Evolve Psych
A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing?
Delusion of grandeur A delusion of grandeur is a fixed false belief that the person is a powerful, important person.
A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing?
Delusion of persecution
A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of:
Dependence versus independence
A female client is admitted to the hospital after attempting suicide. She reveals that her desire for sex has diminished since her child's birth 3 years ago. What is most directly related to the client's loss of interest in sex?
Depression
The nurse determines that the therapy that has the highest success rate for people with phobias is:
Desensitization involving relaxation techniques
A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? (Select all that apply.)
Impulsivity Panic attacks Unemployment Substance abuse
A client with a history of depression tells the nurse about planning to retire from work next year. What common dynamic about retirement should the nurse consider when interacting with this client?
It is a developmental task of significance.
At a staff meeting, the question of a staff nurse's returning to work after completing a drug rehabilitation program is discussed. What is the most therapeutic way for the staff to handle the nurse's return?
Offering the nurse support in a straightforward manner
A client with schizophrenia reports having ongoing auditory hallucinations that he describes as "voices telling me that I'm a bad person" to the nurse. What is the best response by the nurse?
"Try to ignore the voices."
A nurse is caring for a client with the diagnosis of dementia. What should the nurse ask the client to best ascertain orientation to place?
"Where are you?"
A nurse recalls that in a conversion disorder, pseudoneurological symptoms such as paralysis or blindness:
Are generally necessary for the client to cope with a stressful situation
A nurse is working in a daycare center with clients who have cognitive impairments. What does the nurse expect of a client in the middle stages of dementia?
Able to recall events from the past
What should the nurse identify as the foremost basis for the development of schizophrenia?
Biological perspective
A client describes his delusions in minute detail to the nurse. How should the nurse respond?
By changing the topic to reality-based events
What characteristic of anxiety is associated with a diagnosis of conversion disorder?
Relieved by the symptom
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.)
Repetitive activities Self-injurious behaviors Lack of communication with others
A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug?
he blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks. Fluoxetine (Prozac) does not produce an immediate effect; nursing measures must be continued to reduce the risk for suicide. Consuming milk and crackers to help prevent hyperacidity and discomfort is not necessary. Avoiding cheese, pickled herring, and wine is a precaution taken with the monoamine oxidase inhibitors. Weekly blood level checks are not necessary with Fluoxetine.
When answering questions from the family of a client with Alzheimer disease the nurse explains that the disease:
Is a slow, relentless deterioration of the mind
A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test?
"Have you ever felt bad or guilty about your drinking?"
A client with bipolar disorder is exhibiting accelerating activity and flight of ideas. What is the best nursing intervention to limit the accelerating manic behavior?
Engaging the client in conversation while walking slowly in the hall
What is the best nursing intervention to encourage a socially withdrawn client to talk?
Focusing on nonthreatening subjects
What should the nurse do to achieve a primary objective of providing a therapeutic daycare environment for a client who is withdrawn and reclusive?
Foster a trusting relationship
Which suicide method is the least lethal(치명적인)?
Ingesting pills
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?
Suspicious(의혹을 갖는, 수상쩍어 하는) feelings
A hyperactive 9-year-old child with a history of attention deficit-hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety?
Talking with the child about the importance of using a seat belt
What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants?
What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants?
What is most important for the nurse to do when caring for a client who is in an alcohol detoxification program?
Accept the client as a worthwhile person
When working with a client who is in an alcohol detoxification program, it is most important for the nurse to:
Address the client's holistic needs
A nurse is caring for a client with dementia. Which clinical manifestations are expected? (Select all that apply.)
Agitation Short attention span Disordered reasoning Impaired motor activities
A client who is addicted to opioids undergoes emergency surgery. During the postoperative period the health care provider decreases the previously prescribed methadone dosage. For what clinical manifestations should the nurse monitor the client?
Agitation and attempts to escape from the hospital When the methadone dosage is reduced, a craving for opioids may occur, anxiety will increase, and the client will become agitated and may try to leave the hospital to secure drugs.
A nurse is planning care for a depressed client. Which approach is most therapeutic?
Allowing the client time to complete activities
A nurse is caring for a client who has been hospitalized for alcohol withdrawal. The client decides to attend an Alcoholics Anonymous meeting. What is a basic principle of this group?
Amends must be made to each person who has been harmed. The eighth step of the 12 steps of Alcoholics Anonymous (AA) is "Made a list of all persons we had harmed, and became willing to make amends to them all."
What are the "four A's" for which nurses should evaluate clients with suspected Alzheimer disease?
Amnesia, apraxia(운동 불능), agnosia(인지불능증), aphasia(연하 불능)
In conjunction with which classification of medication are trihexyphenidyl, biperiden (Akineton), and benztropine (Cogentin) often prescribed?
Antipsychotics Antipsychotics are used to control the extrapyramidal (parkinsonian) symptoms that often develop as a side effect of antipsychotic therapy. There is no documented use of anxiolytics with antianxiety agents because they do not have extrapyramidal side effects. Barbiturates do not have extrapyramidal side effects that respond to these drugs. Antiparkinsonian drugs usually are not prescribed in conjunction with antidepressants because antidepressants do not cause parkinsonian symptoms.
A client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. Which finding should the nurse consider consistent with this diagnosis?
Appearing composed 침착한, 차분한
A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request?
Autonomy Autonomy is the ethical principle of respecting the independence and right to self-determination of others. In this situation the nurse focuses on helping the client make a choice. Justice is the ethical principle that requires all people to be treated fairly, regardless of sex, age, religion, diagnosis, marital status, or socioeconomic level. Veracity is the ethical principle that requires truthfulness. Beneficence is the duty to do good and promote the welfare of others.
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 Feelings of worthlessness
What should a nurse recognize that a client who uses the defense mechanism of sublimation is doing?
Channeling unacceptable impulses into socially approved behavior The individual using sublimation attempts to fulfill desires by selecting a socially acceptable activity rather than one that is socially unacceptable.
A client has been prescribed chlorpromazine (Thorazine) for the management of positive symptoms of schizophrenia. When the client reports difficulty sustaining an erection, the nurse:
Consults with his provider regarding alternative medication therapies
Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? (Select all that apply.)
Diaphoresis Hyperrigidity Hyperthermia as a result of dopamine blockade in the hypothalamus.
A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that apply.)
Diaphoresis Tachycardia Hypertension
A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place the following interventions in priority order, from the least to the most restrictive.
Diversional activities Limit-setting Medication administration Seclusion Restraints
A client's history demonstrates a pervasive pattern of unstable and intense relationships, impulsiveness, inappropriate anger, manipulation, offensive behavior, and hostility. The admitting diagnosis is borderline personality disorder. What does the nurse anticipate that this client may attempt to do?
Divide the staff into opposing factions to gain self-esteem
A parent of a 17-year-old girl who has been hospitalized for extremely disturbed acting-out behavior leaves a gift for the daughter but says, "I'm too busy to visit today." The daughter becomes upset and tearful after being given the message and opening the package. What does the nurse conclude that the parent's actions represent?
Double-bind message
A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD?
Early onset, before 36 months of age
A nurse recalls that language development in the autistic child resembles:
Echolalia The autistic child repeats sounds or words spoken by others.
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate:
Flight of ideas
A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed?
Fluvoxamine (Luvox)
A client is admitted to the psychiatric hospital after many self-inflicted nonlethal injuries over the preceding month. Of which level of suicidal behavior is the client's behavior reflective?
Gestures
A nurse uses behavior modification to foster toilet-training efforts in a cognitively impaired child. What reward should the nurse provide to reinforce appropriate use of the toilet?
Hug with praise
A client tells the nurse, "That man on the television is talking only to me." What should the nurse document that the client is exhibiting?
Idea of reference An idea of reference, also called a delusion of reference, is a fixed, false personal belief that public events and people are connected directly to the client. An illusion is a misinterpretation of a sensory stimulus. A hallucination is a perceived experience that occurs in the absence of an actual sensory stimulus. Autistic thinking is a distortion in the thought process that is associated with schizophrenic disorders.
A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?
Impulsive
A 4-year-old child is found to have attention deficit-hyperactivity disorder (ADHD). What information about the child's behavior should the nurse expect when obtaining a health history from the parents? (Select all that apply.)
Impulsiveness Excessive talking Playing video games for hours on end Failure to follow through or finish tasks
A college student is brought to the mental health clinic by his parents. The diagnosis is borderline personality disorder. Which factors in the client's history support this diagnosis? (Select all that apply.)
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 most appropriate response by the nurse?
Informing the client in a matter-of-fact tone that everyone must remain with the group
A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?
Intramuscular injections of thiamine Thiamine is a coenzyme necessary for the production of energy from glucose. If thiamine is not present in adequate amounts, nerve activity is diminished and damage or degeneration of myelin sheaths occurs.
An adult is found to have schizotypal personality disorder. How should a nurse describe the client's behavior?
Introverted and emotionally withdrawn
An agitated, acting-out, delusional client is receiving large doses of haloperidol (Haldol), and the nurse is concerned because this drug can produce untoward side effects. Which clinical manifestations should alert the nurse to stop the drug immediately? (Select all that apply.)
Jaundice Tachycardia
A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? (Select all that apply.)
Leaving the bedroom when unable to sleep Exercising in the afternoon rather than in the evening Counting backward from 100 to 0 when his mind is racing
A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?
Malingering
A client's admitting history indicates signs of akathisia. What clinical finding should the nurse expect when observing for this condition?
Motor restlessness
A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should:
Refer the mother to the psychiatrist
What should the nurse do when interacting with an adolescent client with the diagnosis of anorexia nervosa?
Set limits
A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?
Somatic delusion
In which situation is the use of seclusion contraindicated?
The client has expressed severe suicidal thoughts. Seclusion of a person experiencing severe suicidal thoughts places the client at risk for self-harm and so would be contraindicated. When the criteria for seclusion have been met, seclusion would not be contraindicated for someone who wants to be secluded, has been voluntarily admitted, or showed minimal improvement despite being secluded before.
What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness?
The need to follow the prescribed medication regimen Following the prescribed medication regimen is important because side effects and denial of illness may cause clients to stop taking their medications; this is a common cause of relapse or recurrence of symptoms.
A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? (Select all that apply.)
Tremors Anorexia
According to Erikson, a child's increased vulnerability to anxiety in response to separation or pending separation from significant others results from failure to complete a developmental stage. What does the nurse call this stage?
Trust Without the development of trust, the child has little confidence that the significant other will return; separation is considered abandonment by the child. Without identity, the individual will have a problem forming a social role and a sense of self; this results in identity diffusion and confusion. Without initiative, the individual will experience the development of guilt and feelings of inadequacy. Without autonomy, the individual has little self-confidence, develops a deep sense of shame and doubt, and learns to expect defeat.
A nurse is caring for a client with antisocial personality disorder. What client characteristic should the nurse consider when formulating a plan of care?
Usually is unable to postpone gratification(희열) Individuals with antisocial personality disorder tend to be self-centered and impulsive. They lack judgment and self-control and are unable to postpone gratification. Generally they do not suffer from anxiety. These individuals believe that the rules do not apply to them, and they do not profit from their mistakes. These people are too self-centered to have a sense of responsibility to anyone.
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? (Select all that apply.)
Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress
A client receiving the medication buspirone hydrochloride (Buspar) is admitted to the hospital with the diagnosis of possible hepatitis. The nurse identifies that the client's sclerae look yellow. What should be the nurse's initial action?
Withhold the medication The medication should be stopped immediately because jaundice indicates possible liver damage, which prolongs elimination of the drug and may result in toxic accumulation. Milk does not change the effect of the drug. The drug must be stopped, not reduced. The drug is available only in an oral form; in addition, the route of administration will not influence the occurrence of toxic accumulation.
Which client statement supports the diagnosis of somatic delusions?
"My heart stopped beating 3 days ago, and now my lungs are rotting away."
A child with attention deficit-hyperactivity disorder (ADHD) often becomes frustrated and loses control. A nurse uses a variety of graduated techniques to manage disruptive behaviors. List the following interventions in order, from the least invasive to the most invasive.
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 3-year-old child is found to have autism. Which behaviors should the nurse expect when observing this child? (Select all that apply.)
Avoids eye-to-eye contact Performs repetitive activities
During an interview of a client with a diagnosis of bipolar I disorder, manic episode, the nurse expects the client to demonstrate:
Flight of ideas Flight of ideas is a fragmented, pressured, nonsequential pattern of speech typically used during a manic episode.
A client with schizophrenia is experiencing auditory hallucinations. A nurse makes the following statements when interacting with this client. Place these statements in the order in which they should be made.
"Hearing voices must be frightening." "The voices you hear are part of your illness." "I don't hear any voices." "Come with me for a walk." "Let's play cards with another client in the recreation room."
A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?
"How will you manage the next time your problems start piling up?"
A nurse approaches a depressed client who is sitting alone in the dayroom. What is best for the nurse to say to the client?
"I'll be sitting with you for a while today."
During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be?
"Let's discuss this concern a little more."
A client is found to have paranoid schizophrenia, and the practitioner prescribes a typical antipsychotic medication. After a 1-month hospitalization the client is discharged home with instructions to continue the antipsychotic and a referral for weekly mental health counseling. The picture illustrates the client's physical status as observed by the nurse on the client's first visit to the community mental health clinic. What extrapyramidal side effect has developed?
Akathisia Akathisia, an extrapyramidal side effect of typical antipsychotics, is motor restlessness. The client is unable to sit or stand still and feels the need to move, pace, rock, swing the legs, or tap the feet. The condition occurs within 5 to 90 days of the initiation of therapy. Dystonia is muscle spasms of the face, tongue, head, neck, jaw, or back, usually resulting in exaggerated posturing. This extrapyramidal side effect of typical antipsychotics occurs within 1 hour to 1 week of the initiation of therapy. Tardive dyskinesia is facial, ocular, oral/buccal, lingual/masticatory, and systemic movements. This extrapyramidal side effect of typical antipsychotics may occur 6 months or more after the initiation of therapy. Pseudoparkinsonism has characteristics similar to those of Parkinson's disease (e.g., shuffling gait, tremors, rigidity, bradykinesia). This extrapyramidal side effect of typical antipsychotics may occur anytime after the initiation of therapy.
The nurse recalls that the major defense mechanism used by an individual with a phobic disorder is:
Avoidance
An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." The nurse identifies the defense mechanism known as:
Denial
Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug. (Select all that apply.)
Flushing Headache Dyspepsia
Sildenafil (Viagra) is prescribed for a man with erectile dysfunction. A nurse teaches the client about common side effects of this drug. (Select all that apply.)
Flushing Headache Dyspepsia
A nurse is planning activities for a withdrawn client who is hallucinating. Which activity will be most therapeutic for the client?
Going for a walk with the nurse Going for a walk with the nurse facilitates one-on-one interaction and the development of a trusting relationship.
The nurse is caring for a client with the diagnosis of bipolar disorder, manic episode. Which clinical findings support the diagnosis? (Select all that apply.)
Grandiosity 과장, 떠벌림 Talkativeness Distractibility
A frail, depressed client who frequently paces the halls becomes physically tired from the activity. What action should the nurse take to help reduce this activity?
Have the client perform simple, repetitive tasks
An older client is transferred to a nursing home from a hospital with a diagnosis of dementia. One morning, after being in the nursing home for several days, the client is going to join a group of residents in recreational therapy. The nurse sees that the client has laid out several outfits on the bed but is still wearing nightclothes. What should the nurse do?
Help the client select appropriate attire and offer to help the client get dressed
What is the most appropriate way for the nurse to help a severely depressed adolescent client accept the realities of daily living?
Helping the client fulfill personal hygiene needs
Which feelings should a nurse anticipate a client with bulimia nervosa to report experiencing during an episode of binge eating? (Select all that apply.)
Hopelessness Powerlessness
A nurse is caring for an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?
Loosened associations and hallucinations Loosened associations and hallucinations are the primary behaviors associated with a thought disorder such as schizophrenia. Paranoid delusions and hypervigilance are more common in paranoid-type schizophrenia than in the undifferentiated type
An obviously upset client comes to the mental health clinic and, after pushing ahead of the other clients, states, "I had an argument with my daughter, and now I'm tense, and worried, and angry." What level of anxiety does the nurse determine that the client is experiencing?
Moderate The client is focused on one part of reality but is unable to grasp the total picture; this situation reflects a moderate level of anxiety.
A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The nurse determines that the client is exhibiting:
Neologism
An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using?
Projection The client is assigning to others those feelings and emotions that are unacceptable to him- or herself.
A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? (Select all that apply.)
Provide physical outlets for aggressive feelings Establish a contract regarding manipulative behavior Develop activities that provide opportunities for success
A 30-year-old female client asks the nurse to change her room, stating that she hates her roommate and can't stand to be in the same room with her. Just as she finishes speaking, her roommate enters and the client tells her she missed her and has been all over the unit looking for her. The nurse recognizes that the client is using:
Reaction formation
Unsatisfied needs create anxiety that motivates an individual to action. What should the nurse identify as the purpose for this action?
Reducing tension
A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." The nurse identifies the client's communication as a:
Reflection of depression that is causing feelings of hopelessness
What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?
Regression
An older female client is concerned about maintaining her independent living status. What initial intervention strategy is of primary importance?
Reinforcing routines and supporting her usual habits The client has been able to function well up to this time, and her usual behaviors and routines should be supported. The data presented do not show a need to get the client help with cleaning and shopping, to write down and repeat information, or to set goals and time limits for the client's visits with the nurse.
Incidences of child molestation often are revealed years later when the victim is an adult. Which defense mechanism reflects this situation?
Repression Repression is a coping mechanism in which unacceptable feelings are kept out of conscious awareness; later, under stress or anxiety, thoughts or feelings surface and come into one's conscious awareness. Isolation is the separation of a thought from a feeling tone. Regression is the use of an unconscious coping mechanism through which a person avoids anxiety by returning to an earlier, more satisfying, or comfortable time in life. Introjection is the integration of the beliefs and values of another into one's own ego structure.
A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified (autistic disorder). What should the nurse consider most unusual for the child to demonstrate?
Responsiveness민감성 to the parents
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?
Reward appropriate conduct
The nurse interviews a young female client with anorexia nervosa to obtain information for the nursing history. What will the client's history most likely reveal? (Select all that apply.)
Ritualistic behaviors Desire to improve her self-image
What is the nurse's specific responsibility when the rights of a client on a mental health unit are restricted by the use of seclusion?
Seclusion and restraints are special procedures for dealing with aggressive acting-out behavior for the protection of the client and others; clear documentation is essential when the client's rights are restricted. Informing the client's family is not necessary because the use of seclusion or restraints is included in the general consent form that is signed on admission. Pharmacological intervention should be monitored for all clients. There is not a typical form; however, documentation is required to justify the need for seclusion or the use of restraints.
An individual whose employment has been terminated because his company has been acquired by another company is brought by a family member to the mental health clinic because of extreme depression. While talking with the nurse the client says, "I'm a useless, worthless person. No wonder I lost my job." What type of delusion does the nurse identify?
Self-deprecation(자기비난 비하) The client's statement is self-derogatory and reflects a low self-appraisal.
A mother of a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD) tells the nurse that when she is reading storybooks to her son, about halfway through the story he becomes distracted, fidgets, and stops paying attention. The nurse suggests that the mother:
Shorten the rest of the story
What is the most appropriate intervention for the nurse to implement after finding a disturbed client in bed in the fetal position?
Sitting down in a chair by the client and saying, "I'm here to spend time with you." "I'm here to spend time with you" accepts the client at the client's current level and allows the client to set the pace of the relationship. Touching the client may be misinterpreted and may precipitate an aggressive response.
An autistic toddler is sitting in a corner, rocking and spinning a top. How can the nurse be most therapeutic when approaching this toddler?
Sitting with the toddler while watching the spinning top to provide a nonintrusive presence
A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be?
Staying physically close to the client
A withdrawn client refuses to get out of bed and becomes upset when asked to do so. What nursing action is most therapeutic?
Staying with the client until the client calms down
During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?
Stressors that appear to precipitate the client's disruptive behavior
A client has been taking prescribed risperidone (Risperdal) 3 mg twice a day for the past 8 days. A friend brings the client to the outpatient clinic. The client reports tremors, shortness of breath, a fever, and sweating. What should the nurse do?
Take the client's vital signs and arrange for immediate transfer to a hospital These clinical manifestations signal the presence of neuroleptic malignant syndrome; the cardinal sign of this condition is a high body temperature. Therefore the nurse first should document the hyperthermia and then arrange for immediate hospitalization.
An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit?
"Around 2:30 in the afternoon is the best time to visit."
A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." The best response response by the nurse is:
"Everyone has a bed. This one is yours."
The parents of an adolescent girl are upset about their daughter's diagnosis of anorexia nervosa and the treatment plan that has been proposed. What is the best response by the nurse when the client's parents ask to bring food in for the client?
"For now, let the staff handle her food needs."
When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic?
"I want to talk with you because you are important to me."
A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse?
"You would rather not live."
A nurse in a community therapeutic recreation program is working with a client with dysthymia. The treatment plan suggests group activities when possible for this client. What is the priority rationale for this intervention?
A group can offer increased support.
On the psychiatric unit a client has been receiving high doses of haloperidol (Haldol) for 2 weeks. The client says, "I just can't sit still, and I feel jittery(초조한)." Which side effect does the nurse suspect that the client is experiencing?
Akathisia(정좌 불능) Akathisia, a side effect of haloperidol (Haldol), develops early in therapy and is characterized by restlessness and agitation. Torticollis is characterized by a stiff neck (wry neck). Tardive dyskinesia is characterized by gross involuntary movements of the extremities, tongue, and facial muscles that develop after prolonged therapy. Pseudoparkinsonism is characterized by motor retardation, rigidity, and tremors; the reaction resembles Parkinson's syndrome but usually responds to decreasing the dose, the administration of an antidyskinetic medication, or discontinuation of the haloperidol.
What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program?
Alcoholism involves the entire family.
A nurse is caring for a client with generalized anxiety disorder. Which factor should be evaluated to determine the client's present status?
Behavior
A hospitalized client with a borderline personality disorder consistently breaks the unit's rules. How will confronting the client about this behavior help the client?
By fostering self-awareness
A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? (Select all that apply.)
Calm Matter-of-fact
When planning care for an older client, the nurse remembers that aging has little effect on a client's:
Capacity to handle life's stresses An individual's ability to handle stress develops through experience with life; aging does not reduce this ability but often strengthens it. The senses of taste and smell are often diminished in the older individual. Muscle or motor strength is diminished in the older individual. Short-term memory is diminished in the older individual, whereas long-term memory remains strong.
A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? (Select all that apply.)
Euphoria Agitation Hypervigilance Impaired judgment
Risk for assaultive behavior is highest in the mental health client who:
Experiences command hallucinations
A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. The nurse remembers that the main reason that clients use self-mutilation 자해 is to:
Express anger or frustration
What should the nurse include when planning activities for an older nursing home resident with a diagnosis of dementia?
Familiar activities that the resident can complete successfully
A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse's objective for this client be?
Feeling comfortable with the nurse
A depressed client is admitted to the mental health unit. What factor should the nurse consider most important when evaluating the client's current risk for suicide?
Impending anniversary of the loss of a loved one
The nurse explains to the mother of a preschool child that Erikson identified the developmental conflict of children from 3 to 5 years as:
Initiative versus guilt Initiative versus guilt is the developmental conflict that faces the preschool child; the child will feel guilty if initiative is stifled by others.
A client with a history of sleeplessness, lack of interest in eating, and excessive purchases on charge accounts is seen in the mental health clinic. The adaptation that the nurse should expect the client to exhibit is:
Intrusive involvement with environmental activities
How can the nurse best minimize psychological stress in an anxious client who has been admitted to the psychiatric unit?
Learn what is of particular importance to the client
A client with a history of chronic alcoholism is admitted to the mental health unit. What does the nurse identify as the cause of a client's use of confabulation?
Marked loss of memory
The parents of a child with attention deficit-hyperactivity disorder ask the nurse about using medication. What is the most frequently prescribed medication for this disorder?
Methylphenidate (Ritalin)
A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? (Select all that apply.)
Multiple losses Declines in health
What should the nurse do to develop a trusting relationship with a disturbed child who acts out?
Offer support and encourage safety during play activities Offering support and encouraging safety during play activities sets a foundation for trust because it allows the child to see that the nurse cares.
Which psychotherapeutic theory uses hypnosis, dream interpretation, and free association as methods to release repressed feelings?
Psychoanalytical model The psychoanalytical model studies the unconscious and uses the strategies of hypnosis, dream interpretation, and free association to encourage the release of repressed feelings. The behaviorist model holds that the self and mental symptoms are learned behaviors that persist because they are consciously rewarding to the individual; this model deals with behaviors on a conscious level of awareness. The psychobiological model views emotional and behavioral disturbances as stemming from a physical disease; abnormal behavior is directly attributed to a disease process. This model deals with behaviors on a conscious level of awareness. The social-interpersonal model affirms that crucial social processes are involved in the development and resolution of disturbed behavior; this model deals with behavior on a conscious level of awareness.
What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others?
React to the feeling tone of the client's delusion
What is the best nursing intervention when the language of a client in the manic phase of a bipolar disorder becomes vulgar and profane?
Recognizing that the behavior is part of the illness but setting limits on it
A nurse is caring for an older adult with the diagnosis of dementia. Which manifestations are expected in this client? (Select all that apply.)
Resistance to change Inability to recognize familiar objects Inability to concentrate on new activities or interests Tendency to dwell on the past and ignore the present
A nurse begins a therapeutic relationship with a client with the diagnosis of schizotypal personality disorder. What is the best initial nursing action?
Respecting the client's need for social isolation
A 12-year-old child who has a history of school failure and destructive acting out is admitted to a child psychiatric unit with the diagnosis of conduct disorder. The youngest of three children, the child is identified by both the parents and the siblings as the family problem. The nurse recognizes the family's pattern of relating to the child as:
Scapegoating 심리) 전가(轉嫁) ((고통을 준 본인을 벌할 수 없을 경우 다른 사람을 공격하는 현상)) When all members of a family blame one member for all their problems, scapegoating is occurring.
A teenager with anorexia nervosa is admitted to the adolescent unit of a mental health facility and signs a contract calling for her to gain weight or lose privileges. There is no weight gain after a week. What should the nurse explain to the client?
The prearranged consequences will go into effect.
A nurse, understanding the possible cause of alcohol-induced amnestic disorder, should take into consideration that the client is probably experiencing:
Thiamine deficiency
What characteristic uniquely associated with psychophysiological disorders differentiates them from somatoform disorders?
Underlying pathophysiology
A client in the early dementia stage of Alzheimer's disease is admitted to a long-term care facility. Which activities must the nurse initiate? (Select all that apply.)
Weighing the client once a week Having specialized rehabilitation equipment available Establishing a schedule with periods of rest after activities
What clinical findings may be expected when a nurse cares for an individual with an anxiety disorder? (Select all that apply.)
Worrying about a variety of issues Converting the anxiety into a physical symptom Displacing the anxiety onto a less threatening object Demonstrating behavior common to an earlier stage of development
A nurse concludes that a client's withdrawn behavior may temporarily provide a:
Defense against anxiety
A nurse is working with a couple and their two children. The 14-year-old son has been in trouble at school because of truancy and poor grades. The 16-year-old daughter is quiet and withdrawn and refuses to talk to her parents. The parents have had severe marital problems for the past 10 years. The priority nursing concern at this time is how the:
Couple's marital(결혼,부부 생활)의 problems are affecting their children
An 8-year-old child is found to have oppositional defiant disorder. What behavior noted by the nurse supports this diagnosis?
Argues with adults Oppositional defiant disorder is a repeated pattern of negativistic, disobedient, hostile, defiant behavior toward authority figures, usually exhibited before 8 years of age.
An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. A specific outcome criterion unique to adolescents with this problem is:
Demonstration of respect for the rights of others
After a traumatic event, a client is extremely upset and exhibits pressured and rambling speech. What therapeutic technique can the nurse use when a client's communication rambles?
Focusing Focusing is indicated when communication is vague; the nurse attempts to concentrate or focus the client's communication on one specific aspect. Touch invades the client's space and will not help focus the client's communication. Silence prolongs the rambling communication; the client needs to be focused. Until the concern is identified and explored, summarizing is impossible.
The nurse is caring for a client with Alzheimer's disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, the nurse will instruct staff to monitor the client:
For attempts at eating inedible objects
When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. (Select all that apply.)
Planning for future safety Validating the experiences Promoting access to community services
The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do?
Prefill a weekly drug box with the medications for the spouse to self-administer
A male client with a diagnosis of antisocial personality disorder is admitted to the mental health hospital. What is the priority nursing intervention?
Presenting a united, consistent staff approach
A client with a conversion disorder is experiencing paralysis of a leg. The nurse can expect this client to:
Recover use of the affected leg but, under stress, to again experience these symptoms
At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse?
Seeking consensual validation
When reviewing the medications for a group of clients on a psychiatric unit, the nurse concludes that the pharmacotherapy for anxiety disorders is moving away from benzodiazepines and moving toward:
Selective serotonin reuptake inhibitors Selective serotonin reuptake inhibitors have better safety profiles and do not carry the risk of substance abuse and tolerance.
