Chemical Dependence and Mood & Thought NCLEX questions
A client with dissociative identity disorder (DID) requires hospitalization. Which intervention would most likely appear in the client's plan of care plan?
arrange for the staff to check on the client every 15 to 30 minutes
The nurse is collecting data for a client diagnosed with a dementia disorder. Which factor is most important for the nurse to determine when collecting data for this diagnosis?
degree of impairment
The health care provider prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question prior to administration?
heparin sodium
A nurse is obtaining data for physical health problems in a client who uses heroin. Which medical consequence of heroin does the nurse recognize commonly occurs?
hepatitis
A mother who has a history of chronic heroin use has lost custody of her children due to abuse and neglect. She has been admitted to an inpatient substance-abuse program. Which client statement should a nurse associate with a positive prognosis for this client?
"I cannot control my use of heroin. It's stronger than I am."
A nurse is teaching a women's group about ovarian cancer. Which client is at the highest risk for this disease?
45-year-old client who has never been pregnant
A nurse is caring for a client with borderline personality disorder. Which nursing intervention has priority?
maintaining consistent, realistic limits
On the pediatric unit, a nurse is caring for a group of clients. Which client should the nurse see first?
10-year-old with asthma whose oxygen saturation levels are dropping
A nurse is reviewing STAT laboratory data of a client presenting in the emergency department. At what minimum blood alcohol level should a nurse expect intoxication to occur?
100 mg/dL
A client undergoing treatment for an anxiety disorder is being cared for by a nursing student. The nursing faculty asks the student When is such a disorder considered chronic and generalized? What timeframe does the student provide about the existence of the client's "excessive anxiety and worry about two or more life circumstances"?
6 months
Which medication can control the extrapyramidal effects associated with antipsychotic agents?
Amantadine
In assessing a client diagnosed with polysubstance abuse, the nurse should recognize that withdrawal from which substance may require a life-saving emergency intervention?
Diazepam (Valium)
A dystonic reaction can be caused by which medication?
Haloperidol
Which statement, made by a client with paranoid personality disorder, shows that education about social relationships is effective?
Sometimes I can see what causes relationship problems.
A 10-month-old infant with bacterial meningitis was just started on antibiotic therapy. Which nursing action is especially important in this situation?
Wear a mask while providing care.
The nurse is caring for a client with dementia. Which nursing action is the priority?
maintaining optimal physical health
Which finding does the nurse recognize is commonly associated with use of alcohol in a young, depressed adult woman?
sexual abuse
A client recovering from alcohol addiction has displayed limited coping skills. Which characteristic indicates relationship problems?
the client has poor problem solving skills
A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be appropriate?
"Your cursing is interrupting the activity. Take time out in your room for 10 minutes."
A client states, "I can't eat because my bowels have turned against me." The nurse determines that the client is exhibiting which behavior?
somatic delusion
A client in the behavioral health unit with a history of noncoercive paraphilia is experiencing an auditory hallucination. What is the priority nursing action?
stay with the client
While interacting with a client with dissociative identity disorder (DID), a nurse observes characteristics of an alter personality. The client goes from being calm to being angry and shouting. Which response would be most appropriate?
tell me how you are feeling right now
When preparing a client for electroconvulsive therapy (ECT), the nurse should make sure that:
the client has undergone a thorough medical evaluation.
A client experiencing alcohol withdrawal is upset about going through detoxification. Which goal is the priority?
the client will work with the nurse to remain safe
A nurse holds the hand of a client who is withdrawing from alcohol. What is the nurse's rationale for this intervention?
to assess for fine tremors
The nurse will be assuming care for a client with borderline personality disorder. What data does the nurse anticipate collecting? Select all that apply.
unpredictable moods intense personal relationships
The nurse is assigned to care for a client with amnesia. When preparing to deliver care, which action will best meet the needs of this client?
use short simple commands when providing instructions
A home health nurse is caring for a client diagnosed with a functional neurologic symptom disorder manifested by paralysis in the left arm. An organic cause for the deficit has been ruled out. Which nursing intervention is most appropriate for this client?
Identify primary or secondary gains that the physical symptom provides.
How can the nurse help a client with anorexia nervosa recognize distortions of thought?
Identify the client's misperceptions of self.
Upon admission for symptoms of alcohol withdrawal a client states, "I haven't eaten in 3 days." Assessment reveals BP 170/100 mm Hg, P 110, R 28, and T 97F (36C) with dry skin, dry mucous membranes, and poor skin turgor. What should be the priority nursing diagnosis?
Imbalanced nutrition: less than body requirements
Which characteristics would the nurse expect to see in the client with schizophrenia?
Loose associations, grandiose delusions, and auditory hallucinations
While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. The nurse caring for this client would expect the health care practitioner to prescribe which medication to control the client's anxiety?
Lorazepam
A client is prescribed digoxin 0.125 mg by mouth stat. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes the incorrect dose has been administered. How should the nurse proceed?
Obtain vital signs, and immediately notify the primary health care provider and charge nurse of the error.
A client is diagnosed with somatic symptom disorder. What understanding should the nurse have regarding somatic symptom disorder when rendering care to this client?
Symptoms are real to the client, even though there may not be an organic etiology.
Before eating a meal, a client with obsessive-compulsive disorder (OCD) must wash his or her hands for 18 minutes, comb his or her hair 444 strokes, and switch the bathroom light on and off 44 times. When creating the plan of care, what is the most appropriate goal for this client?
Systematically decrease the number of repetitions of rituals and the amount of time spent performing them.
A client taking alprazolam reports lightheadedness and nausea every day while getting out of bed. Which action should the nurse take to objectively validate this client's problem?
Take the client's blood pressure
A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?
Tardive dyskinesia
A nurse is preparing to assist a client in coping with stress. What nursing interventions will be effective? Select all that apply.
Teach relaxation exercises. Minimize environmental stimuli. Encourage verbalization of feelings. Establish a trusting relationship.
A client is diagnosed with illness anxiety disorder. When assisting with the plan of care, which intervention should be included?
Teach the client adaptive coping strategies.
A nurse is gathering data from a client who talks freely about feeling depressed. During the interaction, the nurse hears the client state, "Things will never change." What other indications of hopelessness should the nurse look for? Select all that apply.
bouts of anger periods of irritability feelings of worthlessness self-destructive behaviors
The nurse is caring for a client diagnosed with bulimia and observes the Russell sign. What symptoms will the nurse observe?
bruised knuckles
A client is admitted to the acute care facility with an amnesic disorder. Which condition should the nurse monitor the client for that is associated with this disorder?
cerebral anoxia
A client is being treated at a community mental health clinic. A nurse has been instructed to observe for any behaviors indicating dissociative identity disorder (DID). Which behavior would be included?
change in dress, mannerism and voice
A 2-day-old boy is scheduled for circumcision without anesthesia. When reviewing the neonate's plan of care, which measure would the nurse likely find as most important after the procedure?
charting the time of the neonate's voiding
When planning care for a client who has ingested phencyclidine (PCP), which of the following is the highest priority?
client's safety needs
The nurse is providing care to a client with Alzheimer's disease (AD). Which nursing intervention takes priority?
control the environment by providing structure, boundaries, and safety
The nurse is caring for a client with a cognitive disorder. Which characteristic does the nurse observe that correlates with a cognitive disorder?
deficit in memory
A client is referred to a mental health clinic by the court for harassing a couple next door and claiming that the husband was in love with her. She wrote love notes and called him on the telephone throughout the night. The client is employed and has had no problems with her job. The nurse interprets these findings as suggesting which condition?
delusional disorder
A client is admitted after being found on a highway, throwing rocks and debris and yelling at motorists. When approached by the nurse, the client shouts, "You're the one who stole my husband from me." The nurse interprets the client's statement as indicating which condition?
delusional experience
The nurse is reviewing the teaching provided to the family of a client with a psychiatric disorder about traditional antipsychotic drugs and their effect on symptoms. The nurse understands that which symptom would be most responsive to these types of drugs?
delusions
In group therapy, a client who has used intravenous (I.V.) heroin every day for the past year says, "I don't have a drug problem. I can quit whenever I want. I've done it before." The nurse determines that this statement is indicating which defense mechanism?
denial
Johnette is reviewing her lessons in Pharmacology. She is aware that the general classification of drugs belonging to the opioid category is analgesic and:
depressant
A client with dependent personality disorder is working on goals for self-care. Which short-term goal statement would be the initial goal?
determine activities that can be performed without help
Initial interventions for the client with acute anxiety include:
encouraging the client to verbalize feelings and concerns.
Which short-term goal is most appropriate for the client with paranoid personality disorder who has impaired social skills?
identify personal feelings that hinder social interaction
The nurse is caring for a client who exhibits pinpoint pupils and decreased blood pressure, pulse, respirations, and temperature. These signs may indicate which disorder?
opiate intoxication
A nurse is implementing interventions for the care of a client admitted with a diagnosis of schizotypal personality disorder. Which behavior would the nurse most likely observe in the client during this situation?
paranoid thoughts
The nurse is reviewing a nursing care plan for a client with a psychophysiological disorder. Nursing interventions should address which symptoms?
physical symptoms as well as psychosocial and spiritual problems
An LVN/LPN working on a busy unit decides to delegate some tasks to the unlicensed assistive personnel (UAP). Which client tasks can be delegated to the UAP? Select all that apply.
positioning a client intake and output measurement ambulation of a client
A client who experienced alcohol withdrawal is no longer having hallucinations or tremors and states, "I would like to enter a rehabilitation facility to stop drinking." Which intervention is appropriate?
promote participation in a treatment program
A nurse is caring for a neonate with congenital hypothyroidism. Which data should the nurse anticipate ?
puffy eyelids
A 16-year-old female was admitted to the hospital for treatment of anorexia nervosa. A nurse is teaching the client's mother about the disease process. The nurse recognizes that the teaching was effective when the mother states that anorexia nervosa is characterized by:
refusal to maintain normal body weight
An adolescent client with a diagnosis of schizophrenia has become very clingy and begins sucking their thumb while interacting with the nurse. The nurse understands that these behaviors indicate which defense mechanism?
regression
A client reports having a difficult time settling down for sleep in the evening. What nursing intervention would assist the client in achieving a positive outcome?
reinforce time management skills
A nurse is caring for an adult client in a long-term-care facility who has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first?
remove items that the client could use for self-inflicted injury
The nurse administers bromocriptine (Parlodel) to Bryan who is undergoing detoxification for amphetamine abuse. The rationale for this medication is to:
restore depleted dopamine levels.
A client who is diagnosed with borderline personality disorder has become attached to one nurse and refuses to speak with other staff members, claiming that they are mean, abusive, and are withholding medication. To address this behavior, which intervention would be most appropriate?
rotate the nurses who are assigned to the client
A nurse is caring for a client suspected of having posttraumatic stress disorder (PTSD). The nurse is aware that the client is also commonly at high risk for developing which condition?
self harm and violent behavior
A nurse is reviewing a client's history. Which characteristic would lead the nurse to suspect that a client is experiencing a depersonalization/derealization disorder?
sensation of detachment from body or mind
Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?
signs of increased intracranial pressure (ICP)
A nurse is trying to determine if a client who uses heroin has any drug-related legal problems. Which question is the best to ask the client?
"Have you received any legal violations related to your drug use?"
A client has a history of daily bourbon drinking for the past 6 months. He is brought to an emergency department by family who report that his last drink was 1 hour ago. It is now 12 midnight. When should a nurse expect this client to exhibit withdrawal symptoms?
between 3am and 11am
When preparing a lecture on psychiatric nursing, which particularly useful principle of the psychoanalytic model would the nurse educator include?
All behavior has meaning.
A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive disorder (OCD) symptoms. When the client's partner asks what OCD is, what is the appropriate nursing response?
"Clients with OCD experience repetitive thoughts and recurring, irresistible impulses."
A client in a psychiatric facility is prescribed a selective serotonin reuptake inhibitor (SSRI) for depression. The client tells the nurse they have had three seizures after taking the drug for 2 weeks. What question would be appropriate to ask at this time?
"Do you take any herbs, such as St. John's wort or evening primrose?"
The nurse is caring for a client with posttraumatic stress disorder (PTSD) and the family informs the nurse that loud noises cause a serious anxiety response. Which explanation by the nurse would help the family understand the client's response?
"Environmental triggers can cause the client to react emotionally."
The nurse is conducting a follow-up phone call with the parent of a child with nephrosis who was recently discharged. Which statement by the parent indicates the discharge instructions are being followed correctly? Select all that apply.
"I am administering my child's prednisone once a day, every day." "I am weighing my child every morning and keeping a logbook." "If my child's morning urine has 2+ protein for 2 days in a row, I will call the health care provider."
The health care provider has prescribed olanzapine for a client. Which statement from the client would indicate the medication is having the desired effect?
"I am feeling more comfortable talking with others."
A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic?
"I don't hear the voice, but I know you hear what sounds like a voice."
A client with a history of schizophrenia is having hallucinations. The client shouts to the nurse, "You're stepping on spiders! Move aside. Don't you see them?" Which response by the nurse would be best?
"I don't see them, but I know you believe you do."
A 54-year-old client who was admitted to the psychiatric unit during an acute phase of schizophrenia has hardly eaten and hasn't bathed or changed his clothes for 3 weeks. He undergoes 4 weeks of psychotherapy and medication adjustment. Which statement by the client indicates that he's ready for discharge?
"I know a sign of my disease is not bathing and maintaining my personal appearance."
A nurse is caring for a client who threatens suicide and is placed on constant observation. The nurse follows the client into the bathroom. The client says, "You don't need to follow me into the bathroom. Give me some space." Which response by the nurse is most appropriate?
"I must stay with you until we are sure you will not hurt yourself."
A client is taking chlorpromazine as part of a treatment plan. Which response by the client indicates that the client understands the education about the drug?
"I need to schedule appointments for routine medication checks."
A client with type 1 diabetes is at 22 weeks' gestation after the first pregnancy ended in spontaneous abortion at 18 weeks' gestation. The nurse is reinforcing instructions with the client about exercise during her pregnancy. Which statement indicates that the client has an appropriate understanding of her exercise needs?
"I need to walk with a friend or family member."
The nurse notices that a client with obsessive-compulsive disorder dresses and undresses numerous times each day. Which comment by the nurse would be therapeutic?
"I saw you change clothes several times today. That must be very tiring."
A client needs to have a fecal occult blood test performed on three consecutive bowel movements. To prepare the client for this test, the nurse provides information about the required dietary restrictions. The nurse knows the teaching has been successful when the client makes which statement?
"I should not eat any poultry, red meat, and turnips for 4 days before I begin this test."
A client is given triazolam for a sleep disorder. The nurse is reinforcing some teaching precautions concerning the medication. Which statements by the client indicate an understanding of the information provided?
"I shouldn't confuse this medication with Haldol."
A nursing student is surprised that a young couple is seeking treatment for Infertility. When asked by the nursing instructor to define it in a 25-year-old couple, how does the student respond?
"It is the couple's inability to conceive after 1 year of unprotected attempts."
A nurse is reinforcing the teaching plan with a client diagnosed with dissociative identity disorder (DID). Which statement by the client indicates that the education has been effective?
"My brain has temporarily hidden my memories of the rape to protect me."
A client who lost her spouse suddenly 30 years ago tells a nurse during an interview, "My husband's shoes are at the side of the bed where he left them." The client's daughter informs the nurse that her mother constantly speaks about her deceased husband. Which statement by the daughter shows an understanding of maladaptive grief?
"My mother is in a prolonged phase of the grief process."
A client admitted to the behavioral health unit diagnosed with antisocial personality disorder has made all of the telephone calls permitted for the day. The client asks the nurse, "Can't I just make one more phone call?" Which response by the nurse would be best?
"No, you can't. You have used all of your allotted phone calls."
Which client statement demonstrates positive progress toward recovery from substance abuse?
"Taking those pills got out of control. It cost me my job, marriage, and children."
A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be therapeutic?
"That must be frightening to you. Can you tell me how you feel about it?"
A client with dissociative amnesia says, "You must think I'm really stupid because I have no recollection of the accident." Which response would be most appropriate?
"The brain sometimes protects us by not letting us remember traumatic events."
A student nurse is gathering data on a client admitted to the unit who is visibly anxious. The instructor concludes the student has an understanding of the cardiovascular effects produced by the sympathetic nervous system based on which statements? Select all that apply.
"The client will have an increased heart rate." "The client will have an increased urine output."
A schizophrenic client with delusions tells the nurse, "There is a man wearing a red coat who's out to get me." The client exhibits increasing anxiety when focusing on the delusions. Which of the following would be an appropriate response?
"This subject seems to be troubling you. Let's walk to the activity room."
A client asks a nurse not to tell his or her parents about an alcohol problem. Which response is most appropriate?
"What do you think will happen if you tell your parents?"
A nurse is caring for a client who just separated from a partner with alcohol addiction. Which nursing statement conveys empathy?
"You made a very difficult decision by advocating for yourself. I am here if you want to talk."
One day after being admitted with bipolar disorder, a client becomes verbally aggressive during a group therapy session. Which response by the nurse would be therapeutic?
"You're disturbing the other clients. I'll walk with you around the patio to help you release some of your energy."
A woman, age 18, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with functional neurologic symptom disorder. The client asks the nurse, "Why has this happened to me?" What is the most appropriate response?
"Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened."
A 3-year-old is to receive 500 mL of dextrose 5% in normal saline solution over 8 hours. At what rate (in milliliters per hour) should a nurse set the infusion pump? Round your answer to a whole number.
63
The nurse is assigned to care for four neonates. Which neonate should she assess first?
A 4-hour-old, 10-lb, 7-oz (4,734 g) boy delivered vaginally
Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which action is most appropriate?
Accept the client's fears, allowing the client to take a sponge bath.
On the first day of a client's alcohol detoxification, which nursing intervention should take priority?
Administer ordered chlordiazepoxide (Librium) in a dosage according to protocol
When reviewing medications for a pharmacology examination, the nursing student recognizes which drugs may be abused because of tolerance and physiologic dependence?
Alprazolam and phenobarbital
The nurse is caring for a client who has schizophrenia. What is the first-line treatment for this client?
Antipsychotics
A nurse observes a coworker administering a medication several hours after it had been scheduled. When confronted, the coworker simply makes a dismissive joke and then charts the medication as given at the scheduled time. What should the witnessing nurse do? Place the actions in chronologic sequence. All options must be used.
Approach the coworker in a calm and professional manner. Request a private meeting to discuss the incident. Express concern and clearly inform the nurse the behavior is unethical. Encourage the nurse to take responsibility for these actions. Report the incident to the nurse-manager if resistance is noted.
A nurse needs assistance in getting an older adult client with confusion back into bed from the chair. The nurse leaves the client sitting alone in the room while going to find someone to assist with the transfer. While the nurse is gone, the client gets out of the chair, falls, and sustains an injury. What did the nurse fail to do?
Arrange for continual care of the client.
The nurse is caring for a client who is agitated and is trying to get out of bed. What should the nurse do first to keep the client free of injury?
Ask the unlicensed assistive personnel to sit with the client.
Which is the priority nursing intervention for a client admitted for acute alcohol intoxication?
Assess aggressive behaviors in order to intervene to prevent injury to self or others.
Which instructions should the nurse include when teaching a client about quetiapine therapy? (Select all that apply.)
Avoid becoming overheated or dehydrated during therapy. Change positions slowly to prevent orthostatic hypotension. Contact the prescriber before taking over-the-counter preparations.
A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior?
Avolition
A client with a history of heavy alcohol use is brought to an emergency department (ED) by family members who state that the client has had nothing to drink in the last 24 hours. Which client symptom should the nurse immediate report
Blood pressure of 180/100 mm Hg
The nurse believes that a client being admitted for a surgical procedure may have a drinking problem. How should the nurse further evaluate this possibility?
By using a screening tool such as the CAGE questionnaire
Which medication orders should a nurse anticipate for a client who has a history of complicated withdrawal from benzodiazepines?
Chlordiazepoxide (Librium) and phenytoin (Dilantin)
A physician's order states to administer lorazepam, 20 mg by mouth twice per day, to treat anxiety. How should the nurse proceed?
Clarify the order with the prescribing physician because the amount prescribed exceeds the recommended dose.
A nurse is caring for a newly admitted client diagnosed with schizophrenia and is started on antipsychotic medication. When reviewing the client's file, which notation would alert the nurse to notify the health care provider before implementing?
Client is scheduled to have a myelogram within 48 hours of admission.
A nurse evaluates a client's patient-controlled analgesia (PCA) pump and notices 100 attempts within a 30-minute period. Which is the best rationale for assessing this client for substance dependence?
Clients who are dependent on alcohol or benzodiazepines may have developed cross-tolerance to analgesics and require increased doses to achieve effective pain control.
A nurse is caring for a client who is scheduled to undergo electroconvulsive therapy (ECT) next week. The client has been taking a benzodiazepine for several months. Which nursing action is appropriate?
Contact the health care provider who prescribed benzodiazepine.
A nurse is caring for a client who states, "I can't keep living like this. I just want to end it all." What is the nurse's best response?
Do you plan to harm yourself
A client has a history of post-traumatic stress disorder (PTSD). What assessment finding does the nurse anticipate?
Dreams and flashbacks of the event
A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, the client has muscle contractions that contort his neck. This client is exhibiting which extrapyramidal reaction?
Dystonia
The nurse is assisting with the development of a plan of care for a client with generalized anxiety disorder (GAD). Which intervention is important to include?
Encourage the client to use a diary to record when anxiety occurred, its cause, and which interventions may have helped.
A client with dementia in a long-term care facility is prescribed haloperidol as needed for agitation and wandering. What nursing interventions are appropriate prior to administration?
Exhaust all nonpharmacologic interventions.
After seeking help at an outpatient mental health clinic, a client who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, the client returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for this client?
Exploring the meaning of the traumatic event with the client
A client states to the nurse, "The voices are telling me to do terrible things." As part of the client's initial therapy, which action would be most likely included?
Find out what the voices are saying
While reviewing the mental health chapter, which symptoms does the nursing student identify as the positive symptoms of schizophrenia?
Hallucinations, delusions, and disorganized thinking
What medication would probably be ordered for the acutely aggressive schizophrenic client?
Haloperidol
A nurse determines that a client who used alcohol has nutritional problems. Which strategy is best for addressing the client's nutritional needs?
Help the client to recognize and follow a balanced diet.
A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing the beating of his wife at gunpoint, he has been unable to move his arms, complaining that they are paralyzed. When planning the client's care, the nurse should incorporate nursing interventions with which focus?
Helping the client identify and verbalize feelings about the incident
The nurse is caring for a 15-year-old client whose parent expresses concern about the client's weight loss and constant dieting. Which client comment requires immediate nursing intervention?
I am fat compared to other kids who are in my grade.
The nurse is obtaining data about the early life of a client with borderline personality disorder (BPD). Which statement made by the client would correlate with this diagnosis?
I had a violent, chaotic family life
The nurse is caring for a client who has post-traumatic stress disorder (PTSD) after a sexual assault. Which client statement is consistent with the diagnosis of PTSD?
I keep having visions of the event happening.
The nurse is caring for a client asking for information about cocaine. Which statement by a client indicates that reinforcement of teaching about cocaine use has been effective?
I started using cocaine more and more until I couldn't stop
The nurse is instructing a client about using the antianxiety medication lorazepam. Which statement by the client indicates a need for further education?
I usually drink a beer every night to help me sleep.
A nurse is observing the effectiveness of an assertiveness group attended by a client with dependent personality disorder. Which client statement indicates the group had therapeutic value?
I want to talk about something that is bothering me
A client diagnosed with panic disorder and agoraphobia is talking with the nurse about the progress made in treatment. Which statement indicates a positive client response?
I went to the mall with my friends last week.
A nurse is reinforcing education for a client who has been prescribed buspirone for long-term treatment of anxiety. The nurse determines that the education has been effective when which statement is made by the client?
I will not take the medication with grapefruit juice.
A nurse is reinforcing instruction for a client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg by mouth three times per day. The nurse determines that the education regarding the client's diagnosis and medication has been effective when the client gives which response?
I'll avoid caffine
The effectiveness of monoamine oxidase (MAO) inhibitor drug therapy in a client with posttraumatic stress disorder (PTSD) can be demonstrated by which client self-report?
I'm sleeping better and don't have nightmares.
A famous pregnant client comes to the health care provider's office for a routine prenatal examination. While the client is in the office, the media arrives asking for information about the client. What should the nurse do?
Inform the media that you can't comment about whether the person is being seen in the office.
A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5' 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention that takes highest priority would the nurse implement?
Initiating caloric and nutritional therapy as ordered
A 40-year-old client is admitted to the hospital for alcohol abuse for the third time in the past 9 months. The health care team recommends rehabilitative treatment for this client. Why was this treatment recommended?
It helps the client identify the relationship between his problems and alcohol consumption.
An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which collection data observed by the nurse support this diagnosis?
Lack of self-esteem, strong dependency needs, and impulsive behavior
The nurse is caring for a client with bulimia. The plan of care for this client includes strict management of dietary intake. Which other important nursing intervention would the nurse include in the plan of care?
Let the client choose his or her own food and stay with the client for 1 hour after each meal.
A client who was attempting to carry out a suicide plan is admitted to the unit. Which nursing intervention is the highest priority for this client?
Making sure that a health care team member stays with the client
A 49-year-old painter who recently fractured his tibia worries about his finances because he can't work. To treat his anxiety, his physician prescribes buspirone, 5 mg by mouth three times per day. During buspirone therapy, the client should avoid which of the following drugs?
Monoamine oxidase (MAO) inhibitors
The nurse is gathering data from a client with dissociative identity disorder (DID). Which statement would the nurse most likely hear from the client?
My father loved me one day and hit me the next.
While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take?
Notify the physician upon arrival at the operating room.
The nurse is caring for a schizophrenic client who becomes violent and delusional. Which therapeutic actions are best? (Select all that apply.)
Obtain additional staff assistance as needed. Ensure the safety of the client and others in the area. If restraints are required, explain what is being done and why.
A nurse is assisting with planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety?
Place the call bell within the client's reach and ensure the client knows how to use it.
A client with a history of alcohol use refuses to take the prescribed vitamin supplement. The client asks, "What good will that do me?" What teaching will the nurse provide?
Prolonged alcohol use can cause vitamin def
A client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which nursing strategy should the nurse use when dealing with this client's distorted perceptions and feelings?
Provide objective data and feedback regarding the client's weight and attractiveness.
A 32-year-old homeless client is referred to an outpatient treatment program for delusional behavior. A nurse notes during the history-taking process that the client eats only one meal a day, which is high in fat and contains no vegetables. The client also states that she rarely eats fruit. Which approach can the nurse use to help the client eat more nutritious meals?
Provide the client with a nutritional lunch and arrange for the nutritionist and psychiatrist to see the client after lunch.
The nurse is assigned to care for a client with anorexia nervosa. Initially, which most appropriate nursing intervention would the nurse implement for this client?
Providing one-on-one supervision during meals and for 1 hour afterward
A client has followed an antipsychotic medication regimen for a number of years. The health care provider treats a urinary tract infection with antibiotic therapy. Which action would be most appropriate?
Reinforce instruction on the medication, possible adverse effects, and a return demonstration for teaching effectiveness.
Which therapeutic strategy is used to reduce anxiety in a client diagnosed with illness anxiety disorder?
Relaxation exercises
A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety?
Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.
A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate?
Remove the client from the dayroom and reorient in a safe place.
The health care provider prescribes a new drug for a client with generalized anxiety disorder. Which teaching will the nurse provide?
Repeat for me how to take this medication as prescribed.
A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for the client at this time?
Risk for injury
A client with a history of insomnia has been taking chlordiazepoxide (Librium) 15 mg at night for the past year. The client currently reports getting to sleep. Which nursing diagnosis appropriately documents this problem?
Risk for injury R/T addiction to Librium
What should be the priority nursing diagnosis for a client experiencing alcohol withdrawal?
Risk for injury R/T central nervous system stimulation
A client has a history of schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan?
Sitting up for a few minutes before standing to minimize orthostatic hypotension
A nurse is caring for a client diagnosed with panic disorder who begins to hyperventilate. What is the priority nursing action at this time?
Stay with the client to maintain safety.
A client preparing for final exams arrives at the student health center. The client has not slept all night, is sobbing hysterically and hyperventilating, and states, "I can't go on." Which nursing response is appropriate?
Studying for finals can be very stressful. Let's sit together and talk about how you are feeling."
The nurse is working in a psychiatric facility on an anxiety disorder unit. The unit is locked and clients have scheduled group and family therapy sessions. Which other standard is maintained on this unit for a client diagnosed with panic disorder?
Suicide precautions are instituted.
A nurse is caring for a client experiencing a panic attack. Which intervention by the nurse would be most appropriate?
Tell the client to take deep breathes.
The mother of a 3-year-old child is complaining that her son still throws temper tantrums when he doesn't get his way. How should the nurse advise the mother to respond?
Tell the mother to ignore the child because eventually he will stop having temper tantrums.
A client experiencing paranoid delusions states, "They are conspiring against me; they're after me all night." Which response by the nurse would be the most empathic?
That sounds frightening.
A nurse is caring for an older adult client with late-stage Alzheimer's disease. The client's spouse tells the nurse that the client has become very dependent, stating, "I feel guilty taking time for myself because the client cries out when I'm not present." When assisting with developing a plan for the client's spouse, which outcome would be most appropriate?
The caregiver distinguishes obligations that must be fulfilled and limit those that are unnecessary.
The nurse is collecting data from a parent regarding the child's behavior. Which behavior is consistent with the diagnosis of conduct disorder in this child?
The child purposely hurts animals
The nurse is caring for four clients on a medical surgical unit. Which interaction between the nurse and a client is the best example of the nurse using the ethical principle of fidelity?
The client asked for information regarding a new medication. The nurse provided written instructions.
A client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. When collecting data on this client, which typical manifestation does the nurse anticipate?
The client assumes an attitude that is the opposite of an impulse that the client harbors.
The health care provider has prescribed methylphenidate. Which findings in the client's medical history would warrant concern about this therapy? Select all that apply.
The client has a history of alcoholism. The client's history indicates a recent myocardial infarction.
A client diagnosed with alcohol abuse joins a community 12-step program and states, "My life is unmanageable." How should the nurse interpret this client's statement?
The client has accomplished the first of 12 steps advocated by Alcoholics Anonymous.
The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, if noted in this client's history, would cause the nurse to notify the health care provider for accuracy of the prescription?
The client is also receiving labetalol.
During group therapy, a client diagnosed with chronic alcohol dependence states, "I would not have boozed it up if my wife hadn't been nagging me all the time to get a job. She never did think that I was good enough for her." How should a nurse interpret this statement?
The client is using rationalization to excuse his alcohol dependence.
A nurse is interviewing a client in an outpatient substance-abuse clinic. To promote success in the recovery process, which outcome should the nurse expect the client to initially accomplish?
The client will correlate life problems with alcohol use.
A nurse is caring for a client with anorexia nervosa. When assisting with the development of the client's plan of care, which goal would the nurse identify as the highest priority?
The client will establish adequate nutritional intake
A client who is preparing for discharge to a halfway house must be referred to an outpatient clinic. Which criteria should be considered when choosing an outpatient treatment program for this client?
The clinic is within walking distance, and a staff member will send a caseworker to the halfway house to assess the client and develop a treatment plan.
The nurse is assisting with a plan of care for a client in the behavioral health unit with antisocial personality disorder. What goal would be appropriate for this client?
The family must stop reinforcing inappropriate negative behavior.
A lonely, depressed divorcée has been self-medicating with cocaine for the past year. Which term should a nurse use to best describe this individual's situation?
The individual is experiencing psychological dependency.
While reading a journal article, a nurse comes across a discussion of the causes of dissociative disorders. Which information would the nurse most likely find in the discussion?
They occur as a result of the brain trying to protect the person from severe stress.
Which statement is correct about clients who have somatic symptom disorder?
They usually seek medical attention
The nurse is providing group therapy for a group of adolescents who witnessed the violent death of a peer. Which outcome would best meet the needs of the students?
To discuss the effect of the trauma on their lives.
A client diagnosed as having panic disorder is admitted to the inpatient psychiatric unit. Until admission, he or she had been a virtual prisoner in the house for 5 weeks because of agoraphobia, afraid to go outside even to buy food. The nurse, when planning care for this client, determines which action as this client's overall goal?
To help the client function effectively in his or her environment
Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder?
To prevent or relieve symptoms of anxiety.
Lorazepam is often given along with a neuroleptic agent, such as haloperidol. What is the purpose of administering the drugs together?
To reduce anxiety and potentiate the sedative action of the neuroleptic
A man found wandering in a local park is unable to state who or where he is or where he lives. He is brought to the emergency department, where his identification is eventually discovered. The client's wife states that he was diagnosed with Alzheimer's disease 3 years ago and has had increasing memory loss. She tells the nurse she is worried about how she'll continue to care for him. Which response by the nurse would be most helpful?
What aspect of caring for your husband is causing you the greatest concern?"
The parent of a client approaches the nurses' station in tears because the client's diagnosis of conversion disorder. Which response is best?
What is it that upsets you the most?
A client with bulimia nervosa is discussing abnormal eating behaviors. Which statement indicates the client is beginning to understand this eating disorder?
When I am feeling lonely I start to binge
The nurse is preparing to administer a dose of chlorpropamide to a client with type 2 diabetes. Before administering the drug, the nurse checks the client's allergies and notices that the client is wearing an allergy alert bracelet that indicates an allergy to sulfa drugs. Which action should the nurse take?
Withhold the drug and notify the health care provider.
For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take?
Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.
A client is admitted to the psychiatric unit with a tentative diagnosis of psychosis. Her physician prescribes the phenothiazine thioridazine, 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:
a calming effect from which the client is easily aroused.
The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which trait would the nurse be likely to uncover during data collection?
a low tolerance for frustration
The nurse evaluates a client who is 36-hours postoperative. Which sign or symptom indicates to the nurse that the client is experiencing a complication?
a warm, erythematous tender incision
Which factor should the nurse be most concerned about when caring for a client taking an antianxiety medication?
abrupt withdrawal
A client taking metronidazole asks the nurse if it is okay to drink alcohol while taking this medication. What is the nurse's best response?
abstain from alcohol while on this drug
A client is in the first stage of labor. Her cervical dilation has progressed from 4 to 7 cm. The nurse understands that the client is most likely in which phase?
active phase
The nurse is caring for a client who has been diagnosed with delirium. Which of the following is characteristic of delirium?
acute onset and last hours to a number of days
A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action is to:
administer an as-needed dose of benztropine I.M. as ordered.
A client who is diagnosed with anxiety is prescribed sertraline, a selective serotonin reuptake inhibitor (SSRI). Which adverse effects would the nurse reinforce when assisting in creating a medication teaching plan? Select all that apply.
agitation sleep disturbance dry mouth
A client with depersonalization/derealization disorder is prescribed drug therapy as part of the treatment plan. Which medication would the nurse most likely administer if prescribed? (Select all that apply.)
alprazolam lorazepam clonazepam
During the initial interview, a client with schizophrenia tells the nurse, "I don't enjoy things anymore. I used to love to read mystery books, but even that isn't enjoyable now." The nurse correctly identifies that the client is experiencing which condition?
anhedonia
After a surgical procedure, the health care provider orders a clear-liquid diet for a client. The nurse advises the unlicensed assistive personnel (UAP) to check the client's food tray for which of the following allowable items? Select all that apply.
apple juice, chicken broth, and gelatin ginger ale, jello, and a fruitless popsicle
The nurse is assisting with the development of a treatment plan for a client with a specific phobia. Which intervention should the nurse prepare the client for?
behavioral therapy
A nurse is collecting data on a client who is suffering from stress and anxiety. When collecting data from the client, the nurse interprets what reported symptom as a common physiologic response to stress and anxiety?
diarrhea
A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by:
disturbances in affect, perception, and thought content and form.
The nurse is obtaining data when the postpartum client comes for follow-up visits at 2, 4, and 6 weeks. When would be the best time for the client to have postpartum depression screenings?
during each of the three visits using the Edinburgh Postnatal Depression Scale
A client with major depression hasn't responded to antidepressants. Which intervention should the nurse prepare the client for?
electroconvulsive therapy ECT
A client is admitted to a long-term-care facility with a diagnosis of organic mental disorder. The client has been wearing the same undergarments for several days. Which nursing intervention would best prevent further regression in the client's personal hygiene habits?
encourage the client to perform as much self care as possible
A client with a diagnosis of borderline personality disorder is admitted to the unit after slashing their wrist. When assisting with the planning of care, which goal is most appropriate for this client?
establish a therapeutic relationship with the client
Which short-term goal is appropriate for a client with borderline personality disorder who displays low self-esteem?
express fears and feelings
A client with a history of bipolar disorder came to the hospital with an exacerbation. The client has been prescribed lithium and has not taken it for the past 2 weeks. What finding is the nurse likely observe?
flight of ideas
Family members of a client with bipolar disorder tell the nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:
flight of ideas and inflated self esteem
Which communication guideline should the nurse use when talking with a client experiencing mania?
focus and redirect conversation as necessary
A psychotic client reports to the evening nurse that the day nurse put something suspicious in his water with his medication. The nurse replies, "You're worried about your medication?" The nurse's communication is:
focusing on emotional content
A client is admitted for abrupt onset of paralysis in the left arm. Although no physiologic cause has been found, the symptoms are exacerbated when the client speaks about losing custody of children in a recent divorce. The nurse determines these findings are characteristic of what disorder?
functional neurologic symptom disorder
The nurse is assigned to care for a client with early-stage Alzheimer's disease (AD). Which nursing interventions should be included in the client's care plan? Select all that apply.
furnish the client's environment with familiar possessions assist the client with activities of daily living (ADLs) as necessary assign tasks in simple steps
A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:
gently but firmly set limits on time spent in bed during the day.
A nurse is caring for a client who experiences false sensory perceptions that occur without external stimuli. How will the nurse document this observation?
hallucinations
Which nursing intervention comprises the major component of a cocaine addiction treatment program?
helping the client acknowledge the current level of dependency
A client is experiencing recurrent episodes of dissociative fugue. Which nursing intervention would be most helpful to reduce these recurrent episodes?
helping the client identify resources to deal with stressful situations
The nurse finds a client with Alzheimer's disease wandering in the hall at 3 a.m. The client has removed all clothing and says to the nurse, "I'm just taking a stroll through the park." What is the priority action by the nurse?
immediately help the client back to his or her room and into some clothing
A client diagnosed with schizophrenia several years ago tells the nurse about feeling "very sad." The nurse observes that the client is smiling when saying it. When documenting this observation, the nurse would describe it using which term?
inappropriate affect
When receiving a client assignment, which assignment should the licensed practical nurse (LPN) recognize as being outside of the LPN scope of practice? Select all that apply.
initiating a blood transfusion completing an initial admission assessment
A client has depression after the death of a child. After a suicide attempt, the client is admitted to the inpatient psychiatric unit. During the admission interview, the client reports no longer wanting to die. Which action would be most appropriate for the nurse?
inspect the clients personal belongings for potentially dangerous items
While providing care to a client receiving antipsychotic therapy, the nurse suspects that the client is experiencing tardive dyskinesia based on which finding?
involuntary movements
An adolescent client is diagnosed with attention deficit hyperactivity disorder (ADHD). What statement made by the client demonstrates an understanding of the disorder?
it increases sensitivity to the environment and surroundings
During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:
joint abnormalities.
The nurse is gathering data to determine the status of a client with a respiratory rate of 4 breaths/minute. What additional data should the nurse obtain?
level of consciousness (LOC) and a pulse oximetry value
A client with schizophrenia tells the nurse he hears the voices of his dead parents. To help the client ignore the voices, the nurse should recommend that he:
listen to a personal stereo through headphones and sing along with the music.
A nurse is providing care to a client diagnosed with bipolar disorder, currently experiencing mania. When reviewing the plan of care for the client, which intervention would the nurse most likely implement at this time?
listening attentively with a neutral attitude, avoiding situations involving increased stimulation
A nurse is carrying out the plan of care developed for a client diagnosed with dissociative identity disorder (DID). Which intervention would be the priority for this client?
maintaining consistency when interacting with the client
A nurse on the psychiatric unit is caring for a client with antisocial personality disorder. Which behavior is the nurse most likely to observe?
manipulation, shallowness, and the need for immediate gratification
A licensed practical nurse is providing care for a client who is undergoing opiate withdrawal. The client is receiving medication therapy to minimize the effects. Which drug would the nurse expect to administer to the client?
methadone
The nurse is providing care to a client with appendicitis. Which priority nursing intervention should the nurse perform?
monitoring for signs of peritonitis
A client gave birth to an infant 3 days ago and now does not know where she is, does not realize she has a child, and is hearing voices and seeing animals in her hospital room. What would the nurse do first?
notify the health care provider
A client undergoing treatment for paranoia refuses to take his risperidone, stating, "I think it's poisoned." Which action by the nurse is appropriate?
omitting the dose and notifying the health care provider
A client chronically complains of being unappreciated and misunderstood by others. She is argumentative and sullen. She always blames others for her failure to complete work assignments. She expresses feelings of envy toward people she perceives as more fortunate. She voices exaggerated complaints of personal misfortune. The client most likely suffers from which personality disorder?
passive aggressive personality
A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to?
perceptual impairment
Which nursing intervention would help a client diagnosed with Alzheimer's disease (AD) perform activities of daily living?
provide ample time for the client to perform basic tasks
An agitated and incoherent client, age 29, comes to the emergency department and reports having visual and auditory hallucinations. The history reveals that the client was hospitalized for schizophrenia from ages 20 to 21. The physician prescribes haloperidol, 5 mg I.M. The nurse understands that this drug is used in this client to treat:
psychosis
The nurse is caring for a client who has been diagnosed as having social anxiety disorder. Which intervention would be appropriate for the nurse to encourage the client to develop?
public speaking
The nurse asks a client with a suspected dementia disorder to recall what was eaten for breakfast. What data is the nurse gathering from this client?
recent memory
The nurse is developing a teaching plan for a client receiving clozapine. The nurse should stress the importance of which aspect of follow-up care?
routine CBC with differential
A nurse is providing care to a client with delusional disorder who has been admitted to the inpatient psychiatric unit. The client states, "I can't stand this itching and burning any more. All these bugs are crawling all over my skin. See, it's like they're swarming all around me and drilling holes in my skin." On inspection, the skin is clean, dry and intact without any evidence of redness or irritation. The nurse suspects that the client is experiencing which type of delusion?
somatic
The nurse is working as part of the interdisciplinary team in caring for a client with dissociative identity disorder. Which behavior reported by a family member would indicate that the client's therapy is effective?
the client sleeps through the night
A client with dissociative identity disorder (DID) is admitted to an inpatient psychiatric unit. A nurse-manager asks all staff to attend a meeting. Which is the most likely reason for the meeting?
to allow staff members to discuss concerns about working with a client with DID
Which behavior by the nurse would demonstrate caring to a client with a diagnosis of anxiety disorder?
verbalize concern about the client
During data collection, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of:
waxy flexibility
A nurse is preparing to reinforce education with a client who uses alcohol. What client data would be most important for the nurse to obtain?
willingness to learn
A nursing instructor is teaching students about cirrhosis of the liver. Which of the following student statements about the complications of hepatic encephalopathy should indicate that further student teaching is needed?
"A diet rich in protein will promote hepatic healing." "In this condition, blood accumulates in the abdominal cavity."
Nurse Florence assesses Mrs. B with borderline personality disorder. Which of the following behaviors are common to this diagnosis? Select all that apply.
intense fear of being alone evidence of self mutilation attempts unstable moods with impulsive behaviors
A client is admitted to a medical-surgical unit for treatment of an orthopedic injury. In addition to this admitting diagnosis, the nurse notes that the client has a history of borderline personality disorder with episodes of cutting/self- mutilation. Which type of behavior would the nurse expect to be present due to this self-mutilation history? (Select all that apply.)
knife or razor in purse or bag insistence on wearing long-sleeved shirt even in warm temperatures overly hesitant behavior when the nurse attempts to assist with bathing or dressing
Which statement from a client with bulimia shows that the client understands the concept of relapse?
"If I have problems, I can start over again and not feel hopeless."
A client who frequently uses alcohol tells the nurse, "Everyone in my family is an alcoholic, so it's in my genes to be one, too." Which response is most appropriate?
"Problems with alcohol can occur in families, but it is your decision to become and stay sober."
A nurse is caring for a client who has been prescribed disulfiram (Antabuse) as a deterrent to alcohol relapse. Which information should the nurse include when teaching the client about this medication?
"Reactions to combining Antabuse with alcohol can occur 2 weeks after stopping the drug."
A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which would be the most appropriate response by the nurse?
"You told me you got fired from your last job for missing too many days after taking drugs at night."
Which nursing diagnosis takes priority for a client diagnosed with anorexia nervosa?
Imbalanced nutrition: Less than body requirements
Which information is most important for the nurse to reinforce with a client who abuses prescription drugs?
Medication should be used only for the reason prescribed.
A client begins to experience alcoholic hallucinosis. Which appropriate nursing intervention does the nurse implement at this time?
Providing a quiet environment and administering medication as needed and prescribed
A client experiencing alcohol withdrawal states, "I have had periodic hallucinations." Which intervention is best for this client's problem?
allowing the client to talk about their experience
A child presents to the clinic for a follow up after starting methylphenidate for attention deficit hyperactivity disorder. Which findings would indicate to the nurse that the medication is helping the child?
able to concentrate for longer periods of time
A client with anorexia nervosa is admitted to the emergency department. Which finding does the nurse anticipate?
amenorrhea for 1 year
The newly hired nurse at Nurseslabs Medical Center is assessing a client who abuses barbiturates and benzodiazepine. The nurse would observe for evidence of which withdrawal symptoms?
anxiety, tremors and tachycardia
On discharge after treatment for alcoholism, a client plans to take disulfiram as prescribed. When teaching the client about this drug, the nurse emphasizes the need to:
avoid all products containing alcohol
A client is struggling with alcohol dependence. Which communication strategy is most effective for the nurse?
avoid blaming or lecturing the client
A nurse is developing strategies to prevent relapse with a client who uses alcohol. Which client intervention is important?
avoiding people, places, and activities from the former lifestyle
Nurse Aldrich is working with the family of Mary Ann, a client with personality disorder. Which of the following should Nurse Aldrich encourage the family members to work on?
improving self function
An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. When obtaining data, which behaviors would be characterized as compulsions? Select all that apply.
checking and rechecking that the television is turned off before going to school repeatedly washing the hands routinely climbing up and down a flight of stairs three times before leaving the house
A client who uses alcohol tells a nurse, Alcohol helps me sleep." Which information about alcohol use affecting sleep is most accurate?
continued alcohol use can cause insomnia
A nurse is caring for a client who is undergoing treatment for acute alcohol dependence. The client tells the nurse, "I don't have a problem. My wife made me come here." Which defense mechanism does the nurse determine the client is using?
denial and rationalization
A nurse is caring for a client with anorexia nervosa who requires a high-protein, high-calorie diet. When offering appropriate choices for snacks, which snack would be best for this client?
egg salad and peanuts
Nurse Wilma is teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She explains that using alcohol when taking this medication can result in:
flushing, vomiting and dizziness
A client who has been drinking alcohol for 30 years asks a nurse if the immune system has suffered permanent damage. Which response is best?
There's usually less resistance to infections.
The nurse is interviewing a client on admission to the chemical dependency unit for alcohol detoxification. When asked about alcohol use, the nurse suspects which estimation that this client is most likely to provide?
Underestimate the amount consumed
Which of the following nursing statements exemplify the cognitive process that must be completed by a nurse prior to caring for clients diagnosed with substance-abuse disorders? (Select all that apply.)
"I am easily manipulated and need to work on this prior to caring for these clients." "Because of my father's alcoholism, I need to examine my attitude toward these clients." "I'll need to set boundaries to maintain a therapeutic relationship."
A client recovering from cocaine use is participating in group therapy. Which statement by the client indicates that the client has benefited from the group?
"I finally realize the short high from cocaine isn't worth the depression."
A client is questioning the nurse about a newly prescribed medication, acamprosate calcium (Campral). Which is the most appropriate reply by the nurse?
"This medication will help you maintain your abstinence."
A client's wife has been making excuses for her alcoholic husband's work absences. In family therapy, she states, "His problems at work are my fault." Which is the appropriate nursing response?
"Your husband needs to deal with the consequences of his drinking."
The nurse is caring for a client with a diagnosis of bulimia nervosa. After reviewing the client's lab results, the primary health care provider has written a prescription for 20 mEq of potassium chloride oral solution to be administered today. The label on the oral solution states potassium chloride oral solution 40 mEq/15 mL. How many mL should the nurse administer? Record your answer using one decimal place.
7.5
A recovering alcoholic relapses and drinks a glass of wine. The client presents in the emergency department (ED) experiencing severe throbbing headache, tachycardia, flushed face, dyspnea, and continuous vomiting. What may these symptoms indicate to the ED nurse?
A reaction to disulfiram (Antabuse)
A client is admitted to the inpatient adolescent unit after being arrested for attempting to sell cocaine to an undercover police officer. The nurse assists in writing a behavioral contract. Which action would the nurse incorporate to best promote compliance by this client?
The contract should be written jointly between the nurse and client.
A client diagnosed with chronic alcohol dependency is being discharged from an inpatient treatment facility after detoxification. Which client outcome related to Alcoholics Anonymous (AA) would be most appropriate for a nurse to discuss with the client during discharge teaching?
After discharge, the client will immediately attend 90 AA meetings in 90 days.
The nurse is caring for a client who is under the influence of a controlled substance and becoming agitated. In what priority should the nurse perform these tasks?
Alert hospital security
When a client with personality disorder begins demonstrating manipulative behavior, which of the following nursing actions are most appropriate? Select all that apply.
Ask the client to think about the consequences of behavior. Develop a consistent team approach to handle the client's behaviors. Provide immediate feedback concerning the client's specific behaviors. Set limits in a clear, direct manner.
The grandparents of a client with anorexia nervosa want to support the client, but are not sure what they should do. Which intervention is best?
Encourage positive expressions of affection.
A client is admitted for alcohol detoxification. During detoxification, which symptoms should the nurse expect to assess?
Gross tremors, delirium, hyperactivity, and hypertension
A client is admitted to the substance abuse unit for alcohol detoxification. Which symptom does the nurse anticipate will be present? Select all that apply.
Hallucinations Seizures Agitation Diaphoresis Nausea and vomiting
A nurse is monitoring a client for signs of early alcohol withdrawal. Which most consistent assessment finding associated with early alcohol withdrawal would the nurse expect to find?
Heart rate of 120 to 140 beats/minute
Mrs. B is diagnosed with borderline personality disorder has a nursing diagnosis of Risk for self-directed violence, which is related to the client's self mutilation behavior (burning arms with cigarettes). Which client behavior would indicate a positive outcome of intervention?
Mrs. B tells the nurse about wanting to burn herself
When a client abuses a CNS depressant, withdrawal symptoms will be caused by which of the following?
Norepinephrine rebound
A client diagnosed with depression and substance abuse has an altered sleep pattern and demands that a psychiatrist prescribe a sedative. Which rationale explains why a nurse should encourage the client to first try nonpharmacological interventions?
Sedative-hypnotics are potentially addictive and will lose their effectiveness due to tolerance.
In a toddler, which of the following injuries is most likely the result of child abuse?
Several small, dime-sized circular burns on the child's back
Which term should a nurse use to describe the administration of a central nervous system (CNS) depressant during alcohol withdrawal?
Substitution therapy
A nurse is caring for a client who typically consumes 15 to 20 beers per week and is extremely defensive about alcohol intake. The client admits to experiencing blackouts and has had three alcohol-related motor vehicle crashes. What's the best action for this client?
abstain from alcohol all together
A client with chronic alcoholism may be predisposed to develop which condition?
heart failure
A nurse is receiving the chart of an adolescent client who has been admitted to the unit. When reading the progress notes above, the nurse sees a laboratory result that indicates a condition consistent with a diagnosis of bulimia nervosa. Which condition does the nurse suspect?
hypokalemia
A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the nurse expects the health care practitioner to most likely prescribe which drug?
lorazapam
The nurse is caring for an adolescent client receiving a selective serotonin reuptake inhibitor (SSRI) as part of the treatment plan for anorexia nervosa. Which action is a priority intervention related to the SSRI therapy?
monitor for suicidal thoughts
A client tells a nurse, "I've been clean from drugs for the past 5 years, but my life really hasn't changed." Which concept should be explored with this client?
personal development
A nurse is working with a client with anorexia nervosa who has acrocyanosis in the extremities. Which short-term goal is most important for the client?
promote systemic circulation
A client with anorexia nervosa tells a nurse about always feeling fat. Which intervention is best for this client?
reinforce education about the dynamics of the disorder
A nurse is providing care to a client who has been admitted to the facility for alcohol withdrawal. When collecting data on the client, which findings would the nurse most likely note as indicating that the client is experiencing mild early withdrawal? Select all that apply.
restlessness
A client addicted to alcohol begins individual therapy with a nurse. Which goal should be a priority for the client?
learning to express feelings
The nurse is caring for a client with a history of cocaine abuse. Which test might be ordered following a return to an inpatient treatment facility?
urine screen
The nurse is teaching a client with bulimia nervosa about the complications of laxative abuse. Which client statement reflects that teaching has been effective?
using laxatives can prevent my body from absorbing essential nutrients
A nurse is assisting a client with a knowledge deficit about the effects of alcohol on the body. When assisting with the development of the client's plan of care, which goal would the nurse identify as the highest priority?
verbalize the results of substance abuse
A client being treated for morbid obesity is 5' 3" tall and weighs 250 lb (113.4 kg). She has lost 60 lb (27 kg) over the past year. A nurse is advising the client about adding an exercise regimen to her diet program. Which exercise is the most appropriate for the nurse to suggest?
walking for 20 minutes a day
