CHAPTER 17 - MENTAL HEALTH
Lithium carbonate is ordered for a client with overactive behavior. The nurse should observe the client for which of these side effects? 1. Diarrhea 2. Rhinitis 3. Glycosuria 4. Rash
1. Diarrhea is a common side effect of lithium carbonate and may indicate toxicity. Rhinitis (runny nose), glycosuria (sugar in the urine), and rash are not side effects of lithium.
A client says to the nurse, "I have something to tell you because I know you can keep a secret." To respond to his statement, the nurse should make which of these remarks? 1. "It's nice that you trust me to keep a secret." 2. "I would like to hear your secret." 3. "I cannot promise that I can keep your secret." 4. "A secret is not a secret when it is repeated."
3. The nurse cannot promise not to tell a client's secret. The client may tell of a suicide plan or something else that must be shared with the physician or other staff members.
When the nurse detects that a client is using defense mechanisms, the nurse should make which of these interpretations of the client's behavior? 1. The client is attempting to reestablish emotional equilibrium. 2. The client is using self-defeating measures. 3. The client is demonstrating illness. 4. The client is asking for support from significant others.
1. Defense mechanisms are measures that the client uses to reestablish emotional equilibrium. Some are self-defeating, and some are good.
A young woman is admitted for the first time with a diagnosis of catatonic schizophrenia and is receiving chlorpromazine (Thorazine) daily. She is to go home for a weekend pass. What is the most important instruction to give her relative to her medications? 1. "Use a sunscreen lotion, and do not drink alcoholic beverages." 2. "Do not drink wine or beer or eat hard cheeses." 3. "Stay away from persons with colds and infections, and report any rashes immediately." 4. "Drink plenty of orange juice, and take your pills with milk."
1. Chlorpromazine (Thorazine) causes photosensitivity. Because it is a central nervous system drug, alcohol should not be taken.
A 23-year-old premedical student is admitted to a psychiatric hospital in a withdrawn, catatonic state. For two days prior to admission, she remained in one position without moving or speaking. On the unit, she continues to exhibit waxy flexibility as she sits all day. What is the first priority for the nurse during the initial phase of hospitalization? 1. Watch for edema and cyanosis of the extremities 2. Encourage the client to discuss her concerns, which may have led to the catatonic state 3. Provide a warm, nurturing relationship with a therapeutic use of touch 4. Identify the predisposing factors in her illness
1. Circulation may be severely impaired in a client with a waxy flexibility who tends to remain motionless for hours unless moved. She does not speak and will not be able to discuss her concerns or identify predisposing factors during the initial stages. Touch is not used at this stage.
A 40-year-old man is admitted to the psychiatric unit for treatment of anxiety neurosis. For several weeks, he has had increasingly frequent periods of palpitations, sweating, chest pain, and choking. His nursing diagnosis is "severe anxiety, stressor unidentified." Which of these measures is appropriate during the client's attacks? 1. Supporting and protecting him 2. Engaging him in socially productive behavior 3. Having him review the circumstances that precipitated the symptoms 4. Ignoring him until the symptoms subside
1. He needs support during this time. He will be unable to pay attention to details or to think clearly during an anxiety attack. Note that his symptoms include chest pain and choking.
While a client is taking chlorpromazine (Thorazine), he should be observed for which of these symptoms? 1. Pseudoparkinsonism 2. Dehydration 3. Manic excitement 4. Urinary incontinence
1. Pseudoparkinsonism is one of the extrapyramidal side effects that occur with phenothiazine drugs. If this is severe, an antiparkinsonian drug is prescribed. The other choices are not side effects of chlorpromazine (Thorazine.) The client is more apt to experience urinary retention than incontinence.
The nurse is assessing a 22-month-old child who is thought to be autistic. During an interview with the nurse, the child's mother makes all of the following statements about his behavior until he was 1 year old. Which statement most strongly suggests that the child may be autistic? 1. "He was a good baby and rarely cried when I left the room." 2. "He slept very well after each feeding." 3. "He spit out every new food the first time I gave it to him." 4. "He started to walk without learning to crawl first."
1. The child with autistic behavior reveals a disturbance in the development of social relationships. There is often an absence of responsive behavior toward the approach of the parents, and typically, the child seems as content alone as in the presence of the parents.
A 25-year-old woman has admitted herself to the psychiatric unit for treatment of Valium addiction. She is currently taking 150 mg PO of Valium per day, which she gets from various doctors or buys off the streets. The first night she is on the unit, she dresses in a short, see-through nightgown and approaches the male nurse. She states that she is "coming down" and just needs a little comforting and conversation. What is the best initial response by the nurse? 1. "Please put on your bathrobe and then we can talk." 2. "I'm very busy now. Maybe one of the other nurses can help you." 3. "What seems to be the problem?" 4. "What you are experiencing is very common. It should get better soon."
1. The client's behavior suggests an attempt at manipulation. Manipulative behavior is best handled by setting limits. Asking her to put on a robe sets limits. Answers 2 and 3 are incorrect because they avoid the problem. Answer 4 does not address the problem behavior, which is manipulation.
Chlorpromazine hydrochloride (Thorazine) is prescribed for a young adult with schizophrenia. For three days, the chlorpromazine (Thorazine) is to be administered intramuscularly. Before administering chlorpromazine (Thorazine) intramuscularly to the client, the nurse should make which of these assessments? 1. Checking his blood pressure 2. Testing his urine for glucose 3. Testing his patellar reflexes 4. Checking laboratory results for his serum potassium level
1. The hypotension caused by chlorpromazine (Thorazine) is more severe when the drug is administered intramuscularly. The other choices do not relate to side effects of chlorpromazine (Thorazine).
An elderly woman is hospitalized with chronic organic brain syndrome. When her daughter visits, she does not recognize her. The daughter begins to cry and shares her concerns with the nurse. Which statement by the nurse would demonstrate an empathetic response? 1. "It must be difficult for you to visit your mother when she is confused about who you are." 2. "If you are going to cry when you come to visit, maybe you should not visit." 3. "It is not unusual for people in your mother's condition to forget who other people are." 4. "If these visits upset you, maybe you should telephone your mother instead of visiting."
1. This answer is empathetic because it lets the daughter know that the nurse has an understanding of what the daughter must be feeling. Answers 2 and 4 are incorrect because the nurse is giving advice and neglects the daughter's feelings. Answer 3 is not correct because it generalizes and minimizes the daughter's feelings.
A client with cancer states that he has no reason to live anymore. What is the most therapeutic response for the nurse to give at this time? 1. "You feel as though you have no reason to live?" 2. "Your wife needs you and wants you to live." 3. "Your children care about you." 4. "I care about what happens to you."
1. This response opens communication and encourages him to express his feelings.
Chlorpromazine (Thorazine) is prescribed for a client. Which of the following, if observed in the client, would suggest chlorpromazine (Thorazine) toxicity? 1. Tremors 2. Sore tongue 3. Rash 4. Hoarseness
1. Tremors suggest chlorpromazine (Thorazine) toxicity.
An adult woman is admitted to the detoxification unit for alcohol withdrawal. Her husband tells the nurse that he is fed up. Either she gets treatment or he is leaving her. Two days later, the woman develops delirium tremens. At this time, which of these nursing diagnoses should be given priority in caring for this client? 1. Risk for injury related to impulsiveness 2. Noncompliance with medical regimen related to denial of illness. 3. Grieving related to her husband's threat of abandoning her 4. Relocation stress syndrome related to transfer to a strange environment
1. When a client is having delirium tremens, the potential for physical injury may be life threatening. Protective measures are a priority. All of the other diagnoses could be appropriate at some point in the care but not at this time.
After the nurse has had several brief conversations with a newly admitted client, the client suddenly says, "I'm afraid to ride in an elevator; I know it's silly, but I can't help it." Which of these responses by the nurse would be the best example of acknowledgment? 1. "It's hard to manage without using elevators." 2. "Being afraid to ride in elevators seems unreasonable to you." 3. "Perhaps you should consider why you are afraid to ride in an elevator." 4. "The speed of elevators frightens you."
2. Acknowledgment is really restating what the client says. This answer is a restatement of "I'm afraid to ride in an elevator; I know it's silly, but I can't help it."
The treatment goal for a client with severe anxiety will have been achieved when the client demonstrates which of these behaviors? 1. The client recognizes the source of the anxiety. 2. The client is able to use the anxiety constructively. 3. The client can function without any sense of anxiety. 4. The client identifies the physical effects of the anxiety.
2. Anxiety can be used constructively as a learning and motivating tool. The goal is not to eliminate anxiety but to have the client respond appropriately to it and not be overwhelmed by it.
A 52-year-old man is admitted to the psychiatric unit. He states that he does not sleep well, has not been eating, and has no energy. He tells the admitting nurse, "I don't think you can make me feel better. There's no use in talking to me. Leave me alone." What is the most appropriate interpretation of his behavior? 1. The client needs solitude. The nurse should leave him alone. 2. The client is depressed. The nurse should stay with him. 3. The client needs encouragement. The nurse should assure him that he will get well soon. 4. The client is in a bad mood. The nurse should tell him to cheer up.
2. He is exhibiting the classic symptoms of depression, and the nurse should stay with him. He should be evaluated for suicide potential.
A young man who is admitted with antisocial behavior seeks the attention of a young, attractive nurse, and he finds many excuses to involve the nurse in conversation. The nurse should have which of these understandings of this situation? 1. The nurse should help him in any way possible. 2. The nurse is responsible for maintaining a therapeutic relationship with him. 3. The nurse should prepare to act as an advocate for him. 4. The nurse is uniquely able to gain his confidence.
2. It is common for the client with an antisocial personality disorder to single out a staff member who he will attempt to manipulate for the gratification of his wishes. The nurse must be aware of the client's motivations and of the responses that he may be attempting to elicit from the nurse. The nurse may mistakenly interpret the client's desire to communicate as an expression of real interpersonal closeness, or the nurse may engage in fantasies about saving the client from his destructive behavior. The realistic assessment of the situation is based on the understanding that the nurse can establish guidelines of the plan of care.
Following withdrawal from alcohol, the client agrees to participate in group therapy sessions for a period before being discharged. Initially, group therapy may have which of these effects on the client? 1. She will develop insight into her reasons for needing alcohol. 2. She will experience periods of extreme anxiety. 3. She will be able to set realistic goals for herself. 4. She will be able to identify the personality traits she needs to change.
2. It is expected that any client beginning group therapy will experience a period of uncertainty, during which considerable anxiety will be felt. Only when the client has progressed through this phase and through the phases of aggression and regression will she arrive at the adaptation phase, during which she may develop insight into her behavior. It is important to understand the phases through which participants move in group therapy.
An adolescent with a diagnosis of severe anorexia nervosa is now on the adolescent psychiatric unit after being in intensive care to achieve fluid and electrolyte balance. In developing the nursing care plan, which of the following will be of highest priority? 1. Weighing her before and after each meal 2. Observing her for two hours after each meal 3. Teaching her the elements of good nutrition 4. Recording her food intake
2. Observing her to be sure she does not induce vomiting is the highest priority.
The morning after admission for withdrawal from alcohol, a client is restless, tremulous, and somewhat agitated. The nurse should take which of these actions at this time? 1. Offer her medicinal whiskey 2. Observe her behavior closely 3. Darken the client's room 4. Prepare to place her in restraints
2. Physiological dependence on alcohol is responsible for the syndrome that occurs when alcohol is withdrawn. The syndrome includes the symptoms of tachycardia, elevated blood pressure, nausea, restlessness, tremors, hallucinations, and convulsions, and ultimately may progress to delirium tremens. The client who is being detoxified must be monitored carefully for the development of these symptoms so that adequate measures can be taken to prevent injury, to meet metabolic and nutritional needs, and to minimize anxiety. Medicinal whiskey is not used during detoxification. Although the client in withdrawal may become confused and agitated, the use of physical restraints should be avoided if possible because they tend to increase agitation. The room should not be darkened; this tends to promote shadows that may be misintrepreted (this client is prone to illusions).
A 15-year-old girl is brought to the hospital by her parents. She is 5 feet, 7 inches tall and weighs 80 pounds. Her parents report that she eats very little. This evening, she is very difficult to arouse and had to be carried into the emergency room. A diagnosis of anorexia nervosa is made. Which of the following is the nurse most likely to observe/ measure when assessing this client? 1. Enlarged breasts 2. Scanty pubic hair 3. Decreased visual acuity 4. Tachycardia
2. Secondary sex characteristics tend to disappear. Her breasts will get smaller. She will have bradycardia, not tachycardia.
A client asks the nurse about participation in Alcoholics Anonymous. In addition to arranging for a visit by someone from Alcoholics Anonymous, the nurse should explain that the primary purpose of the organization is to: 1. explore the individual member's need for dependence on alcohol. 2. help members abstain from alcohol. 3. teach members how to manage social situations without the need for alcohol. 4. increase public awareness of the results of alcoholism.
2. Self-help and peer support are offered by AA in an ongoing education program that assists the members to achieve abstinence from alcohol. The other purposes may be secondary, but the primary purpose is to help members abstain from alcohol.
A woman is admitted to the hospital because of recent overactive behavior. She enters the dining room for lunch after everyone is seated and eating. She runs around telling everyone that she has just been invited to speak at an important political meeting. She then sits down and starts to eat. After taking a few bites, she gets up and walks quickly out of the dining room. What initial action should the nurse take to meet the client's nutritional needs? 1. Serve her meals in her room 2. Give her finger foods to eat 3. Sit with her while she eats 4. Discuss with her the importance of eating
2. The client is too active to eat and, at the moment, is unable to control this overactivity. Nursing actions to meet nutritional needs include giving her finger foods that she can eat while moving about.
The nurse is caring for an elderly woman admitted with chronic organic brain disease. When her daughter visits, she asks, "Are you my maid?" How should the nurse describe the client's behavior? 1. Impaired judgment 2. Disorientation 3. Impairment of abstract thinking 4. Delusions
2. The client is unable to recognize her daughter. The symptom of disorientation in organic mental disorders is characterized by the inability to recall day or time, place, who they are, or the person or position of the person to which they are relating. Impaired judgment and impaired abstract thinking may be seen in organic mental disorders, but they are not the behaviors described. They are both examples of impaired intellectual functioning, characterized by the inability to recall and use general knowledge in decision making and problem solving. Perceptual impairments such as delusions may occur in organic mental disorders; delusions are manifested by a fixed idea for which there is no factual basis. This is not the behavior described.
A woman is admitted to the detoxification unit. She admits to drinking increasingly larger amounts of alcohol for the past five years. What question is most important for the nurse to ask initially? 1. "How much alcohol do you drink daily?" 2. "When was your last drink?" 3. "When did you last eat?" 4. "What type of alcoholic beverages do you drink?"
2. The nurse must determine when the client had her last drink to help anticipate when withdrawal symptoms will occur.
A homeless woman is admitted to the hospital. When she is admitted, she is asked to keep her possessions in a locker that is in her room. She insists on removing several articles to carry around with her. Following nursing interventions, she continues to carry most of her possessions around with her. The nurse should make which of these interpretations of this behavior? 1. The client needs to keep busy. 2. The client needs to maintain her identity. 3. The client needs to be a focus of attention. 4. The client needs a means of becoming involved with others.
2. The nurse should understand that the client's possessions represent an extension of herself and an affirmation of her personal identity in an alien environment. It is most therapeutic to allow the client to use this coping behavior as long as she is not dangerous.
A young woman has admitted herself to the psychiatric unit for treatment of Valium addiction. A schedule of drug withdrawal is ordered by the doctor. Which of the following may the nurse expect to see as the Valium dose is decreased? 1. Decreased blood pressure 2. Tremors and hyperactivity 3. Increase in appetite 4. Grandiosity
2. Tremors and hyperactivity are common symptoms of Valium detoxification. Although blood pressure should be monitored, it generally does not decrease. Increased appetite and grandiosity are not symptoms of detoxification.
An adult man is being treated for depression and has been taking amitriptyline (Elavil) for three days. His wife says to the nurse, "I don't think the medicine is doing anything for him. He is still depressed." What is the best response for the nurse to make? 1. "I will observe him carefully and make a full report to the physician." 2. "Depression takes awhile to clear. We are seeing small behavior changes." 3. "The medicine takes two to three weeks to be effective. It is too soon to see behavior changes." 4. "His doctor is pleased with his progress. Have patience."
3. Amitriptyline (Elavil) is a tricyclic antidepressant that requires two to three weeks for therapeutic effects to be seen.
To initiate a relationship with a child who may be autistic, the nurse would probably be most effective by using which of these approaches? 1. Playing peek-a-boo 2. Having him point to designated body parts 3. Sitting with him 4. Playing an action game like Ring around the Rosy
3. Because of the autistic child's avoidance of interpersonal contact and the disturbance in language development that typically occurs, a therapeutic approach to the child offers the nurse's presence without making demands for a response or imposing personal closeness.
The nurse is caring for a 75-year-old widow admitted to the psychiatric hospital by her daughter, who became concerned when her mother began to talk in a confused manner about her husband who has been dead for seven years. In the hospital, especially at night, the client wanders into the other clients' rooms looking for her husband. What is the most appropriate action for the nurse to take when this woman wanders into the rooms of the other clients? 1. Lock the door to her room 2. Tell her to stay in her room except for meals 3. Take her by the hand and guide her back to her room 4. Tell her that she will be restrained if she continues to wander
3. Gently providing guidance allows her to maintain her esteem and communicates supportive caring. Locking the door to her room is not safe for the client and interferes with her independence. Telling the client to stay in her room is ineffective because she has a memory impairment. Restraints increase feelings of helplessness, frustration, and inadequacy.
A young woman who has a washing ritual has been late for breakfast each of the three days since admission. What is the most appropriate nursing intervention? 1. Give her a choice of getting to breakfast on time or not eating breakfast 2. Restrict her privileges if she is late again 3. Get her up early so she can complete her washing ritual before breakfast 4. Insist that she stop washing her hands and go to breakfast
3. In the early part of hospitalization, the nurse should allow the client to perform the ritual and still eat. Given a choice, the obsessive-compulsive client would choose the ritual. Restriction of privileges this early in treatment is not reasonable. Insisting that she stop washing her hands could precipitate a panic attack.
A client with severe anxiety manifested by many somatic complaints starts psychotherapy. She becomes increasingly anxious, and her physical symptoms intensify. The nurse should make which of these interpretations of her observations? 1. The client needs to be involved in modifying the goals of therapy. 2. The client may be developing a physical illness unrelated to her emotional problems. 3. The client is responding to therapy as expected at this time. 4. The client is probably beginning to have insight into her behavior.
3. In the initial stage of psychotherapy, as clients begin to confront the conflicts that are the source of their symptoms, it is common for them to experience an intensification of anxiety and defensive behavior. The nurse should anticipate this phenomenon.
In attempting to establish a therapeutic relationship with a child who may be autistic, the nurse should expect to encounter which of these problems? 1. Hallucinations 2. Impaired hearing 3. Bizarre behavior 4. Clinging to others
3. The child often demonstrates peculiar motor behavior in the form of spinning, rocking, head banging, and repetitive arm movements. Hallucinations are not evident in the autistic child. Failing to respond to parents' voices is not evidence of impaired hearing. Autistic children tend to respond well to music. The child with autism does not relate to others and thus will not be seen clinging to others.
A woman who is severely depressed begins to improve. Which of these behaviors may be indicative of an impending suicide attempt? 1. Responding sarcastically when asked about her family 2. Avoiding conversation with some clients on the unit 3. Identifying with problems expressed by other clients 4. Appearing detached when walking about the unit
4. As the depressed client begins to improve, the risk of suicide is increased because the person now has a greater amount of energy. Behaviors that may indicate that the client is planning a suicide attempt include a sudden lightening of mood, an air of relaxation, or the appearance of detachment.
A 75-year-old woman has been widowed for 12 years. She was forced to vacate her apartment several months ago when fire destroyed the building. She has been wandering about the city, begging for money to buy food, and sleeping on park benches or in secluded areas of large buildings. She carries her personal belongings in three bundles. One day she enters the bus terminal and becomes very noisy and quarrelsome. The police are called, and she is brought to a psychiatric unit. To plan care for this woman, which of these actions should be taken first? 1. Determine her interests 2. Obtain information about her family 3. Identify her emotional needs 4. Evaluate her physical condition
4. Because, in some cases, the symptoms of organic mental disorder are attributable to systemic illness, nutritional disorders, and effects of drugs, it is imperative that the client be given a thorough physical examination so that physiological problems that may be causing her behavior or may simply coexist can be addressed.
A woman is being treated for severe depression. During the acute phase of her illness, which of these measures should have priority in her care? 1. Keeping her in seclusion 2. Repeating unit routines to her in detail 3. Urging her social interaction with other clients 4. Providing her with physical care
4. During the acute phase of depression, the client is not meeting her physical needs. The nurse must meet these needs.
An adult is being treated for depression. One day he appears at the nursing station and gives one of the nurses his favorite book. He smiles happily and says, "I want you to have this." The nurse's response is based on which understanding? 1. Nurses should not accept gifts from clients. 2. His actions indicate an improvement in communication skills. 3. The nurse should support actions that bring the client obvious pleasure. 4. Giving away objects of personal importance is a suicidal warning sign.
4. Giving away items may be a sign that he is going to commit suicide.
A young woman who is fearful of getting into elevators is admitted. Two days after admission, she is scheduled for group therapy sessions that meet on the sixth floor. Her room is on the second floor. The other clients and the nurse go to the sixth floor on the elevator. The client starts trembling and refuses to get on the elevator. Which action is most therapeutic for the nurse to take? 1. Firmly insist that she get on the elevator with the other clients 2. Explain to her that the elevator is safe and take her on a separate elevator from the rest of the group 3. Excuse her from group therapy until she will get on the elevator 4. Assign someone to walk up the stairs with her
4. Her anxiety is high when faced with the elevator. Forcing her to get on the elevator may precipitate an anxiety attack or panic reaction. Note that this is early in the course of her hospitalization. The nurse must not force her to get on the elevator.
A man who is being treated for paranoia walks toward the nurse's desk and observes the nurse making a telephone call. A few minutes later, he accuses the nurse of having called the police. How should the nurse interpret his behavior? 1. Projection 2. Reaction formation 3. Transference 4. Ideas of reference
4. Ideas of reference are a common symptom in paranoid disorders. The person interprets an event occurring in the environment as having particular significance or reference to himself.
Which nursing action would help to reduce stress and to aid an obsessive-compulsive client in using a less maladaptive means of handling stress? 1. Provide varied activities on the unit, because a change in routine can break a ritualistic pattern 2. Give him unit assignments that do not require perfection 3. Tell him of changes in routine at the last minute to avoid the buildup of anxiety 4. Provide an activity in which positive accomplishment can occur so he can gain recognition
4. Positive accomplishment will help to boost self-concept and self-confidence. A client with ritualistic behavior will do best when routine activities are set up and anxiety-producing changes are avoided. Perfection-type activities bring satisfaction (cleaning and straightening a linen closet). He needs to know changes in routine in advance in order to cope with the anxiety produced by the changes.
Three days after admission for treatment of Valium addiction, a young woman briefly left the hospital to talk to a visitor. Her psychiatrist has threatened to discharge her for noncompliance with the treatment program. The client seems very despondent, refusing to get out of bed. The evening nurse finds the client crying, "I've screwed everything up. It's hopeless. It's no use." In responding to the client, which of the following would be most appropriate? 1. "You've screwed everything up?" 2. "Why do you feel it's no use?" 3. "Sometimes we have to hit bottom before things get better." 4. "You sound like you're feeling very sad. Are you thinking about harming yourself?"
4. The client stated, "It's hopeless, it's no use." The nurse is identifying the overall feeling tone of the client's communication and is directly asking for feedback about her suicide potential. Most suicide clients will give truthful information when directly asked. Answer 1 is a reflective statement and can allow her to continue talking, but it is appropriate after her suicide potential is assessed. Answer 2 asks for an analysis and may be distracting to the theme. Answer 3 invalidates the client's thoughts and feelings.
Mr. S. is a man who has not spoken for years. He is diagnosed as having paranoid schizophrenia. One day, when Ms. J., another client, was standing facing the elevator, the man approached her from behind and reached for her as if to strangle her. What is the most appropriate action for the nurse to take at this time? 1. Grab Mr. S. by the arm to stop him. 2. Ask other clients to assist her. 3. Say, "Mr. S., that is not appropriate behavior." 4. Get Mr. S.'s attention and call for help.
4. The nurse should get his attention so that he will release the other client. Help is needed.
A young woman was referred to the psychiatrist by her family physician because she is fearful of getting into elevators. During the course of therapy, it was discovered that her initial fear was of men and that it had changed to elevators. Which of the following mechanisms is demonstrated by this change? 1. Repression 2. Identification 3. Projection 4. Displacement
4. The original fear of men was displaced onto elevators, a safer object.
Following withdrawal from alcohol, a client is to receive disulfiram (Antabuse). The medication is prescribed for which of these purposes? 1. To minimize the effects of alcohol 2. To improve detoxification by the liver 3. To increase her utilization of vitamins 4. To help her refrain from drinking alcohol
4. The purpose of Antabuse is to help the client abstain from alcohol. The client who takes Antabuse regularly will experience symptoms of nausea, vomiting, and palpitations when even a small amount of alcohol is consumed. The drug is usually used for only a limited time in conjunction with other treatment methods.
An elderly woman with Alzheimer's disease refuses to eat and begins to lose weight. Which approach by the nurse will likely be most effective in getting the client to eat? 1. Explaining to her the necessity of eating three meals daily 2. Asking the client what she thinks should be done about her lack of eating 3. Telling the client that if she doesn't eat, she will be given tube feedings 4. Accompanying her to meals and assisting her in eating
4. This approach conveys caring, support, and helpfulness. It also ensures that the client knows where and when to eat. Impaired intellectual functioning that is evident in organic mental disorders interferes with the person's ability to reason or solve problems. Answer 3 will increase frustration and anger.
A man who is severely depressed following the death of his wife sits in the dayroom for hours at a time, not speaking to anyone and showing no interest in unit activities. He does not answer when spoken to. Which action should the nurse take to help him at this time? 1. Encourage him to talk about his children 2. Start playing a game in which he can participate 3. Turn on the television for him to watch 4. Speak to him briefly from time to time without expecting an answer
4. This client is severely depressed and needs an environment that places few demands on him. His self-esteem will be raised by knowing that someone cares enough about him to speak to him. In time, he may respond. Note that the scenario states twice that he does not speak; therefore, encouraging him to talk about his children is not appropriate.
An adult male is being treated for depression. He has been in the hospital for three weeks. Which observation by the nurse is indicative of improvement in his condition? 1. He appears for breakfast unshaven. 2. He says, "I now have the answer to my problems." 3. He refuses to eat, saying, "I don't like hospital food." 4. He initiates a conversation with another client.
4. This indicates that he is less withdrawn. Answer 1 indicates poor self-esteem. Answer 2 may be a suicidal warning sign.
A woman has been having auditory hallucinations. When the nurse approaches her, she whispers, "Did you hear that terrible man? He is scary!" Which would be the best response for the nurse to take initially? 1. "Tell me everything the man is saying." 2. "I don't hear anything. What scary things is he saying?" 3. "Who is he? Do you know him?" 4. "I didn't hear a man's voice, but you look scared."
4. This is a reality-based response as well as one that acknowledges the client's nonverbal reaction. The nurse should not focus on the "voice" because that reinforces the hallucination and does not place doubt. Answer 2 voices doubt but focuses on the voice, not the client's feelings.
Two nights after admission for alcohol withdrawal, the client runs out of her room. She is confused and disoriented and says, "Let me out of here. Bugs are crawling all over that room." The nurse should take which of these actions? 1. Escort her back to her room and show her that there is nothing to fear 2. Assist her back into bed and then search her room for alcohol 3. Take her to a quiet area and ask her if she usually has nightmares 4. Have a staff member stay with her and notify the physician
4. Visual and tactile hallucinations are indicative of the development of delirium tremens. The presence of a staff member offering reassurance and orientation may reduce the client's growing sense of panic and prevent self-injury. The physician should be informed of the client's condition so that the use of a tranquilizer may be considered. Showing her that there is nothing to fear is not appropriate when the confusion is due to withdrawal. There is no need to search her room for alcohol. The behavior suggests withdrawal, not intoxication. The behavior suggests withdrawal symptoms, not nightmares.
