speech, are angry, and have impaired relationships. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. These clients are anxious, fearful, tense, and rigid. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. These clients are dramatic, erratic, labile, impulsive, hostile, and manipulative.
The nurse understands that paranoid delusions may be related to the defense mechanism of: Projection Regression Repression Identification
Projection Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within. Regression is the use of a behavioral characteristic appropriate to an earlier level of development. Repression is the involuntary exclusion of painful or conflicting thoughts from awareness. Identification is taking on the thoughts and mannerisms of an individual who is admired or idealized.
Nursing management of a forgetful, disoriented client who exhibits inappropriate behaviors signifying dementia should be directed toward: Restricting gross motor activity to prevent injury Preventing further deterioration in the client's condition Maintaining scheduled activities through behavior modification Rechanneling the client's energies into more appropriate behaviors
Rechanneling the client's energies into more appropriate behaviors Disoriented clients need assistance in how they direct their energy to limit inappropriate behaviors. The staff cannot prevent all gross motor activity; the client needs to use his muscles, but their use must be controlled. Further deterioration usually cannot be prevented in this disorder. Behavior modification methods do not work well with disoriented, forgetful clients.
What characteristic of anxiety is associated with a diagnosis of conversion disorder? Free-floating Relieved by the symptom Consciously felt by the client Projected onto the environment
Relieved by the symptom The client's anxiety results from being unable to choose psychologically between two conflicting actions. The conversion to a physical disability removes the choice and therefore eases the anxiety. The anxiety is not free floating or diffuse but rather localized and converted to a physical disability. The conversion of the anxiety to a physical disability occurs on an unconscious level; the original anxiety no longer exists, and the client generally is not anxious about the physical disability. The anxiety is internalized into a physical symptom, not projected onto the environment.
When interacting with an adolescent client with the diagnosis of anorexia nervosa, it is most important that the nurse: Show empathy. Maintain control. Set and maintain limits. Focus on food and nutrition.
Set and maintain limits. The client's security is increased by limit-setting; guidelines remove responsibility for behavior from the client and increase compliance with the regimen. The client needs limit-setting, not empathy. Simply maintaining control is not therapeutic and increases the power struggle. Emphasis on food and nutrition may establish a power struggle between the client and the nurse.
A nurse is caring for several extremely depressed clients. The nurse determines that these clients seem to do best in settings where they have: Multiple stimuli Varied activities Simple daily routines Opportunities for decision-making
Simple daily routines Depression is usually both emotional and physical, so a simple daily routine is the least stressful and least anxiety producing. Too many stimuli increase anxiety in a depressed client. A depressed client has limited interest in any activity; offering many may increase anxiety. An extremely depressed client may be incapable of making even simple decisions.
A client demonstrating manic behavior is elated and sarcastic. The client is constantly cursing and using foul language and has the other clients on the unit terrified. Initially the nurse should: Demand that the client stop the behavior immediately. Tell the client firmly that the behavior is unacceptable. Ask the client to identify what is precipitating the behavior. Increase the client's medication or get a prescription for another drug.
Tell the client firmly that the behavior is unacceptable. A firm voice is most effective; the statement tells the client that it is the behavior, not the client, that is upsetting to others. Demanding that the client stop the current behavior is a useless action; the client is out of control and needs external control. The client does not know what is precipitating the behavior, and asking the client will be frustrating for him. The dosage of the client's medication should be increased or a prescription for another drug should be obtained if the client does not respond to firm limit-setting.
A nurse is planning to teach a group of nursing assistants about auditory hallucinations. What portion of the brain should the nurse include that is involved with these hallucinations? Parietal lobe Frontal cortex Occipital lobe Temporal lobe
Temporal lobe The temporal lobe helps individuals focus on environmental events and integrates smell and hearing. The parietal lobe receives and integrates information about taste and touch. The frontal cortex receives input from all areas of the brain and integrates information about body position, memory, arousal states, and emotions. The occipital lobe is involved in the perception of visual input and depth perception.
When taking a health history from a client who has a moderate level of cognitive impairment as a result of dementia, the nurse expects the presence of: Hypervigilance Increased inhibition Enhanced intelligence Accentuated premorbid traits
Accentuated premorbid traits A moderate level of cognitive impairment because of dementia is characterized by increasing dependence on environmental and social structure and by increasing psychological rigidity with accentuated previous traits and behaviors. Although paranoid attitudes, which are associated with hypervigilance, may be exhibited, the decrease in cognition, disorientation, and loss of memory usually do not lead to hypervigilance. With the decrease in impulse control that is associated with dementia, decreased, not increased, inhibition occurs. Enhancement of intelligence does not occur with dementia, but initially intellectual deterioration is subtle.
A nurse is caring for a client admitted to a mental health unit because of suicidal ideation. Which intervention provides the greatest safety for this client? Seclusion room Four-point restraints Constant one-to-one supervision Removal of unsafe objects from the environment
Constant one-to-one supervision A member of the health team provides a continuous presence to ensure the safety of a client who is at high risk for suicide. Although removing unsafe objects from the environment is important, clients who are intent on self-harm will find ways even if such objects are removed. Seclusion and four-point restraints are overly restrictive.
What is the greatest difficulty for nurses caring for the severely depressed client? Client's lack of energy Negative cognitive processes Contagious quality of depression Client's psychomotor retardation
Contagious quality of depression Depression is contagious; it affects the nurse as well as the client. The client's lack of energy does not make nursing care difficult. Intervening with the client's negative thinking is an expected part of nursing care and does not create special difficulties for the nurse. The client's lack of energy does not make nursing care difficult.
A nurse is making a home visit to a young male client manifesting chronic symptoms of AIDS. The nurse assesses the client for signs of altered mental health function associated with AIDS. Select all that apply. Delusions Memory loss Hopelessness Hyperactivity Paranoid thinking
Correct 1, 2, 3, 5
When implementing a tertiary preventive program for cognitively impaired individuals the nurse should: Teach children how to feed themselves. Encourage the use of birth control by women. Refer children for evaluation if they fail to meet developmental milestones. Use the Denver Developmental Screening Test to evaluate children attending well-child clinics.
Teach children how to feed themselves. Tertiary prevention is focused on interventions that prevent complete disability or reduce the severity of a disorder or its associated disabilities. Referring children for evaluation if they fail to meet developmental milestones is secondary prevention aimed at case-finding and early intervention. Encouraging the use of birth control by women who are cognitively impaired is primary prevention. Using the Denver Developmental Screening Test to evaluate children attending well-child clinics is secondary prevention aimed at case-finding and early intervention.
A daycare environment is recommended for a client with incapacitating behaviors resulting from an obsessive-compulsive personality disorder. The client's partner asks the nurse why this approach is necessary. What is the best response by the nurse? "This environment limits time to carry out the rituals." "A neutral atmosphere facilitates the working through of conflicts." "A location that requires no decision-making will resolve feelings of anxiety." "The daycare setting allows the staff to exert control over unacceptable behaviors."
"A neutral atmosphere facilitates the working through of conflicts." These clients can better work through their underlying problems when the environment is structured, demands are reduced, and the routine is simple. Preventing these clients from carrying out rituals may precipitate panic reactions. Although eliminating the necessity to make decisions may decrease anxiety, simple decision-making should be encouraged. The intention of therapy should be to help the client gain control, not to enable others to do the controlling.
An occupational health nurse is meeting with a new employee to obtain a health history and schedule an appointment with the nurse practitioner for a physical examination. How can the occupational nurse best respond when the new employee exhibits a moderate level of anxiety and verbalizes extreme nervousness about starting the new job? "It's common to feel a little nervous." "You'll be less nervous when you get used to the job." "I felt the same way when I first started working here." "Feeling upset about starting a new job can be difficult.""
"Feeling upset about starting a new job can be difficult."" The response "Feeling upset about starting a new job can be difficult" focuses on the employee's feelings and demonstrates understanding and empathy. The response "It's common to feel a little nervous" negates the employee's feelings and is not therapeutic. The response "You'll be less nervous when you get used to the job" negates the employee's feelings and provides false reassurance. The response "I felt the same way when I first started working here" focuses on the nurse's, rather than the employee's, feelings.
A clinically depressed young mother whose husband has been killed tells the nurse that she sees no purpose in life and feels like ending it all. What is the best response by the nurse? "How much consideration have you given to the method you'd use to kill yourself?" "Death is hard on everyone, but people make it through every day. You'll see; things will get better." "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now." "You feel that way now, but you still have your whole life ahead of you. Why don't you try to make a new start?"
"It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now." The response "It can be hard to lose someone you care about so much; it can seem that life isn't worth living right now" validates the client's experience and opens a channel of communication for further exploration; empathy helps build trust. Asking how much consideration the client has given to the method she would use to kill herself is premature; the nurse should first explore the client's feelings before discussing thoughts and plans. Telling the client that death is hard on everyone but people make it through every day and that things will get better is false reassurance; it invalidates the client's experience. Telling the client that she has her whole life ahead of her and advising her to make a new start is false reassurance; it invalidates the client's experience.
The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse? "It must be frustrating to deal with your child's behavior." "Have you considered any alternatives to using medication?" "Perhaps you're looking for an easy solution to the problem." "Let me teach you about the side effects of medications used for ADHD."
"It must be frustrating to deal with your child's behavior." Stating that it must be frustrating acknowledges the parent's distress and encourages verbalization of feelings. Asking whether any alternatives have been considered is insensitive to the parent's feelings; it may be more appropriate later, when the parent's stress has diminished. Although the parent may be looking for an easy answer to the problem, this response is confrontational and may close off communication. Asking to teach the parent about the side effects of ADHD medications is insensitive to the parent's feelings; it may be more appropriate later if medication is prescribed and health teaching is started.
The nurse is interviewing a female adolescent with anorexia nervosa who is malnourished and severely underweight. The nurse concludes that the client is experiencing secondary gains from her behavior when she says: "I'm as big as a house." "I get straight A's in school." "My mother keeps trying to get me to eat." "My hair is beginning to fall out in clumps."
"My mother keeps trying to get me to eat." The client's behavior has gotten attention for her; it provides a sense of power and control. "I'm as big as a house" reflects a disturbed perception about her body. Although clients with anorexia nervosa are concerned about social acceptance, perfectionism, and achievement and may obtain high grades in school, good grades are not a secondary gain related to the eating behaviors associated with anorexia nervosa. Hair falling out in clumps is a result of starvation, not a secondary gain.
A client with a mood disorder is being discharged from a psychiatric hospital after agreeing to continue follow-up visits with a therapist. During the last interview with the nurse before discharge, the client says, "I've told you a lot about my life and my problems, but there are a few things that bother me that I've told no one." What is the most therapeutic response by the nurse once it has been determined that the client is not at risk for harming herself or others? "The purpose of our getting together is to discuss your problems." "Do you want to work on those during the few minutes we have left?" "What kind of problem have you not shared with me during our time together?" "One purpose of continuing counseling is to allow you to discuss things that bother you."
"One purpose of continuing counseling is to allow you to discuss things that bother you." Clients may introduce new topics during the last session to avoid termination; the nurse should encourage them to discuss these problems as outpatients. Two purposes of the last interview are to summarize and terminate, not to begin discussion of new problems. The last minutes of the last interview are not the appropriate time to introduce new problems.
A client with the diagnosis of borderline personality disorder is manipulative and uses this behavior to get cigarettes from other clients. One day the client begins to badger another client. What should the nurse say while removing the client from the area? "You must leave people alone; this behavior is unacceptable." "There will be consequences if you do not stop annoying people," "Tell me how you feel when you are exerting control over people." "I'm surprised that you're still bothering people; you seemed to have improved lately."
"You must leave people alone; this behavior is unacceptable." Limits must be set when the client's behavior physically or emotionally imposes on other clients. The response "There will be consequences if you do not stop annoying people" is a threat and is contraindicated. Although the response "Tell me how you feel when you are exerting control over people" is an exploration of feelings, which is important, the priority at this time is to set limits and protect the other clients. The response "I'm surprised you're still bothering people; you seemed to have improved lately" devalues the client and may precipitate feelings of guilt.
One morning a client with the diagnosis of acute depression says to the nurse, "God is punishing me for my past sins." What is the best response by the nurse? "Why do you think that?" "God is punishing you for your sins?" "You really seem to be upset about this." "If you feel this way, you should talk to a member of the clergy."
"You really seem to be upset about this." "You really seem to be upset about this" focuses on the client's feelings rather than on the statement and serves to open a channel of communication. "Why do you think that?" asks the client to decide what is causing the feelings; most people are unable to explain why they feel as they do. Although paraphrasing may stimulate further communication, the statement does not focus on feelings. "If you feel this way, you should talk to a member of the clergy" does nothing to stimulate further communication; in fact, it tells the client to talk about feelings with someone else.
A hospitalized client with a mood disorder begins to be less hyperactive. One day the client says to the nurse, "My husband and I have problems getting along sometimes. We see things differently." Which response is nontherapeutic? "What do you normally do when this happens?" "Tell me what you mean by 'see things differently'." "Not getting along with your spouse can be upsetting." "You seem calmer today than you have been the last several days."
"You seem calmer today than you have been the last several days." The nurse changes the subject in this response; in this situation it is better to continue discussing the same subject. "Tell me what you mean by 'see things differently'" is a therapeutic response that asks the client to clarify and elaborate. "Not getting along with your spouse can be upsetting" is an acceptable response because it focuses on the client's implied feelings. "What do you normally do when this happens?" is a therapeutic response because it allows the nurse to explore coping techniques with the client.
The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. The best term to describe this situation is: Amnesia Aphasia Apraxia Agnosia
Agnosia Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.
A client with the diagnosis of schizophrenia who has been hospitalized on a mental health unit for 2 weeks is to be discharged home. The client is vacillating between being happy and sad about going home. What term best describes these conflicting emotions? Double bind Ambivalence Loose association Inappropriate affect
Ambivalence The simultaneous existence of two conflicting emotions, impulses, or desires is known as ambivalence. A single communication containing two conflicting messages is known as a double-bind message. A lack of connections between thoughts is known as loose associations. Inappropriate affect is not two conflicting emotions but instead the inappropriate expression of emotions.
A 19-year-old adolescent is admitted to the emergency department with multiple fractures and potential internal injuries. The client's history reveals multiple drug abuse for the past 8 months. When caring for this client, the nurse determines that the most serious life-threatening responses usually result from withdrawal from: Heroin Methadone Barbiturates Amphetamines
Barbiturates Withdrawal from central nervous system depressants, such as barbiturates, is associated with more severe morbidity and mortality. Symptoms begin with anxiety, shakiness, and insomnia; within 24 hours convulsions, delirium, tachycardia, and death may occur. Withdrawal from heroin or methadone is rarely life threatening, but it does cause severe discomfort, including abdominal cramping and diarrhea. Withdrawal from amphetamines is rarely life threatening, but it causes severe exhaustion and depression.
An antipsychotic has been prescribed to be taken three times a day by a client who was admitted to the psychiatric service because of delusions and physical and verbal abuse of others. What client behavior demonstrates a therapeutic response to the medication? Exhibits enthusiasm about the food in the hospital Becomes aware of the behavior and its consequences Begins to get involved with the activities of others on the unit Remains preoccupied with the delusions but is less verbally abusive
Becomes aware of the behavior and its consequences As the therapeutic level is reached and maintained, the client's psychotic symptoms decrease and insight increases. Exhibiting enthusiasm about the food or beginning to get involved with the activities of others on the unit does not indicate that the client is responding therapeutically to the medication. Remaining preoccupied with the delusions but is less verbally abusive is an indication that the client is not responding to the medication.
What should the nurse identify as the foremost basis for the development of schizophrenia? Seasonal perspective Biological perspective Immunological perspective Psychoanalytical perspective
Biological perspective The biological factors, including genetics, neuroanatomy, and abnormal neurotransmitter-endocrine interactions, prevail as the origin of schizophrenia as a result of studies conducted during the twentieth century. Psychoanalytic perspective no longer is thought of as the primary basis for schizophrenia. A seasonal or immunological perspective is not the primary basis for schizophrenia.
A clinically depressed female client on a psychiatric unit of a local hospital uses embroidery scissors to cut her wrists. After treatment, when the nurse approaches, the client is tearful and silent. What is the best initial intervention by the nurse? Note client's behavior, record it, and notify the practitioner. Sit quietly next to the client and wait until she begins to speak. Say, "You're crying. I guess that means you feel bad about attempting suicide and really want to live."
Comment, "I notice that you seem sad. Tell me what it's like for you and perhaps we can begin to work it out together." Noting that the client seems sad and asking her to describe her feelings so the nurse and client can begin to work it out together recognizes feelings and behavior; it encourages the client to share feelings and promotes trust, which is essential for a therapeutic relationship. Although noting, recording, and notifying the practitioner of the client's behavior are important actions, they are not enough; nursing intervention with the client must be included. Without verbal encouragement, the depressed client will not respond to this intervention. Saying that because the client is crying she must feel bad about attempting suicide and really want to live assumes too much and may be inaccurate; an indirect approach should be used.
When assessing the mental status of a 7- or 8-year-old child, it is most important for the nurse to: Listen to the parents' description of the child's behavior. Compare the child's function from one occasion to another. Engage the parents in a discussion about the child's feelings. Determine the child's mental status with the use of direct questions.
Compare the child's function from one occasion to another. Comparison over time is the only way for the nurse to accurately assess the mental status of a child. Listening to the parents' description of the child's behavior may be unrealistic and foster bias. The nurse should consider the parents' description of behavior but should rely on personal assessment and observation over time. The child's ability to discuss feelings is limited. In addition, the child's feelings are subjective symptoms that are known only by the child. Determining the child's mental status with the use of direct questions can be threatening and may precipitate anxiety.
For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply. Irritability Tachycardia Hallucinations Increasing anxiety Profuse diaphoresis
Correct 1, 2, 4, 5 Alcohol is a central nervous system depressant; irritability and increasing anxiety reflect the body's neurologic adaptation to the withdrawal of alcohol. Tachycardia and diaphoresis are early signs of withdrawal that result from autonomic overactivity. Hallucinations are not early signs of alcohol withdrawal; they usually do not occur before 48 to 72 hours of abstinence.
A nurse is assessing a client with dementia. Which clinical manifestations are expected? Select all that apply. Agitation Pessimism Short attention span Disordered reasoning Impaired motor activities
Correct 1, 3, 4, 5 The behavior of clients with dementia tends to be inappropriate, restless, and agitated. Cognitive abilities are impaired, as evidenced by a short attention span, limited ability to focus, and limited judgment and insight. Reasoning is disordered, speech may be incoherent, and memory, particularly short-term memory, is impaired. Impaired motor activity (apraxia) and impaired coordination (ataxia) are associated with dementia. Pessimism is more characteristic of depression, not dementia. The two often occur together and should be identified and treated appropriately
A nurse is assessing a client with a diagnosis of primary insomnia. Which findings from the client's history may be the cause of this disorder? Select all that apply. Chronic stress Severe anxiety Generalized pain Excessive caffeine Chronic depression Environmental noise/distractors
Correct 1, 4, 6 Acute or primary insomnia is caused by emotional or physical stress not related to the direct physiologic effects of a substance or illness. Excessive caffeine intake can cause disruptive sleep hygiene; caffeine is a stimulant that inhibits sleep. Environmental noise causes physical and emotional discomfort and is therefore related to primary insomnia. Severe anxiety is usually related to a psychiatric disorder and therefore causes secondary insomnia. Generalized pain is usually related to a medical or neurologic problem and therefore causes secondary insomnia. Chronic depression is usually related to a psychiatric disorder and therefore causes secondary insomnia.
A nurse who is assessing a recently hospitalized client with a diagnosis of opioid addiction should look for signs of withdrawal. What are these signs? Select all that apply. Seizures Yawning Drowsiness Constipation Muscle aches
Correct 2 5 Yawning and muscle aches are clinical manifestations of opioid withdrawal, which occurs after cessation or reduction of prolonged moderate or heavy use of opioids. Seizures do not occur with opioid withdrawal. Insomnia, not drowsiness, occurs with opioid withdrawal. Diarrhea, not constipation, occurs with opioid withdrawal
A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? Select all that apply. Discuss how others can precipitate anxiety. Provide physical outlets for aggressive feelings. Establish a contract regarding manipulative behavior. Develop activities that provide opportunities for success. Encourage the client to verbalize negative feelings to others.
Correct 2, 3, 4 Channeling energy to healthy physical activities can decrease violent behavior. A behavioral contract is used to reinforce problem solving and encourage the use of social skills. Successful experiences improve the client's self-esteem and should decrease the manipulative behavior. Clients with conduct disorders tend to generate stress for others, not the other way around. Verbalization of negative feelings to others can often escalate and result in antisocial or acting out behavior.
A nurse is implementing interventions to assist an aggressive client in deescalating the agitated behavior. Select all that apply. Physical contact with the client to show caring Encouraging the client to express his perceived needs Avoiding verbal struggles in an attempt to demonstrate authority Providing the client with clear options to the unacceptable behavior Referring to the client in an authoritarian manner to demonstrate control of the situation Explaining the expected outcomes if the client is unable to control the unacceptable behavior
Correct 2, 3, 4, 6 Encouraging the client to express his perceived needs provides the client with a sense of being heard and respected. Verbal struggling will likely increase the tension and aggressive behavior of the client. Providing options will allow the client to effectively change behaviors if he is capable of doing so. Explaining outcomes for continued unacceptable behavior allows the client to make a decision to change behaviors if he is 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.
The nurse can identify the most commonly demonstrated comorbid disorders associated with generalized anxiety disorder (GAD) by assessing the client for which of the following? Select all that apply. Obesity Signs of alcohol withdrawal Phobias Impaired cognitive function Suicidal ideations
Correct 2, 3, 5 The most frequent comorbid conditions associated with GAD include alcohol abuse, simple phobias, and major depression. Obesity and impaired cognitive function generally are not identified as being comorbid conditions associated with GAD.
A woman who has severe rheumatoid arthritis becomes depressed and is admitted to the psychiatric unit. The nurse begins to work with her in one-on-one sessions to help her cope with her depressive episode. The best long-term goal for this client is that she will: Eat at least two meals per day with other clients. Maintain self-care and attend structured activities. Make a positive verbal comment to another client daily. Decrease negative thinking about herself, others, and life.
Decrease negative thinking about herself, others, and life. The best long-term goal is that the client attains a positive attitude about the self, others, and life in general; this indicates that treatment has been effective and the client may be discharged. Eating at least two meals per day with other clients is a short-term goal associated with a therapeutic milieu. Maintaining self-care and attending structured activities is a short-term goal and an expected behavior on an inpatient unit. Making a positive verbal comment to another client daily is an intermediate goal that helps the client focus on others; this goal is a step toward achieving long-term goals.
A client with a history of schizophrenia has recently begun reporting symptoms of depression and is now being prescribed a selective serotonin reuptake inhibitor (SSRI). In light of the information in the client's chart, the nurse's priority is: Educating both the client and family on how to identify the early signs of extrapyramidal symptoms Requesting a gastrointestinal consult to identify the cause of the client's need for frequent antacids Stressing the importance of managing the client's diet while taking the prescribed antidepressant Discuss the stressors that have developed since the client moved in with his sister and brother-in-law
Educating both the client and family on how to identify the early signs of extrapyramidal symptoms 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 an MAOI and not an SSRI. Identifying and addressing stressors is important, but it does not take priority in this situation.
Nurses on a psychiatric unit have secluded a client who has the diagnosis of bipolar I disorder, manic episode, and who has been losing control and throwing objects while in the dayroom. The most important intervention for the client who is given a PRN medication and confined to involuntary seclusion is to: Continue intensive nursing interactions. Evaluate the client's progress toward self-control. Determine whether any staff member has been injured. Observe the client for side effects of the medication given to the client.
Evaluate the client's progress toward self-control. For the safety of the client and everyone on the unit, improvement in a client's level of self-control is essential before the degree of restraint and seclusion is progressively reduced. Continuing intensive interaction at this time would not be productive and could cause the client's behavior to escalate. The nurse's prime responsibility should be the client; staff members can assess other staff members. Observing the client for side effects of medications is only one of the many factors in determining the client's level of self-control.
A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feelings stop." What clinical manifestation is evident? Feelings of panic Suicidal tendencies Narcissistic ideation Demanding personality
Feelings of panic The client can no longer control or tolerate these overwhelming feelings and is seeking help. The client has not indicated plans for self-harm. Narcissistic ideation is not typical of a narcissistic personality. The client's behavior does not indicate a demanding personality.
A client arrives at the mental health clinic complaining about feelings of extreme terror when attempting to ride in an elevator and feelings of uneasiness in large crowds. He reports that these fears are interfering with his concentration at work. What does the nurse identify as the source of these symptoms? Conflict with society, resulting in an obsession Depression about life events, resulting in unreasonable fears Generalized anxiety about conflicts, resulting in unreasonable fears Repression of a terrifying incident in an elevator, resulting in an obsession
Generalized anxiety about conflicts, resulting in unreasonable fears Phobias are specific fears that often serve as a means of coping with generalized anxiety. Conflicts with society do not result in phobias. Although depression is related to phobias, finding a direct connection to life events is difficult.
A nurse in the mental health clinic is counseling a client with the diagnosis of depression. During the counseling session the client says, "Things always seem the same. They never change." The nurse suspects that the client is feeling hopeless. For what indication of hopelessness should the nurse assess the client? Outbursts of anger Focused concentration Preoccupation with delusions Intense interpersonal relationships
Outbursts of anger Clients who are depressed and feeling hopeless also tend to have inappropriate expressions of anger. Depressed clients frequently have a diminished ability to think or concentrate. Preoccupation with delusions is usually associated with clients who have schizophrenia rather than with clients experiencing depression and hopelessness. Clients who are depressed and feeling hopeless tend to be socially withdrawn and do not have the physical or emotional energy for intense interpersonal relationships.
A client is admitted with a bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display? Elated affect related to reaction formation Loose associations related to a thought disorder Physical exhaustion related to decreased physical activity Paucity of verbal expression related to slowed thought processes
Paucity of verbal expression related to slowed thought processes As depression increases, thought processes become slower and verbal expression decreases due to lack of emotional energy. Elation is associated with bipolar disorder, manic episode; the affect of a depressed person is usually one of sadness, or it may be blank. Loose associations are related to schizophrenia, not depression. Physical exhaustion is associated with bipolar disorder, manic episode; decreased physical activity does not produce physical exhaustion.
A psychotic male client is admitted to the hospital for evaluation. While obtaining the history, the nurse asks why he was brought to the hospital by his parents. The client states, "They lied about me. They said I murdered my mother. You killed her. She died before I was born." What does the nurse recognize that the client is experiencing? Ideas of grandeur Confusing illusions Persecutory delusions Auditory hallucinations
Persecutory delusions The client's verbalization reflects feelings that others are blaming the client for negative actions. There are no data to demonstrate the client is having feelings of greatness or power. There are no data to demonstrate the client is experiencing confusing misinterpretations of stimuli. There are no data to demonstrate the client is hearing voices at this time.
A nurse is caring for an adolescent with the diagnosis of anorexia nervosa. The plan of care should include helping the client: Plan nutritious meals. Change attitudes about nutrition. Understand that more food must be eaten. Recognize how the need to control influences behavior.
Recognize how the need to control influences behavior. The client's focus on controlling eating redirects attention away from those areas that are felt to be out of the client's control. This is how addressing life's more difficult problems and challenges are avoided. Planning nutritious meals may not be productive because these clients believe that they are eating nutritious meals. It is not the client's attitudes or beliefs about food but instead the distorted self-image that is the problem. Understanding that more food must be eaten may not be productive because these clients believe that they are eating enough food.
A nurse is assessing a client with the diagnosis of schizophrenia, undifferentiated type. What defense mechanisms should the nurse anticipate that this client might use? Projection Repression Regression Conversion
Regression Regression is an unconscious defense mechanism that reduces anxiety by returning to behavior that was successful in earlier years. Regression commonly is used by clients with undifferentiated schizophrenia to reduce anxiety. Projection is the attributing of unacceptable feelings or thoughts to others. It is an organized defense used by clients with paranoid, not undifferentiated, schizophrenia. Clients with undifferentiated schizophrenia have psychotic manifestations that are extreme and do not have thought processes effective enough to use projection. Repression is unintentionally putting disturbing thoughts, feelings, or desires out of the conscious mind. Clients with schizophrenia are not able to do this and therefore have a need to escape from reality. Conversion is an unconscious defense mechanism in which a person develops physical symptoms that have no organic cause. Conversion serves the purpose of reducing anxiety. Conversion is not used by clients with undifferentiated schizophrenia.
What characteristic uniquely associated with psychophysiological disorders differentiates them from somatoform disorders? Emotional cause Feeling of illness Restriction of activities Underlying pathophysiology
Underlying pathophysiology The psychophysiological response (e.g., hyperfunction or hypofunction) produces actual tissue change. Somatoform disorders are unrelated to organic changes. There is an emotional component in both instances. There is a feeling of illness in both instances. There may be a restriction of activities in both instances.
A client was recently given a diagnosis of a manic episode of a bipolar I disorder. What activity is most therapeutic for this client at this time? Doing a craft project Playing a game of table tennis Playing cards with another patient Walking around the unit with a nurse
Walking around the unit with a nurse Walking allows the client to burn excess energy in a safe, acceptable activity. A one-on-one activity demonstrates that the nurse cares and may allow the nurse to verbally interact with the client. A quiet activity such as a craft project for a person who is hyperactive is unrealistic and would be frustrating for the client. A game of table tennis would be too stimulating and competitive, both of which may increase anxiety. A hyperactive client does not have the ability to be quiet and focus on a card game.