EAQ Psych Questions

A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam 7.5 mg intramuscularly stat is prescribed. Diazepam is available as 5 mg/mL. How many milliliters will the nurse administer? Record your answer using one decimal place. ___ mL

1.5

The nurse is caring for a client with bulimia nervosa. Which outcome criteria are important to discuss with the client? Select all that apply. Resuming menstruation Achieving 85% of ideal body weight Abstaining from binge-purge behaviors Describing a realistic perception of body shape Demonstrating three learned skills for managing stress

Abstaining from binge-purge behaviors Describing a realistic perception of body shape Demonstrating three learned skills for managing stress

An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis? Easily distracted Argues with adults Lies to obtain favors Initiates physical fights

Argues with adults

A hospitalized client with borderline personality disorder consistently breaks the unit's rules. How will confronting the client about this behavior help the client? By controlling anger By reducing anxiety By setting realistic outcomes By fostering self-awareness

By fostering self-awareness

The nurse is caring for a 30-year-old client who was admitted yesterday with borderline personality disorder (BPD). What is the most important intervention for the nurse caring for a client with BPD? Setting limits Offering advice Being an attentive listener Encouraging group activities

Setting limits

The nurse is working with a client who talks freely about feeling depressed. During the interaction the client states, "Things will never change." What findings support the nurse's conclusion that the client is experiencing hopelessness? Select all that apply. Bouts of crying Self-destructive acts Presence of delusions Feelings of worthlessness Intense interpersonal relationships

bouts of crying Self-destructive acts feelings of worthlessness

During the intake interview at a mental health clinic, a client in withdrawal reveals to the nurse long-term, high-dose cocaine use. Which signs and symptoms support the conclusion that the client has been abusing cocaine for a prolonged time? Select all that apply. Sadness Euphoria Loss of appetite Impaired judgment Psychomotor retardation

sadness Psychomotor retardation

A client is found to have a conversion disorder. What is the typical reaction by the client to the physical symptom? Anger Apathy Anxiety Agitation

Apathy

An assistant to a dean at a local university is admitted to the psychiatric inpatient unit for assessment and treatment. The client claims to be president of the university. What type of delusion does the nurse identify? Somatic Grandiose Erotomanic Persecutory

Grandiose

A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients? Inept Eccentric Impulsive Dependent

Impulsive

A client with schizophrenia says to the nurse, "I've been here 5 days. There are five players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder? Word salad Loose association Thought blocking Delusional thinking

Loose association

Identify factors associated with an increased incidence of abuse within a family. Select all that apply. Acute illness Pregnancy Drug abuse Chronic illness Sexual orientation

Pregnancy Drug abuse Sexual orientation

Which action would the nurse think should be excluded to prevent staff from having posttraumatic stress disorder (PTSD) during a mass casualty assessment? To work less than 12 hours Encourage and motivate team members To work continuously without any breaks To discuss feelings with the team members

To work continuously without any breaks

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

"I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"

A depressed client is brought to the emergency department after taking an overdose of a sedative. After lavage the client says, "Let me die. I'm no good." What is the most appropriate response by the nurse? "Tell me why you did this." "You must have been upset to try to take your life." "Of course you're good; we'll take excellent care of you." "You've been through a rough time; let me take care of you."

"You must have been upset to try to take your life.

What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client? Contradicting the client's persecutory delusions Accepting the client's statements as the client's beliefs Medicating the client when these thoughts are expressed Redirecting the client whenever a negative topic is mentioned

Accepting the client's statements as the client's beliefs

A hospitalized psychiatric client with the diagnosis of histrionic personality disorder demands a sleeping pill before going to bed. After being refused the sleeping pill, the client throws a book at the nurse. What does the nurse recognize this behavior to be? Exploitive Acting out Manipulative Reaction formation

Acting out

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs? Allow the client to undress when ready to help maintain identity. Provide two outfits and help the client decide which one to wear. Explain that clean clothes will look more attractive and increase self-esteem. Get assistance and remove the clothing to meet the client's basic hygiene needs.

Allow the client to undress when ready to help maintain identity.

The nurse discusses basic neurotransmitter theory with students during their mental health rotation. Education will be deemed successful if students identify that a decrease in gamma-aminobutyric acid (GABA) will result in which outcome? Anxiety Depression Paranoid schizophrenia Dementia of the Alzheimer type

Anxiety

What is the nurse's primary outcome goal when managing the care of a client diagnosed with generalized anxiety disorder (GAD)? Creating an anxiety-free environment for the client Assisting the client with the development of healthy, adaptive coping mechanisms Identifying the triggers that produce anxiety in the client Providing reinforcement that the client's anxiety issues can be eliminated

Assisting the client with the development of healthy, adaptive coping mechanisms

An adolescent is admitted to the psychiatric service in stable physical condition with the diagnosis of anorexia nervosa. The adolescent has lost 20 lb (9.1 kg) in 6 weeks and is very thin but is excessively concerned about being overweight. What is the most important initial nursing intervention? Complimenting the physical appearance of the adolescent Explaining the value of adequate nutrition to the adolescent Exploring the reasons that the adolescent does not want to eat Attempting to establish a trusting relationship with the adolescent

Attempting to establish a trusting relationship with the adolescent

A child with attention deficit-hyperactivity disorder (ADHD) often becomes frustrated and loses control. A nurse uses a variety of techniques to manage disruptive behaviors. List the following interventions in order, from the least invasive to the most invasive. 1. Placing the child in a time-out 2. Using a signal to remind the child to use self-control 3. Monitoring behavior for cues of rising anxiety 4. Avoiding situations that usually precipitate frustration 5. Refocusing the child's behavior with a specific directive

Avoiding situations that usually precipitate frustration Monitoring behavior for cues of rising anxiety .Using a signal to remind the child to use self-control .Refocusing the child's behavior with a specific directive .Placing the child in a time-out

A client with schizophrenia uses the word "worriation" when talking with the nurse. How should the nurse respond? By correcting the pronunciation of the word By asking for clarification of the word's meaning By ignoring its use while interacting with the client By telling the client to use words that everyone can understand

By asking for clarification of the word's meaning

Which drug causes euphoria and hallucinations in an addicted adolescent but does not show any ill effects when withdrawn abruptly? Heroine Cocaine Cannabis Morphine

Cannabis

A mental health nurse is working on a unit where many clients have the diagnosis of alcoholism. Which defense mechanism does the nurse identify as most commonly used by clients who are alcoholics? Denial Projection Displacement Compensation

Denial

People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? Select all that apply. Guilt Denial Altruism Confusion Helplessness

Denial Confusion Helplessness

A client is found to have a mood disorder, hypomanic episode. To support the diagnosis, the nurse should identify the signs and symptoms associated with this disorder. Select all that apply. Distractibility Flight of ideas Low self-esteem Increased need for sleep Psychomotor retardation

Distractibility Flight of ideas

The nurse manager is evaluating a primary nurse who is working with a hospitalized adolescent client with the diagnosis of conduct disorder. Which intervention by the primary nurse should the nurse manager question? Discussing unit rules Giving the client choices Explaining the consequences of not following unit regulations Encouraging the verbalization of negative feelings toward others

Encouraging the verbalization of negative feelings toward others

A 6-year-old child with autism is nonverbal and makes limited eye contact. What should the nurse do initially to promote social interaction? Encourage the child to sing songs with the nurse. Engage in parallel play while sitting next to the child. Provide opportunities for the child to play with other children. Use therapeutic holding when the child does not respond to verbal interactions.

Engage in parallel play while sitting next to the child.

A client has the diagnosis of histrionic personality disorder. Which behavior should the nurse expect when assessing this client? Boastful and egotistical Rigid and perfectionistic Extroverted and dramatic Aggressive and manipulative

Extroverted and dramatic

A college student is brought to the mental health clinic by parents with a diagnosis of borderline personality disorder. Which factors in the client's history support this diagnosis? Select all that apply. Impulsiveness Lability of mood Ritualistic behavior Psychomotor retardation Self-destructive behavior

Impulsiveness Lability of mood Self-destructive behavior

The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the mostappropriate response by the nurse? Holding the client by the arm to keep the client from leaving the group Instructing the client in a loud voice to get on the bus so the group can go home Informing the client in a matter-of-fact tone that everyone must remain with the group Telling the client that the baseball player will not be permitted to give anyone an autograph

Informing the client in a matter-of-fact tone that everyone must remain with the group

A school nurse is asked to present an educational program on attention deficit-hyperactivity disorder (ADHD) to the staff of an elementary school. What should the nurse emphasize about this disorder? It becomes evident before 4 years of age. Its major clinical manifestation is easy distractibility. It occurs more frequently in lower socioeconomic groups. It causes affected children to sleep more than unaffected children.

Its major clinical manifestation is easy distractibility.

A nurse is developing a care plan for a client with obsessive-compulsive behavior disorder. Which nursing intervention will most likely increase the client's anxiety? Helping the client understand the nature of the anxiety Limiting the client's ritualistic acts to three times a day Involving the client in establishing the therapeutic plan Providing the client with a nonjudgmental environment

Limiting the client's ritualistic acts to three times a day

The nurse provides care for a client with a long history of alcohol abuse. Which drug does the nurse anticipate will be prescribed for the client to prevent symptoms of withdrawal? Lorazepam Phenobarbital Chlorpromazine Methadone hydrochloride

Lorazepam

A nurse is caring for a client who is delusional and talking about people who are plotting to do harm. The staff members note that the client is pacing more than usual, and the primary nurse concludes that the client is beginning to lose control. What is the mosttherapeutic nursing intervention? Moving the client to a quiet place Urging the client to sit down for a short time Encouraging the client to use a punching bag Allowing the client to continue pacing under supervision

Moving the client to a quiet place

A nursing assistant is frequently late for work and often tells the nurse manager that although he leaves his apartment early, he is delayed by heavy traffic. What defense mechanism is being used by the nursing assistant? Undoing Repression Rationalization Overcompensation

Rationalization

A child is found to have attention deficit-hyperactivity disorder (ADHD). What strategy should the nurse teach the parents to help them cope with this disorder? Orient the child to reality. Reward appropriate conduct. Suppress feelings of frustration. Use restraints when behavior is out of control.

Reward appropriate conduct.

A client with the diagnosis of bipolar disorder, manic episode, attends a mental health day treatment program. What supervised activity will be most therapeutic for this client during the early phase of treatment? Doing a needlepoint project Joining a brief swimming competition Walking around the facility with a nurse Playing a board game with another client

Walking around the facility with a nurse

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning? "The client claims to feel fat despite being underweight." "The client experiences recurrent episodes of binge eating." "The client exhibits intense fear of gaining weight although underweight." "The client refuses to maintain body weight over a minimal ideal body weight."

"The client experiences recurrent episodes of binge eating."

A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After assessing the client, what should the nurse ask? "Exactly when did the weakness begin?" "Is this similar to what you usually experience?" "Would you like to leave the group for a while?" "What emotion were you feeling before you felt the weakness?"

"What emotion were you feeling before you felt the weakness?"

A client is admitted to the hospital with ascites. The client reports drinking a quart (liter) of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? "When was your last drink of vodka?" "What prompts your drinking episodes?" "Do you also eat when you drink?" "Why do you mix the vodka with orange juice?"

"When was your last drink of vodka?"

Place these crisis interventions in the order the nurse would implement them for a client experiencing escalating levels of anxiety . .Attempt to identify the source of the anxiety .Provide firm but kind directions. .Encourage deep breathing and relaxation techniques. .Place the client in restraints if deemed dangerous.

.Attempt to identify the source of the anxiety .Encourage deep breathing and relaxation techniques. .Provide firm but kind directions. .Place the client in restraints if deemed dangerous.

A client with obsessive-compulsive disorder has become immobilized by elaborate handwashing and walking rituals. The nurse recalls that the basis of obsessive-compulsive disorder is often what feelings? Anxiety and guilt Anger and hostility Embarrassment and shame Hopelessness and powerlessness

Anxiety and guilt

A client with a borderline personality disorder is admitted to the mental health unit. What should the nurse do to maintain a therapeutic relationship with the client? Provide an unstructured environment to promote self-expression. Be firm, consistent, and understanding and focus on specific target behaviors. Use an authoritarian approach, because this type of client needs to learn to conform to the rules of society. Record but ignore marked shifts in mood, suicidal threats, and temper displays, because these last only a few hours.

Be firm, consistent, and understanding and focus on specific target behaviors.

A nurse who is working on a psychiatric unit notes that a client with schizophrenia is beginning to pace around the lounge while glaring at other clients. How should the nurse respond to this behavior? By pointing out the behavior to the client By walking with the client to a quiet area on the unit By suggesting that the client go to the gym to work out By arranging for an additional staff member to be present in the vicinity of the client

By walking with the client to a quiet area on the unit

A client is found to have a borderline personality disorder. What is a realistic initial intervention for this client? Establishing clear boundaries Exploring job possibilities with the nurse Initiating a discussion of feelings of being victimized Spending 1 hour twice a day discussing problems with the nurse

Establishing clear boundaries

The nurse plans to teach a client to use healthier coping behaviors that can consciously be used to reduce anxiety. What might these include? Eating, dissociation, fantasy Sublimation, fantasy, rationalization Exercise, talking to friends, suppression Repression, intellectualization, smoking

Exercise, talking to friends, suppression

A client who was involved in a near-fatal automobile collision arrives at the mental health clinic with complaints of insomnia, anxiety, and flashbacks. The nurse determines that the client is experiencing symptoms of crisis. What is the nurse's initial intervention? Focusing on the present Identifying past stressors Discussing a referral for psychotherapy Exploring the client's history of mental health problems

Focusing on the present

A 3-year-old client has been admitted to the pediatric unit for dehydration resulting from nausea and vomiting. The parents tell the nurse the child has autism and resists being held, acts as if deaf, frequently mimics words or phrases, and is not toilet trained. What is most important for the nurse to do when planning care for this child? Provide a structured routine for the child to follow while in the hospital Involve the parents in the plan of care and encourage their being with the child as much as possible Place the child in a semiprivate room near the nurses' station where activities can be seen and heard Assign different personnel to the child until it is determined which staff members the child relates to best, and then use them to enhance the nurse-child relationship

Involve the parents in the plan of care and encourage their being with the child as much as possible

An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms? Delusions Hallucinations Posttraumatic stress disorder (PTSD) Obsessive-compulsive disorder (OCD)

Posttraumatic stress disorder (PTSD)

An adolescent with the diagnosis of anorexia nervosa is admitted to the psychiatric unit of a local hospital. What should the nurse include in the plan of care? Limited opportunities for decision-making Provision of supervision during and after mealtimes Arrangements for a physical exercise program and time to complete it A request that parents keep their visits to a minimum early in treatment

Provision of supervision during and after mealtimes

After taking a typical antipsychotic medication for 1 month, a client reports, "I feel stiff, my hands shake, and I started drooling." The picture illustrates the client's physical status observed by the nurse in the clinic. What extrapyramidal side effect does the nurse conclude that the client has developed? Dystonia Akathisia Tardive dyskinesia Pseudoparkinsonism

Pseudoparkinsonism

A client with a conversion disorder is experiencing paralysis of a leg. What should the nurse expect this client to do? Experience a spread of the paralysis to other body parts Require continuous psychiatric treatment to maintain independent function Recover use of the affected leg but, under stress, to again experience these symptoms Follow an unpredictable emotional course in the future, depending on exposure to stress

Recover use of the affected leg but, under stress, to again experience these symptoms

A nurse is caring for a client with a somatoform disorder. What should the nurse anticipate that this client will do? Write down conversations to facilitate the recall of information. Monopolize conversations about the anxiety being experienced. Redirect the conversation with the nurse to physical symptoms. Start a conversation asking the nurse to recommend palliative care.

Redirect the conversation with the nurse to physical symptoms.

A client with the diagnosis of schizophrenia refuses to get out of bed and becomes upset. What is the nurse's initial therapeutic response? Requiring the client to get out of bed at once Allowing the client to stay in bed for a while Staying at the bedside until the client calms down Giving the prescribed as-needed tranquilizer to the client

Staying at the bedside until the client calms down

A depressed client reports feelings of helplessness and hopelessness. The nurse hears the client tell another client, "I'll be feeling better soon." In light of this comment, what factor should the nurse assess? Ability to sleep Suicidal thinking Current feelings of depression Subjective ideas about treatment progress

Suicidal thinking

A nurse educates the mother of a four-year-old child about sexual abuse. What behavioral finding explained by the nurse signifies that the child may be a victim of child abuse? The child may attempt suicide. The child may be verbally aggressive. The child may have stress-related concerns. The child may show fear of certain people or places.

The child may show fear of certain people or places.

A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply. The client will become capable of part-time employment. The client will effectively express emotional and physical needs. The client will demonstrate wellness reflective of physical potential. The client will demonstrate an understanding of the mental health disorder. The client will recognize the issues most important to managing this disorder.

The client will effectively express emotional and physical needs. The client will demonstrate an understanding of the mental health disorder. The client will recognize the issues most important to managing this disorder.

A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. What defense mechanism does the nurse know is being utilized by this woman? Projection Regression Repression Displacement

Repression

A client with schizophrenia is observed sitting alone quietly talking. The client appears sad and is tearful. Place the following nursing assessment questions in the appropriate order to best ensure client safety. "What are the voices telling you?" "Are you hearing voices?" "What do you usually do to make the voices stop?" "Are you thinking about hurting yourself or someone else?"

"Are you hearing voices?" "What are the voices telling you?" "Are you thinking about hurting yourself or someone else? "What do you usually do to make the voices stop?"

A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. Which statement best describes how clients with obsessive-compulsive behavior view this disorder? "I know there's no reason to do these things, but I can't help myself." "I don't know why everyone's upset with me—I'm doing nothing wrong." "The things I do take a little time, but they make me a productive person." "The devil makes me do it—it's not my fault that I constantly act this way."

"I know there's no reason to do these things, but I can't help myself."

While speaking with a client with schizophrenia, the nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse? "You aren't making any sense; let's talk about something else." "You're so confused; I can't understand what you're saying to me." "Why don't you take a rest? We can talk again later this afternoon." "I'd like to understand what you're saying, but I'm having difficulty following you."

"I'd like to understand what you're saying, but I'm having difficulty following you."

Schizophrenia is associated with both positive and negative symptoms. While assessing a client with schizophrenia, the nurse notes that the client is experiencing positive symptoms; what does the nurse observe that leads to this conclusion? Select all that apply. Poverty of speech Agitated behavior Lack of motivation Delusions of grandeur Auditory hallucinations

Agitated behavior Delusions of grandeur Auditory hallucinations

When caring for a newly admitted depressed client, a nurse arranges for a staff member to remain with the client continuously. What information supports the nurse's decision to institute this precaution? Select all that apply. Refusal to eat any food Inability to concentrate Agitated pacing in the hall History of suicide attempts Statements that life is not worth living

Agitated pacing in the hall History of suicide attempts Statements that life is not worth living

client is admitted to the psychiatric unit for severe depression with the potential for suicide. What is the most therapeutic nursing intervention when the client becomes more energized and communicative? Continuing to assess the client at regular intervals Encouraging the client to participate in group activities Giving the client more autonomy to decide about privilege Starting to teach the client about medications in preparation for discharge

Continuing to assess the client at regular intervals

The nurse is caring for a client with a somatoform disorder, conversion-type paralysis. What is the best nursing approach? Discussing topics other than the paralysis Explaining the reason for the physical problem Asking how the client feels about being paralyzed Encouraging the client to slowly walk around the room

Discussing topics other than the paralysis

A client is admitted with conversion disorder. What is the primary nursing intervention? Talking about the physical problems Exploring ways to verbalize feelings Explaining how stress caused the physical symptoms Focusing on the client's concerns regarding the symptoms

Exploring ways to verbalize feelings

A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. What does the nurse remember is the main reason that clients use self-mutilation? Control others Express anger or frustration Convey feelings of autonomy Manipulate family and friends

Express anger or frustration

A client comes to the mental health clinic for treatment of a phobia of large dogs. What should the nurse anticipate that this client will demonstrate? Fear of discussing the phobia Resentment toward the feared object Inadequate impulse control when threatened Distortion of reality when discussing the phobia

Fear of discussing the phobia

What is the function of limbic system? Influence emotional behavior Regulate autonomic functions Facilitate automatic movements Relay sensory and motor inputs for cerebrum

Influence emotional behavior

For what clinical manifestations should the nurse assess a client during the first few hours of the alcohol withdrawal? Select all that apply. Irritability Tachycardia Hallucinations Increasing anxiety Profuse diaphoresis

Irritability Tachycardia Increasing anxiety

A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? Select all that apply. Lack of appetite Depressed mood Repetitive activities Self-injurious behaviors Lack of communication with others

Repetitive activities Self-injurious behaviors Lack of communication with others

A child has been hospitalized repeatedly for illnesses of unknown origin. Finally the primary healthcare provider makes the diagnosis of Munchausen syndrome by proxy. What is the most therapeutic approach by the nurse to the involved parent? Confrontation Open communication Health teaching about child-rearing Validation of the child's physical status

Open communication

A client is admitted with bipolar disorder, depressed episode. The nursing history indicates a progressive increase in depression over the past month. What should the nurse expect the client to display? Elated affect related to reaction formation Loose associations related to a thought disorder Physical exhaustion related to decreased physical activity Paucity of verbal expression related to slowed thought processes

Paucity of verbal expression related to slowed thought processes

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on? Disturbed self-esteem Potential for self-harm Dysfunctional verbal communication Impaired perception of environmental stimuli

Potential for self-harm

A client with paranoid schizophrenia wraps the legs in toilet paper, believing that this will provide protection from deadly germs contaminating the floor. What is the best nursing intervention? Limiting the client's access to toilet paper Providing the client with antimicrobial soap Explaining to the client why this action is ineffective Talking with the client about anxiety that focuses on health

Talking with the client about anxiety that focuses on health

A client who was in an automobile accident is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which signs and symptoms should the nurse connect to alcohol withdrawal? Select all that apply. Fatigue Anxiety Runny nose Diaphoresis Psychomotor agitation

anxiety Diaphoresis Psychomotor agitation

A nurse is caring for an angry, hostile client with the diagnosis of borderline personality disorder. What is probably an issue for this client? Low self-esteem Inability to test reality Disturbed energy field Ineffective verbal communication

Low self-esteem

After a week on the mental health unit, a client with the diagnosis of paranoid schizophrenia continues to say, "They're trying to kill me. They all are." What is the best response by the nurse? "We're here to protect you." "No one wants to hurt anyone." "You're having very frightening thoughts." "Tell me more about their wanting to kill you."

"You're having very frightening thoughts."

A depressed client cries when the family does not visit. What is the most therapeutic response by the nurse? "It's difficult to realize that no one cares about you." "Your family didn't visit, and now you're feeling rejected." "It's terrible to have such negative thoughts about yourself." "Your family members work—that's why they don't visit you."

"Your family didn't visit, and now you're feeling rejected."

A client with cyclothymic disorder with hypomanic symptoms is admitted to the psychiatric unit. The client has progressively lost weight and does not take the time to eat the provided food. How can the nurse best respond to this situation? By providing a tray in the client's room By assuring the client that food is deserved By ordering food that the client can hold and eat while moving around By pointing out that the client must replace the energy burned by eating

By ordering food that the client can hold and eat while moving around

What is most important for the nurse to do when caring for a client who is experiencing a paranoid delusion? Touch the client's arm gently to convey concern. Maintain eye contact when talking with the client. Attempt to disprove the client's delusional thoughts. Speak softly when talking with others near the client.

Maintain eye contact when talking with the client.

While assessing an older adult during a regular health checkup, a nurse finds signs of elder abuse. Which physical findings would further confirm the nurse's suspicion? Select all that apply. Presence of hyoid bone damage Presence of cognitive impairment Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)

Presence of burns from cigarettes Presence of bed sores. Presence of unexplained bruises on the wrist(s)

A 23-year-old client is admitted to a psychiatric unit after several episodes of uncontrolled rage at her parents' home, and borderline personality disorder is diagnosed. While watching a television newscast describing an incident of violence in the home, the client says, "People like that need to be put away before they kill someone." The nurse concludes that the client is using what? Denial Projection Introjection Sublimation

Projection

Which nursing intervention is indicated for a client with an anxiety disorder? Encouraging suppression of anger by the client Promoting verbalization of feelings by the client Limiting involvement of the client's family during the acute phase Explaining why the client should accept the psychological factors that are precipitating the anxiety

Promoting verbalization of feelings by the client

What should the nurse include when developing a plan of care for a client in the manic phase of bipolar disorder? Focusing the client's interest in reality Encouraging the client to talk as much as needed Persuading the client to complete any task that has been started Redirecting the client's excess energy to more constructive activities

Redirecting the client's excess energy to more constructive activitie

The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement? Teaching the client about normal newborn care Ensuring adequate bonding time with the infant Giving the client time and space to express her feelings Referring the client to a psychiatric healthcare provider as prescribed

Referring the client to a psychiatric healthcare provider as prescribed

A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member? Regression Repression Dissociation Displacement

Regression

A client with posttraumatic stress disorder is admitted for depression and medication management. On the second night of hospitalization, the client awakens from a nightmare and begins threatening to strangle the roommate for "coming at me with that knife you've got hidden." Place the following nursing interventions in the appropriate order to best ensure client and milieu safety. Institute homicide precautions at night Remove roommate from the room Arrange for a private room the near nurses' station Remain with the client until the agitation is under control Arrange for antianxiety medication to be administered as prescribed

Remove roommate from the room Remain with the client until the agitation is under control Arrange for antianxiety medication to be administered as prescribed Arrange for a private room the near nurses' station Institute homicide precautions at night

A client who has been experiencing excessive stress is hospitalized because of an inability to walk. After a physiologic cause for the problem is ruled out, a diagnosis of somatoform disorder, conversion type, is made. What does the nurse conclude is the cause of the client's paralysis? Nondisabling illness Way to get attention Loss of contact with reality Result of intrapsychic conflict

Result of intrapsychic conflict

When a recently hospitalized client has a tentative diagnosis of opioid addiction, the nurse should assess the client for signs and symptoms related to opioid withdrawal. List them in the order that they will occur as the client progresses through withdrawal. Muscle twitching Runny nose and irritability Return of appetite Flulike syndromes

Runny nose and irritability .Muscle twitching .Flulike syndromes .Return of appetite

When a nurse enters a room to administer an oral medication to an agitated and angry client with schizophrenia, paranoid type, the client shouts, "Get out of here!" What is the most therapeutic response? Stating, "You must take your medicine now." Saying, "I'll be back in a few minutes so we can talk." Explaining why it is necessary to take the medication Withholding the medication before notifying the primary healthcare provider

Saying, "I'll be back in a few minutes so we can talk."

A client in an acute mental health unit appears severely depressed. The client does not initiate conversations or perform personal care. Questions are answered with a barely audible one- or two-word response. The nurse sits with the client and makes no demands. On what premise is the nurse's intervention for this client based? Nurses are required to spend time with assigned clients. Environmental stimulation helps depressed clients feel more worthwhile. Nurses are expected to initiate one-on-one interactions on an acute care unit. Spending time with depressed clients demonstrates that they are worthy of attention.

Spending time with depressed clients demonstrates that they are worthy of attention.

A nurse who has been working with a client with the diagnosis of borderline personality disorder is leaving for vacation in 2 weeks and tells the client. What client response indicates to the nurse that the client's ability to maintain a more mature relationship has progressed? States, "I need to get well enough by then so I can leave, too." Wishes the nurse a safe trip and offers thanks for the help received Responds, "I guess you leaving is just another loss I'll have to adjust to." Informs the nurse that there is no sense in waiting and that the relationship can be ended today

Wishes the nurse a safe trip and offers thanks for the help received

A client with a borderline personality disorder receives the wrong meal tray for lunch and angrily states, "The next time I see the dietician, I'm going to throw this tray at her!" What is the most appropriate response by the nurse? Suggesting that the client calm down and explaining that sometimes trays get mixed up Informing the client that the behavior is inappropriate and sending the client out of the dining room Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietician is unacceptable behavior Informing the client that throwing the tray at the dietician will make matters worse and may result in the client being placed in seclusion

Telling the client that it is frustrating not to get the correct tray but that throwing the tray at the dietician is unacceptable behavior

A client with paranoid schizophrenia tells the nurse, "My neighbors are spying on me because they want to rob me and take money." While hospitalized, the client complains of being poisoned by the food and of being given the wrong medication. The nurse evaluates the client's response to medications and therapy. Which assessment finding leads the nurse to conclude that the client's reality testing has improved? The client eats the food provided on the hospital tray. The client discusses the discharge plans with the staff. The client questions each medication when it is administered. The client asks permission to make phone calls to the hospital administration.

The client eats the food provided on the hospital tray.

A client with a dissociative identity disorder is to be discharged after a 2-week hospitalization. What does the nurse, evaluating the effectiveness of the short-term therapy, expect the client to verbalize? The ability to deal openly with feelings That many of the personalities can be ignored The need for long-term outpatient psychotherapy That the personalities serve no protective purpose

The need for long-term outpatient psychotherapy

A nurse reminds a client that it is time for group therapy. The client responds by shouting, "You're always telling me what to do, just like my father!" What defense mechanism is the client using? Regression Transference Reaction formation Cognitive distortion

Transference

A secretary in a home health agency gossips about coworkers and then writes them notes to tell them how valuable they are to the organization and how much she likes working with them. What defense mechanism is being used by the secretary? Denial Undoing Displacement Intellectualization

Undoing