Cap land NGN

The nurse provides care for a client after electroconvulsive therapy (ECT). It is most important for the nurse to take action? A. Encourage the client to turn from side to side B. Remind the client that memory loss is temporary C. Examine the client carefully for fractures D. Tell the client the seizure was very short

B. Remind the client that memory loss is temporary

The nurse provides care for clients in the pediatric clinic. The nurse understands that according to Erickson's stages of psychological development, developing a sense of personal control and a sense of independence occurs during which time period? A. 18 months to 3 years B. 3 to 6 years C. 6 to 12 years D. 12 to 20 years

A. 18 months to 3 years

The nurse provides care for a client with anorexia nervosa. The nurse knows which statements are true regarding anorexia nervosa? (SATA) A. Adolescent female are most affected B. Anorexia nervosa has the highest mortality rate of all mental disorders C. Clients diagnosed with anorexia nervosa see themselves as emaciated and unhealthy D. Client diagnosed with anorexia nervosa are self-indulgent E. Client diagnosed with anorexia nervosa often see themselves as overweight

A. Adolescent female are most affected B. Anorexia nervosa has the highest mortality rate of all mental disorders E. Client diagnosed with anorexia nervosa often see themselves as overweight

A client is brought to the emergency department with a diagnosis of myocardial infarction and respiratory arrest. The client expires and the client's spouse come to the client's bedside. Which is the best initial action for the nurse to take? A. Allow the spouse to spend time with the client and provide privacy B. Encourage the spouse to pray and offer to call a chaplain C. Inform the spouse of the necessary form which will need to be completed D. Described the client's diagnosis and explain that everything possible was done.

A. Allow the spouse to spend time with the client and provide privacy

The nurse is a university student health center receives a call from an upset student. The student is crying and states, "my partner left me and I don't want to live anymore". Which statement is most appropriate for the nurse to make? A. Are you thinking of hurting yourself right now? B. Did you and your partner have a fight C. Ae you alone D. Can you tell me what happen

A. Are you thinking of hurting yourself right now?

A client uses heroin several times a day. Which signs and symptoms does the nurse expect to observe? (SATA) A. Constricted pupils, depressed respirations B. Drowsiness or sedation C. Vomiting and hypotension D. Agitation and tachycardia E. Slurred or incoherent speech F. Dilated pupils, increased respirations

A. Constricted pupils, depressed respirations B. Drowsiness or sedation E. Slurred or incoherent speech

A client talks with the nurse about feeling overwhelmed since the client was terminated from employment. The client states, "I feel like I can barely get out of bed in the morning". The nurse recognizes the client is in which stage of crisis? A. Disorganization B. Denial C. Blame D. Escape

A. Disorganization

A client diagnosed with schizophrenia is prescribed haloperidol 5 mg twice per day. The nurse observes the client for with most concerning symptoms? (SATA) A. Dizziness and lightheadedness B. Vomiting and diarrhea C. Diuresis and sodium loss D. Hypertension and weight loss E. Muscle spasms and stiffness

A. Dizziness and lightheadedness E. Muscle spasms and stiffness first-generation typical antipsychotic

The nurse provides care to a client who has been informed that results of the client's liver biopsy are pos for cancer. The client is extremely upset and repeats. "What am I going to do?" Which response by the nurse is most appropriate? A. Express concern then sit quietly with the client B. Allow the client to be alone to process the information C. Reassure the client of multiple treatments available D. Notify the client's Family

A. Express concern then sit quietly with the client

The nurse provides care for a client diagnosed with dependent personality disorder. Which client statement best indicates improvement in the client's condition? A. I am planning which herbs I want to plant in my garden B. I need to call my partner at work several times a day C. I want you to help me decide what I should wear today D. I feel like I can not breathe when my spouse leaves for work

A. I am planning which herbs I want to plant in my garden

The nurse instructs a client about phenelzine sulfate. Which statement indicates to the nurse that further teaching is necessary. (SATA) A. I can t wait to have a hot dog with sauerkraut B. I'm going to get some polycarbophil when I get home C. I will be playing doubles tennis with my neighbor D. When I get home, I will take my car out for a road trip E. I usually have a beer or two to relax in the evening F. I like to eat strawberry yogurt for breakfast

A. I can t wait to have a hot dog with sauerkraut E. I usually have a beer or two to relax in the evening

An older adult diagnosed with a terminal illness dies while the family is visiting. Which action is appropriate for the nurse to take? A. Offer the family the opportunity to privately spend time with the client's body. B. Explains that the client is in heaven now and ask if the family would like to pray C. Usher the family from the room immediately and provide postmortem care D. Remove the clients dentures and remove the pillows from behind the clients head

A. Offer the family the opportunity to privately spend time with the client's body.

The nurse provides care to a client experiencing alcohol withdrawal delirium. Which medication does the nurse expect to be prescribed? A. Phenobarbital and chlordiazepoxide B. Disulfiram and chlorpromazine C. Disulfiram and barbiturates D. Tricyclics and sedatives

A. Phenobarbital and chlordiazepoxide

The nurse develops a plan to address the client's need. Select 2 strategies the nurse includes at this time. A. Speak in a low, calm voice B. Remain with the client C. Provides information about eating disorders D. Educate about post-traumatic stress disorder (PTSD) E. Provide detailed information about the procedure

A. Speak in a low, calm voice B. Remain with the client

The nurse is providing medication education to an older adult client diagnosed with heart failure who is preparing for discharge. The client repeatedly interrupts the nurse talking about the client's grandchildren. Which is the best response by the nurse? A. Thank you for telling me about your grandchildren. Let's talk about this medication you will be taking when you go home B. You need to stop talking and listen to this information. It is very important C. When you are through talking about your family, we will need to review your medications D. There isn't enough time for you to tell me about your grandchildren. You must have this information before you go.

A. Thank you for telling me about your grandchildren. Let's talk about this medication you will be taking when you go home

The nurse provides care for an older adult client with a diagnosis of urinary tract infection who has become disoriented and agitated. The nurse suspects the client has developed delirium due to which factors? A. The symptoms developed rapidly B. The client expresses feeling hopeless C. The client has memory deficits D. The client has impaired motor skills

A. The symptoms developed rapidly

A client witnessed the suicide of the client's spouse, and developed total blindness with no identifiable cause after the incident. The client's response to becoming blind is calm and unconcerned. The nurse determines which is the appropriate interpretation of the client's behavior? A. This is a characteristic response to the physical ailment in a conversion reaction B. The client is in a state of shock and does not realize what has happened C. Grief and loss have caused the client to be unable to express emotions. D. The client recognizes the symptoms are not real.

A. This is a characteristic response to the physical ailment in a conversion reaction

The nurse provides care for a preschooler client in the pediatric clinic who involved in play therapy. The nurse understands which is the desired goal of play therapy. A. To allow the client to express feeling and resolve conflict B. To distract the client from the reality of health care C. To evaluate the client's ability to interact with others D. To tire the child and promote better sleep

A. To allow the client to express feeling and resolve conflict

The nurse provides care for a client who has been sexually assaulted by a family friend. The client states, "I never should have come to the hospital. Please don't tell anyone". Which response by the nurse is best? A. You were right to come here for help. I am going to help you B. I wont tell anyone, but you need to talk to your family C. Has this friend ever been inappropriate with you before D. I will have to call the police and take samples for evidence

A. You were right to come here for help. I am going to help you D is not the answer because although it is correct, it is not providing reassurance or emotional support.

The nurse provides care for a client who has been taking a tricyclic antidepressant for the last 12 days. Which behavior does the nurse assess for? A. Angry behavior B. Suicidal behavior C. Withdrawal from reality D. Early-morning waking

B. Suicidal behavior

The nurse provides care for a client who is in a state of crisis due to loss of a job. The client states, "I just can't believe this happening. I didn't do anything to deserve this". Which statement by the nurse is most appropriate? A. Why is that you feel so upset in this situation B. Talk to me about what happened with the job C. Its going to be okay. I'm sure you will get another job soon. D. You seem very stressed. Try to relax.

B. Talk to me about what happened with the job

A client diagnosed with depression is on a psychiatric unit. The client continually reports to the nurse, "My stomach is missing". Which response by the nurse is most appropriate. A. That is not possible. You wouldn't be able to eat anything B. I am here to help you with this problem C. It sounds as if you feel very empty and alone D. This is a common response to depression

C. It sounds as if you feel very empty and alone Clients with depression often have delusions that a body organ is missing or diseased.

The nurse's priority consideration in the client's risk to develop which complication? A. Psychosis B. Separation anxiety C. Panic attack D. Social anxiety disorder

C. Panic attack

The nurse understands a client's needs must be prioritized. According to Maslow's hierarchy of needs, which are most basic to a client's health maintenance plan? A. Safety and security B. Esteem and recognition C. Physiological D. Self-actualization

C. Physiological

The nurse provide care for a client diagnosed with paranoid schizophrenia. The client is alone in the hall, muttering and gesturing angrily. Which is the most appropriate action for the nurse to take? A. Hug the client and encourage the client to verbalize feelings B. Calmly ask if the client is having a hallucination C. Escort the client back to the client's room and provide privacy D. Call for assistance and restrain the client

B. Calmly ask if the client is having a hallucination

A client diagnosed with advanced Alzheimer disease continues to shout, "Help me" numerous time while on the unit. Another client diagnosed with borderline personality disorder is verbally abusive "shut up, why don't you?" Which is the best response by the nurse? A. Sedate the client with Alzheimer disease in an effort to calm the client and other clients B. Confront the client with borderline personality disorder about the verbal behavior C. Confront the client with Alzheimer disease about the verbal behavior D. Isolate the client with borderline personality disorder in a seclusion room

B. Confront the client with borderline personality disorder about the verbal behavior

The nurse provide care for an adolescent client with suspected gonorrhea. The client reports being sexually abused by a parent for the past 5 years. Which action does the nurse perform first? A. Attempt to determine what type of incident preceded the acts of sexual abuse B. Contact child protection agency and report the client's statement immediately C. Assess whether the client understands the meaning of sexual intercourse D. Tell the client that reporting this information is a step toward getting help

B. Contact child protection agency and report the client's statement immediately

A client with a diagnosis of depression is placed on sertraline 50 mg daily. The nurse instructs the client to observe for which adverse effects? (SATA) A. Photophobia B. Dizziness C. epistaxis D. Hypertensive crisis E. Taste changes F. Decrease libido

B. Dizziness E. Taste changes F. Decrease libido Med is SSRI

The middle-aged client is admitted to the hospital with diagnosis of terminal lung cancer. The client's spouse reports to the nurse that the client did not want to come to the hospital and "refuses to slow down". The nurse gives priority to which measure? A. Promote rest and relaxation B. Encourage the client to participate in planning care C. Encourage the client to accept help D. Set limits on excessive activities

B. Encourage the client to participate in planning care

The nurse performs a psychiatric assessment of a client being involuntary admitted to a psychiatric unit. The nurse understands which intervention is prioritized when admitting the client. A. Encouraging the client to feel welcome and accepted B. Ensuring the client is safe and unable to harm self C. Obtaining an extensive history of the client's mental illness D. Considering the client's level of ability to provide own care

B. Ensuring the client is safe and unable to harm self

The nurse instructs a client's spouse about how to cope with client's anxiety. The nurse determines more teaching is needed if the spouse makes which statement? A. I need to be predictable and avoid surprising my spouse B. It is important to confront my spouse during periods of anxiety C. Anxiety represents an unconscious conflict of needs D. Anxiety is decreased by using defense mechanisms

B. It is important to confront my spouse during periods of anxiety

The nurse provides care for a client diagnosed with depression who is scheduled for group therapy. The client asks the nurse, "What's the point of having to talk to a group of people"? Which is the most appropriate response? A. It is comforting to share problems with others who are going through similar experiences B. Members learn new ways to cope with stress and developed insight into their behaviors C. Groups teach the client how to express feelings in a way that is acceptable to others D. Participants encourage one another to adhere to treatment plans.

B. Members learn new ways to cope with stress and developed insight into their behaviors

A client with a diagnosis of bipolar disorder is boisterous, quarrelsome, and unusually energetic. Which intervention is most important for the nurse to include in the client's plan of care. A. Allow the client to make choices about care B. Orient the client to reality C. Ensure the client participates in physical exercise D. Provide the client with frequent activity and distraction

B. Orient the client to reality

The nurse provides care for clients on the detoxification unit. One client says to the nurse, "I know you despise me". Which defense mechanism does the nurse interpret that the client is using? A. Identification B. Projection C. Displacement D. Reaction formation

B. Projection The client is probably using projection, in which one's threats to the ego are perceived to be outside the self.

A client is brought to the emergency department following a motor vehicle accident. The client is agitated and fights against the nurse while care is being provided. The client's drug screen returns positive for cocaine. It is most important for the nurse to provide which intervention? A. Cover the client with blankets and raise the temperature in the room B. Provide a calm atmosphere and monitor respiratory and cardiac status C. Restrain the client and administer a sedative D. Place the client in a well-lighted room and perform neurological assessment every hour

B. Provide a calm atmosphere and monitor respiratory and cardiac status

The nurse provides care for a client with a diagnosis of alcohol use disorder. The client states "I need a drink or two to relax after a busy day at work. I have an incredibly high stress job". The nurse identifies that this statement is an example of which defense mechanism A. Sublimation B. Rationalization C. Displacement D. Intellectualization

B. Rationalization

The nurse prepares to lead a group session for clients who have a dependence on alcohol. The nurse knows that a client with a diagnosis of alcohol use disorder drinks because of which reason? (SATA) A. The client diagnosed with alcohol use disorder enjoys the feeling of being intoxicated. B. The client diagnosed with alcohol use disorder uses alcohol to escape from problems C. The client diagnosed with alcohol use disorder has a greater alcohol tolerance than most people. D. The client diagnosed with alcohol use disorder performs more efficiently when drinking E. The client diagnosed with alcohol use disorder uses alcohol to cover up depression or anxiety

B. The client diagnosed with alcohol use disorder uses alcohol to escape from problems E. The client diagnosed with alcohol use disorder uses alcohol to cover up depression or anxiety

The nurse provides care for a client scheduled for surgery. The client reports drinking socially, but had a beer to relax the previous evening. During the preadmission interview the client states, "I usually don't sleep well and wake up at 4 in the morning. Right now I am very anxious and shaking inside." The clients vital signs are T 100F, P 120 bpm, R 24 per min, and BP 130/90 mmHg. Which conclusion does the nurse make? A. The client has anxiety about surgery B. The client has early signs of alcohol withdrawal. C. The client has delirium tremens D. The client has the onset of an infection.

B. The client has early signs of alcohol withdrawal

The hospice nurse provides care for a client with a diagnosis of end stage heart failure. The client says to the nurse, "Why can't this just end? I'm no good to anyone anymore". Which response is best? A. Don't talk like that. You are here for a reason B. This must be difficult. Please tell me about your feelings C. I understand how you feel. Things will get better D. You are having a hard time aren't you? I am here to help you through it

B. This must be difficult. Please tell me about your feelings

The nurse provides care for a client diagnosed with an obsessive-compulsive personality disorder. The nurse understands that compulsive behaviors serve which purpose for the client? A. To increase awareness of the triggers for the obsessive thoughts B. To provide a sense of relief from anxiety caused by obsessive thoughts C. To increase control the client has over obsessive thoughts D. To improve the client's ability to interact with others

B. To provide a sense of relief from anxiety caused by obsessive thoughts

During group therapy session, several clients verbally attack another client for behaving passively. Which is the most effective action for the nurse to take to move the group in a positive direction? A. Ask the client being attacked to tall the group how the negative behavior of the group feels B. Allow the group to continue the verbal assault C. Call on another client in the group as a diversion D. Tell the other clients in the group to ignore the client

C. Call on another client in the group as a diversion

The nurse provides care for a client diagnosed with antisocial personality disorder. The client shoves another client out of the way to get in line for a snack. Which action should the nurse take? A. Ignore the client and refuse to give attention to the client's negative behavior B. Physically move the client out of the line and firmly tell the client to stop C. Calmly confront the behavior and remind the client of consequences for negative behavior D. Tell the client that the client will not receive a snack and needs to leave the room.

C. Calmly confront the behavior and remind the client of consequences for negative behavior

The nurse provides care for a client with a diagnosis of Alzheimer disease who has an indwelling urinary catheter. While the nurse is checking the catheter, the client begins to kick and hit at the nurse. The client screams, "What are you doing? Leave me alone!" The nurse takes which action first? A. Hold the client's arm down B. Leaves the client to prepare a prescribed sedative C. Calmly identifies self as the nurse and reorients the client D. Firmly tells the client to stop or the client will be restrained

C. Calmly identifies self as the nurse and reorients the client

The nurse admits a client who has a diagnosis of alcohol use disorder and admits to drinking a pint of vodka a day. The client is scheduled for surgical repair of fracture femur following a MVA. The nurse includes which intervention in the client's plan of care. A. Provide stimulation and distraction B. Administer oral disulfiram C. Ensure seizure precautions are in place D. Place client on fluid restriction

C. Ensure seizure precautions are in place

A client is diagnosed with a conversion reaction blindness. Which approach is best when caring for this client? A. Place objects within the client's reach and feed the client if necessary B. Tell the client that the blindness will go away when the client takes anti-anxiety medication C. Focus conversations on the client's feelings and client's ability to cope with any stressful events that proceeded the incidence of blindness D. Provide the client with sunglasses to protect the eye

C. Focus conversations on the client's feelings and client's ability to cope with any stressful events that proceeded the incidence of blindness

The nurse plans care for a client with a history of substance abuse who will be participating in group therapy. The nurse understands which is the primary benefit of group therapy for this client? A. Participating in a group will distract the client from the substance abuse B. Group allow the client to form lasting friendship C. Groups reduce isolation in structured, controlled environments D. A group provides an environment that decreases stimuli and redirects behavior

C. Groups reduce isolation in structured, controlled environments

A client diagnosed with PTSD was held hostage in a bank robbery about 6 weeks ago. The client states that one of the employees was shot and still remains in a coma in a nearby hospital. The client reports daily flashbacks of the incident. Which action by the nurse is best when the client experiences flashbacks? A. Help the client identify areas of life and situation that are not within the clients ability to control. B. Encourage the client to explore the underlying feeling that may cause irrational fears C. Stay with client, offer assurance of safety, and tell the client these feelings are normal D. Assess the impact of trauma on the client's ability to resume activities of daily living and problem-solving

C. Stay with client, offer assurance of safety, and tell the client these feelings are normal

An older adult client diagnosed with terminal cancer has difficulty providing self care due to fatigue and dyspnea. When the nurse comes to assist the client, the client says "whats the use. I might as well just die". Which interpretation of the client's behavior is most justifiable? A. The client is in the acceptance phase about the end of life B. The client is actively dying C. The client is depressed and is physically and emotionally exhausted. D. The client is angry at the nurse's interference and is lashing out.

C. The client is depressed and is physically and emotionally exhausted.

The nurse observes which characteristic in a client diagnosed with a personality disorder? A. Needs are met primarily through manipulation B. Complies with the treatment regimen C. Verbalized feeling of distress D. Withdraws from social contact and unit activities

C. Verbalized feeling of distress

The nurse provides care for a client diagnosed with an anxiety disorder. While the client is in the recreation room with several other clients, the clients begins to sweat profusely and breathe rapidly. The client states, "I feel like I am having a panic attack" Which response by the nurse is best. A. Just take some deep breaths and calm down. Tell me what is bothering you B. I know you are feeling anxious, but no one is going to hurt you C. You're going to be alright. I'm going to help you back to your room D. Did you take your anti-anxiety medication today

C. You're going to be alright. I'm going to help you back to your room

The nurse provides care for a client who paces and shouts obscenities at other clients and staff. Which activity is best for the nurse to suggest for this client? A. Participating in unit activities B. Attending group therapy C. Reading a book in the room D. Accompanying the nurse to a quiet area

D. Accompanying the nurse to a quiet area

The nurse care for a client who is disoriented to time and place. Which nursing action is most appropriate when the nurse provides care for the client? A. Schedule constant activity and distraction for the client B. Rotate staff frequently to stimulate the client C. Discourage family and friends from caring for the client D. Allow the client to use clothing and personal care items

D. Allow the client to use clothing and personal care items

The nurse finds a client slumped on the floor with a razor blade in hand and a moderate amount of blood dripping from wrist. Which action by the nurse is most important? A. Find out why the client tried to commit suicide B. Telephone the health care provider to explain the situation C. Ask the unlicensed assistive personnel to hold the wrist while the nurse calls the health care provider D. Apply pressure to the wrist and call another nurse for help

D. Apply pressure to the wrist and call another nurse for help

The nurse provides care for a client diagnosed with alcohol abuse who is receiving counseling. Which is a primary goal of counseling for the client? A. Prevent problems which cause the client to drink B. Help the client become more dependent on others for decision making C. Identify persons in the client's life who can prevent the client from drinking D. Assist the client to identify factors that trigger alcohol use

D. Assist the client to identify factors that trigger alcohol use

The nurse in an inpatient psychiatric unit provides care for a client diagnosed with catatonic schizophrenia. The client stand in a corner of the day room in a stupor and exhibits mutism and waxy flexibility of the arms. The nurse understands the treatment plan for the client likely contains which interventions? A. Antipsychotic medications and physical therapy B. Bed rest and speech therapy C. Increased stimulation and group therapy D. Benzodiazepines and electroconvulsive therapy (ECT)

D. Benzodiazepines and electroconvulsive therapy (ECT)

The nurse observes a client for signs of Korsakoff psychosis. Which finding does the nurse expect the client to exhibit? A. Seizures B. Dilopia C. Nystagmus D. Confabulation

D. Confabulation Is a late complication of persistent Wernicke encephalopathy

A client with diagnosis of type 2 diabetes mellitus has very poor control of blood glucose and develops gangrenous ulcers on the feet. After being told the feet will need to be amputated, the client states, "I'm sure if I start taking my medications like I am supposed to my feet will heal" The nurse identifies this as an example of which behavior? A. Conversion B. Acting out C. Compensation D. Denial

D. Denial

Chlordiazepoxide 10 mg by mouth twice a day is prescribed for a client. The nurse assess the client for which adverse effect? A. Skeletal muscle spasms and insomnia B. Anorexia and dry mouth C. Diarrhea and euphoria D. Drowsiness and confusion

D. Drowsiness and confusion

The nurse assesses a client diagnosed with bipolar disorder, acute manic phase. Which symptom does the nurse expect to observe in the client A. Anergia B. Self-blame C. Negativism D. Hyperactivity

D. Hyperactivity

The nurse leads a weekly support group for family caregivers of elderly parents. During the second group session the nurse notes one caregiver in particular takes the lead in most of the discussion. The nurse recognizes the group is in which stage of group development? A. Working stage B. Termination stage C. Pre-group stage D. Initial stage

D. Initial stage

The nurse provides care for a client diagnosed with depression and finds the client crying alone in the room. The client has refused to eat breakfast or have morning care. Which intervention by the nurse is best? A. Allow the client privacy and check on the client B. Encourage the client to come out of the room and socialize with others C. Tell the client to try to eat something and have positive focus D. Offer to sit with the client and help the client get dressed

D. Offer to sit with the client and help the client get dressed

A client diagnosed with alcohol abuse is participating in group therapy. The client describes growing up in a very dysfunctional family. The nurse knows which patterns of behavior are prevalent in family dysfunction? A. Family dysfunction rarely results in violence between family members B. Family members turn to the family unit to deal with short term stressors C. Communication is clear and direct between family members D. Patterns behavior within the family are not supportive of individual members of the family

D. Patterns behavior within the family are not supportive of individual members of the family

A client reports an inability to walk since the sudden death of the client's father 2 months ago. Which intervention is priority? A. Avoid empathizing with the client B. Limit contact between the client and others in the family C. Ignore the client's physical symptoms D. Provide for basic physiological needs that the client cannot meet

D. Provide for basic physiological needs that the client cannot meet

The nurse provides care for a client diagnosed with obsessive compulsive disorder (OCD). The client must, rinse, and dry door handles before or leaving a room. Which action by the nurse is best. A. Encourage the client to control the ritualistic behavior because it interferes with the freedom of others B. Expect the client to participate in unit activities in unit activities without the nurse giving special attention to the behavior. C. Place a time for completion of the ritual before expecting the client with request to move to another room D. Provide time for client to complete the ritual before expecting the client to move from one area to another.

D. Provide time for client to complete the ritual before expecting the client to move from one area to another.

The nurse cares for the client diagnosed with conversion reaction. The nurse identifies that this client utilizes which defense mechanisms? A. Introjection and denial B. Projection and displacement C. Identification and rationalization D. Repression and symbolization

D. Repression and symbolization

A client diagnosed with anxiety reports to the nurse. "I start my new job next week and I am so afraid my new employer will find out I don't know enough to do my job! What if I get fired?" The nurse understands this concern is typical of which kind of anxiety disorder? A. Obsessive compulsive disorder B. Phobic disorder C. Social anxiety disorder D. Signal anxiety disorder

D. Signal anxiety disorder Signal anxiety arises in response to internal conflict or an emerging impulse, and functions as a sign to the self of impending threat, resulting in the preemptive use of a defense mechanism in an attempt to control anxiety.

The nurse cares for clients in the outpatient clinic. A client states to the nurse. I travel by train because I am terrified of flying". Which intervention does the nurse understand the client with a phobia is most likely to respond? A. Antipsychotic medication B. Insight-orientated therapy C. Crisis intervention D. Systemic desensitization

D. Systemic desensitization

The nurse assessment the client with a diagnosis of psychosis who is taking fluphenazine, and notes the client has bizarre facial movements and difficulty swallowing. The nurse understands that the client is exhibiting which adverse effects of this medication? A. Parkinsonism B. Akathisia C. Acute dystonia D. Tardive dyskinesia

D. Tardive dyskinesia

A client is diagnosed with schizophrenia, paranoid type. The nurse evaluates the readiness of the client for participation in unit group activities. Which situation indicates readiness? A. The client thinks the people on TV are speaking to the client B. The client has been on antipsychotic medication for 1 week C. The client plays solitaire in the lounge D. The client plays a game with the nurse and one other client

D. The client plays a game with the nurse and one other client

The nurse provides care for a client diagnosed with depression. The nurse becomes most concerned after observing which behavior? A. The client refuses to join other client working a jigsaw puzzle B. The client reports achiness and soreness "all over" C. The client must be encouraged and assisted to get dressed D. The client repeatedly burns self with a cigarette

D. The client repeatedly burns self with a cigarette

The nurse counsels with a client diagnosis of depression. During the second therapy session, the client sits with arms folded, speaks very little and looks to the floor. Which statement by the nurse is most appropriate. A. You look nice today. Did you do something differently with your hair B. Why aren't you in the mood to talk today C. Are you taking the medication as prescribed D. What would you like to talk about during our time today

D. What would you like to talk about during our time today

Client diagnosed w/antisocial personality disorder is being treated in an inpatient psychiatric facility. Client signed behavior contract, states if client uses inappropriate language in the dining room, client will be restricted to the room to eat. Nurse observes client berate and curse another client in the dining room. Which response by the nurse is best? A. Why are you talking like this? You agreed to speak respectfully to other B. Is there something the two of you are having trouble discussion C. If you continue to act this way you will have to go to your room D. You agreed to the behavior that is acceptable here. You will need to go eat in your room today

D. You agreed to the behavior that is acceptable here. You will need to go eat in your room today

The unlicensed assistive personnel (UAP) states with a critical tone. "The client's family worries about the client but the client doesn't seem to care how anybody feels. "Which response by the nurse to the UAP is best? A. "If we can make the client realize this, perhaps the client will get better" B. "Sometimes it's difficult to see how anxious the clients really are" C. "Perhaps the client's family has caused the client pain" D. "Being critical of the client is not going to help the client is not going to help the client improve.

Sometimes it's difficult to see how anxious the clients really are

The nurse provides care for an older adult client with dementia who has multiple care needs. The client's adult child provides all care for the client and refuses to let anyone else help. The client's child states, I created a lot of problems for my parents when I was younger." The nurse understands the client's adult child is using which defense mechanism? A. Substitution B. Undoing C. Compensation D. Denial

Undoing