Exam 2 Study Guide

A client recently prescribed antidepressants says to the nurse, "My depression is gone. I feel very energetic today. Soon everything will be fine." What response should the nurse provide this client?

"Do you have any sort of suicidal ideas or plans?" Rationale: It is important for the nurse to be aware of verbal and nonverbal hints of suicide by a client to prevent suicide. When there is a sudden rise in the mood and energy of a depressed client, the nurse should understand that the client may have suicidal ideation. These behavioral changes may be the client's attempt to mask suicidal intent. In such situations, the nurse should ask the client directly about suicidal ideation. The client should not be discharged, because the client is not safe. The client should not be congratulated for recovery from depression, because the client is still not mentally stable. The client does not seem to have recovered from depression. Therefore, the nurse should not express satisfaction with the client's recovery.

What is the most important question to ask during assessment of a client diagnosed with an anxiety disorder?

"Have you ever considered suicide?" Rationale: The presence of anxiety may cause an individual to consider suicide as a means of finding comfort and peace. Suicide assessment is important for any client with an anxiety disorder. Hearing voices, poor memory and jumbled thoughts may be related to anxiety but are not as important to the client's safety as risk for suicide.

The nurse is assessing a client diagnosed with depression who has expressed suicidal ideations. The client begins to cry and states, "I lost my job. I don't know how I am going to pay my bills. What if I lose my house?" What is the most appropriate response from the nurse?

"How devastating. Does that make you think about suicide again?" Rationale: Answering with "how devastating," allows for reflection that communicates empathy and allows the nurse to discern the clients probable feelings. Asking a direct question of the client's thoughts on suicide allows for a suicide risk assessment. Staying with the client may be therapeutic but does not address the clients underlying feelings. Asking the client if he or she has family or friends to stay with or sympathizing with the patient about the worry of paying bills may be perceived as ignoring the clients current feelings.

Which statement indicates the existence of a codependent relationship between a client diagnosed with substance abuse and their life partner?

"I'm always so angry about how the addiction controls our lives." Rationale: Codependent individuals find their moods being influenced by the situation and the emotions of the abuser. While the other options reflect common characteristics of a relation involving substance abuse, they do not necessarily demonstrate a codependency.

Which statement made by a client admitted with a diagnosis of chronic depression indicates the need for further assessment?

"I'm not worried. I know that things will be better soon." Rationale: The response "I think things will be better soon" may be a covert, or indirect, clue that the client is thinking of suicide. "I know a lot of people care about me and want me to get better," "I have suicidal thoughts at times, but I don't have any plan and don't think I would ever actually hurt myself," and "I don't have a good support system, but I am planning on joining a recovery group" are all statements that, whereas they may be discussed further, are not clues to suicide but rather clear communication.

An adult has had long-term serious medical problems resulting in decreased libido and sexual performance. The adult's spouse privately says to the nurse, "I don't feel loved anymore. I feel sexual urges but my partner is not interested." What is the nurse's most therapeutic response?

"Let's consider some other ways you can satisfy your needs."

Which factor can adversely affect a person's ability to respond positively to a crisis situation?

A lack of supportive services, an unrealistic perception of the crisis, and reliance on ineffective coping mechanisms. Rationale: A person's equilibrium may be affected adversely by one or more of the following: an unrealistic perception of the precipitating event, inadequate situational supports, and inadequate coping mechanisms. Age and nature of the crisis are not considered as impactful.

A 12-year-old female finds herself feeling anxious and overwhelmed and seeks out the school nurse to report that "Everything is changing; my body, the way the boys who were my friends are treating me, everything is so different." It is likely the child is describing what disorder?

A maturational crisis. Rationale: The maturational crisis of moving from childhood into adolescence may be difficult because many new coping skills are necessary. The child's description does not indicate a personal identity disorder, suicidal ideation, or neurosis.

What statement describes the appropriate method for dealing with transference or countertransference when managing care for clients diagnosed with substance use disorders?

A nurse remains objective throughout the process. Rationale: The nurse remains cautious about personal thoughts, opinions, and feelings, and remains objective throughout the process. A therapeutic relationship should be established between the nurse and the client. There is no need of introducing a new nurse in each session. An ongoing evaluation of the process must be conducted to eliminate transference or countertransference. This is done to maintain the objectivity of the treatment process and teach the client new skills to acquire a healthy lifestyle post recovery. A residential care facility is needed depending on the client's health-related issues. This has no effect on nurse and client relationship.

A family's home and possessions are lost when a massive forest fire burns out of control. What type of crisis has occurred?

Adventitious. Rationale: An adventitious crisis is not a part of everyday life. It results from events that are unplanned and may be accidental, caused by nature, or human-made.

When a tornado results in the loss of homes, businesses, and life, the town residents are likely to experience what form of crisis?

Adventitious. Rationale: An adventitious crisis is unplanned, accidental, and not part of everyday life. Examples are disasters and crimes of violence. Maturational, situational, and endogenous crises generally do not have the factors associated with an adventitious crisis.

A mental health nurse assesses a client diagnosed with antisocial personality disorder. Which co-morbid problem is most important for the nurse to include in the assessment?

Alcohol use and abuse. Rationale: Antisocial disorders have a high rate of concordance with alcohol/substance use disorders, so it is important for the nurse to include this information in the assessment. Generalized anxiety, compulsions and phobias, and dysfunctional sleep patterns are not typically associated with antisocial personality disorder, so it is not as important for the nurse to include them in this assessment.

A client is fearful of riding in elevators and always takes the stairs. Which brain structure is involved in this fear and behavior?

Amygdala. Rationale: The amygdala plays a role in anxiety disorders. It alerts the brain to the presence of danger and brings about fear or anxiety to preserve the system. Memories with emotional significance are stored in the amygdala and are implicated in phobic responses. The thalamus relays sensory information to other brain centers. The hypothalamus is involved in regulation of the autonomic nervous system. The pituitary gland secretes regulatory hormones.

An adult was caught shoplifting merchandise from a community thrift shop. When confronted, the individual replies, "All this stuff was donated, so I can take it." This comment suggests features of which personality disorder?

Antisocial. Rationale: The person's statement shows disregard for others and a lack of remorse, both of which are characteristic of antisocial personality disorder. People with histrionic personality disorder attempt to become and remain the center of attention through manipulative behaviors. Borderline personality disorder (BPD) is marked by unstable, frequent mood changes. Schizotypal personality disorder is characterized by patterns of peculiar behavior and odd speech, which are not evident in this person's statement.

Which symptoms does the nurse recognize as the effect of minor alcohol withdrawal?

Anxiety, insomnia, and palpitations. Rationale: Mild alcohol withdrawal occurs as the alcohol concentration in the blood slightly reduces. It can lead to anxiety, insomnia, and palpitations. Hallucinations and seizures occur in extreme cases of severe alcohol withdrawal.

When working with a client who may have made a covert reference to suicide, the nurse should implement which intervention?

Asking the client directly if he or she is thinking of attempting suicide. Rationale: The nurse should directly address any suicidal hints given by the client. Self-destructive ideas are a personal decision. Talking openly about suicide leads to a decrease in isolation and can increase problem-solving alternatives for living. People who attempt suicide, even those who regret the failure of their attempt, are often extremely receptive to talking about their suicide crisis.

The nurse is performing crisis intervention for a client who has been sexually assaulted. What action should the nurse take first?

Assess the client for any suicidal intentions. Rationale: A client experiencing crisis can develop suicidal behavior to escape from the situation. The nurse should first asses the suicidal intentions of the client to promote the safety of the client. Aside from asking details that pertain only to the client's health and safety, the nurse's priority intervention should not be to ask the client what happened since this could unnecessarily retraumatize the client. The client's perception of the situation and coping skills are assessed after assessing the suicidal intentions of the client, because the safety of the client is of greater importance.

In a clinical interview, a client says, "My mother and I are afraid of darkness, so we always carry a flashlight with us." Which theory is evident in this case?

Behavioral theory. Rationale: According to behavioral theory, the client shows a learned response to specific environmental stimuli. The client has observed his or her mother's fear of darkness and also developed a fear of darkness. According to cognitive theory, the client has poor perception of situations and tends to develop a panic attack by thinking about the situation. According to interpersonal theory, the client develops emotional distress transmitted from mother or caregivers. According to psychodynamic theory, anxiety disorder is developed in a person during childhood due to unconscious conflicts in his or her surroundings.

Which stress management behavior is most reflective of personality disorders?

Blaming a spouse for the client's poor performance at work. Rationale: In people diagnosed with personality disorders (PDs), personality traits tend to be inflexible and unpredictable, and coping strategies tend to be more primitive and immature. They often blame others for their difficulties or even deny having a problem. Binge drinking is associated with addiction. Ritualistic behaviors are associated with obsessive compulsive disorder. Difficulty deciding what movie to view is not associated with a personality disorder.

Which assessment data would be most consistent with a severe opiate overdose?

Blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min. Rationale: The data consistent with opiate overdose are blood pressure, 80/40 mm Hg; pulse, 120 beats/min; respirations, 10 breaths/min. Opiate overdose results in lowered blood pressure with a rise in pulse rate along with respiratory depression.

What information will the nurse include in medication education for a client prescribed an antianxiety medication for obsessive-compulsive behavior?

Caffeinated beverages should be avoided, benzodiazepines have a quick onset of action, and antacid use can affect medication absorption. Rationale: Beverages containing caffeine should be avoided because they decrease the desired effects of the drug. Benzodiazepines are commonly used for treatment of anxiety disorders because they have a quick onset of action. Antacids may delay absorption. Medications should be taken with or shortly after meals to reduce gastrointestinal discomfort. Because of the potential for dependence, these medications ideally should be used for short periods only until other medications or treatments reduce symptoms.

Which situation is most likely to cause a client to demonstrate symptoms of self-hatred and depression?

Chronic low self-esteem. Rationale: Patients experiencing crisis have chronic low self-esteem, posttrauma syndrome, impaired social interaction, and acute confusion. The symptoms of chronic low self-esteem are self-hatred and depression. The symptoms of posttrauma syndrome are denial, hypervigilance, and panic. Symptoms of impaired social interaction include feelings of isolation and little or no social support. Symptoms of acute confusion include feelings of numbness, confusion, and incoherence.

Which statement is true regarding obsessive-compulsive disorder (OCD)?

Clients diagnosed with OCD should be assessed regularly for risk for suicide. Rationale: People suffering from OCD may become desperate and attempt suicide. Risk for suicide should be assessed regularly in these clients. Obsessive-compulsive disorder can begin in childhood, with symptoms present as early as age 3, but symptoms would not be expected in infancy. People with obsessive-compulsive disorders rarely need hospitalization unless they are suicidal or have compulsions that cause injury. Compulsions are ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety. Obsessions are thoughts, impulses, or images that persist, recur, and cannot be dismissed from the mind.

The nurse, performing an assessment of a client with a history of drug abuse, observes many injection marks on the client's forearm. Which drug should the nurse suspect the client is abusing?

Cocaine. Rationale: Cocaine is a stimulant and is administered by snorting, smoking, or injecting. Opium is an opioid that is swallowed or smoked. Hashish is a cannabinoid that is smoked or swallowed. Marijuana is a cannabinoid that is smoked or swallowed.

Which statement is true regarding substance addiction and medical comorbidity?

Conditions such as hepatitis, tuberculosis, and pancreatitis are common comorbidities. Rationale: Conditions such as hepatitis, tuberculosis, and pancreatitis are common comorbidities. Medical comorbidities are common. There is research, such as the 2001-2003 National Comorbidity Survey Replication (NCS-R), showing the correlation between medical comorbidities and psychiatric disorders. It is more likely that medical comorbidities negatively affect substance addiction by causing added symptoms, stress, and burden.

A client is undergoing detoxification for heroin abuse. Which nursing interventions can help prevent a relapse in the future?

Counseling to identify the potential triggers of substance use, helping to acquire skills to regain abstinence in the event of relapse, teaching stress management skills to help avoid substance use, and counseling on adopting healthy coping measures and a sustainable recovery lifestyle. Rationale: Individuals must prepare for and anticipate the possibility of relapse to maintain long-term sobriety. A nurse can help in identifying the triggers to substance use and teaching skills to regain abstinence, stress management, and healthy coping measures. Admitting that there is a problem of addiction and developing awareness and a commitment should occur earlier in the treatment process.

Which steps does the nurse include when planning care for clients being treated for alcoholism?

Create a plan to deal with relapse, recognize that recovery is an achievable goal, and help the individual replace unhealthy defenses with healthy coping. Rationale: To maintain long-term sobriety, each individual must prepare for and anticipate the possibility of relapse. Recognizing that recovery is an achievable goal is part of instilling hope. Addicted persons use denial as an unhealthy defense and need help learning to use healthy coping strategies. Addicted persons must avoid all use of substances. Identifying reasons for substance abuse is part of the unhealthy use of rationalization.

For which characteristics will the nurse look when assessing a client suspected of having antisocial personality disorder?

Deceitfulness, impulsiveness, and lack of empathy. Rationale: Clients with antisocial personality disorder lack conscience. Their sense of right and wrong is impaired, and they tend to do whatever serves them best without consideration for the rights or feelings of others. Perfectionism and related traits are associated with obsessive-compulsive disorder. Avoidance of interpersonal contact is associated with avoidant personality disorder. A need for others to assume responsibility is associated with dependent personality disorder.

In the United States, which agency has overall responsibility to coordinate responses to disasters?

Department of Homeland Security (DHS). Rationale: The DHS has ultimate government responsibility for the safety of United States citizens and territories while assuring adequate preparedness, response, and recovery protocols are immediately available. WHO serves the global community. DHS oversees operations of FEMA. NIMS helps first responders from different disciplines and areas to work together effectively when a community has exhausted its available resources in addressing a large-scale occurrence.

Which traits are typically common among avoidant, obsessive-compulsive, and dependent personality disorders?

Depressed, fearful, and tense. Rationale: Avoidant, obsessive-compulsive, and dependent personality disorders are categorized as cluster C personality disorders. They are typically associated with anxious, fearful, tense, overcontrolled, and depressed behavior. Eccentric and irrational behaviors are typically seen in cluster A disorders. Shallow behavior is associated with cluster B disorders.

A nurse interviews a 15-year-old who has engaged in frequent substance abuse. The nurse should screen the client for which possible comorbid problems?

Depression, conduct disorder, and antisocial personality. Rationale: The high prevalence of psychiatric comorbidity is supported by statistics from multiple national population surveys. Individuals with mood and anxiety disorders, antisocial behaviors, or histories of conduct or oppositional disorders as adolescents are more than twice as likely to have a substance use disorder. Obsessive-compulsive and eating disorders are not comorbidities associated with substance abuse.

A client diagnosed with borderline personality disorder has suicidal intentions. The nurse plans to teach mindfulness and emotion regulation to improve the client's interpersonal effectiveness skills and support which type of therapy?

Dialectical behavior therapy. Rationale: Dialectical behavior therapy is an advanced practice intervention used in clients with borderline personality disorder who have chronic suicidal intentions. This therapy includes cognitive and behavioral techniques like mindfulness and emotion regulation to improve interpersonal effectiveness skills in clients. In family therapy, the family members of the client are taught how to assist the client in handling stress. Family therapy helps the family learn how to function better as a unit. Schema-focused therapy helps clients change their views of themselves by evaluating the behavior of people in stressful conditions. In supportive psychotherapy, the therapist encourages the client to participate in activities to enhance the client's ability to cope with stressors.

Which defining characteristics best apply for the nursing diagnosis of ineffective coping?

Difficulty in relationships, high levels of anxiety, manipulation, and aggression. Rationale: Characteristics for the diagnosis of ineffective coping include difficulty in relationships, high levels of anxiety, manipulative behaviors, and aggression. Interdependence is not considered a symptom of ineffective coping.

Which interventions are associated with primary crisis care?

Discussing impact of crisis on the client, assisting the client with learning new problem-solving techniques, and helping the client to identify environmental changes necessary to reduce stress. Rationale: Primary care promotes mental health and reduces mental illness to decrease the incidence of crisis. On this level the nurse can work with a client to recognize potential problems by evaluating the client's experience of stressful life events; teaching the client specific coping skills, such as decision making, problem solving, assertiveness skills, meditation, and relaxation skills; and assisting the client in evaluating the timing or reduction of life changes to decrease the negative effects of stress as much as possible. This may involve working with a client to plan environmental changes, to make important interpersonal decisions, and to rethink changes in occupational roles. Administering antidepressant medication and planning for discharge are examples of secondary care.

Which medication is commonly prescribed as part of an aversive therapy approach to treatment of addiction?

Disulfiram. Rationale: When taking disulfiram, an individual who ingests alcohol will experience a toxic reaction that causes intense nausea and vomiting, headache, sweating, flushed skin, respiratory difficulties, and confusion. These symptoms are intended to create an aversion to use of alcohol. Gabapentin, acamprosate, and naltrexone are medications are prescribed to reduce discomfort associated with withdrawal.

Which assessment findings does the nurse expect to observe in a client being treated for extreme alcohol intoxication?

Drowsiness, slurred speech, hypotension, and loss of coordination. Rationale: High doses of alcohol adversely affect the nervous system and may cause drowsiness, slurred speech, reduction in blood pressure, and loss of coordination. These effects are due to the depressive action of alcohol on the brain and the nervous system. Constipation is an aftereffect seen with the intake of opium.

Which personality traits are associated with borderline personality disorder?

Emotional dysregulation, impulsivity, and hypersensitivity. Rationale: Borderline personality disorder is highly associated with impulsivity, hypersensitivity, and emotional dysregulation. People with this disorder act quickly and impulsively in response to their emotions without considering the consequences. Because of their hypersensitivity, they exhibit separation anxiety. The emotional dysregulation trait is indicated by frequent mood swings. The trait of shyness predisposes people to schizoid personality disorder. People with the disinhibition trait show a lack of concern for the consequences of their actions. They are predisposed to antisocial personality disorder. People with an aggressive disregard trait who exhibit violent tendencies with no concern for others often have antisocial personality disorder.

The nurse is conducting crisis intervention for a client in a flood-affected area. What appropriate actions should the nurse take?

Encourage the client to set realistic goals and focus on the present problems of the client. Rationale: The nurse should plan a focused intervention and encourage the client to set realistic goals. Having a focused intervention helps to effectively manage the client's problems. Setting realistic goals helps the client to achieve them, preventing the frustration and disappointment that occur when goals are not met. The nurse should deal only with the present problems of the client to resolve the immediate crisis and return the client to at least a precrisis level of functioning. The nurse should not focus on the previous problems of the client because they may not be relevant. A client in crisis need not have a chronic psychiatric disorder. The nurse should assume that the client is mentally healthy, and is only in a state of disequilibrium due to the present situation.

Which coping mechanism is commonly adopted during a crisis?

Engaging in other physical activity. Rationale: During a crisis, clients use different coping techniques to cope with the situation. Some clients may get involved in physical activity such as walking to relieve restlessness. Because the client has had a crisis, the client may not be psychologically stable and might not be able to set realistic goals. Some clients may try to cope with the stress by talking to others. Some clients tend to overeat in order to cope with stress.

What are individuals displaying when they believe they have a right to hurt others, take what they want, and treat others unfairly?

Entitlement. Rationale: Having a sense of entitlement means a belief in one's right to hurt others, take what he or she wants, and treat others unfairly. Splitting is the inability to integrate both the positive and the negative qualities of an individual into one person. Impulsivity is engaging in risky behaviors without first evaluating the potential consequences. Manipulation involves finding the right angle to lure a person into complying with one's own desires.

Panic attacks in Latin American individuals often involve which symptom?

Fear of dying. Rationale: Fear of dying is often involved in panic attacks in Latin Americans. Blushing may be related to social phobias in Japanese and Korean cultures. Offensive verbalizations are typically not seen in panic attacks. Repetitive involuntary actions are typically not seen in panic attacks.

A woman gets a report of abnormal cells from a Pap smear. She calls her attorney to prepare a will and tells her family, "I won't be around much longer." Which nursing diagnosis and etiology are most applicable to this situation?

Fear related to misinterpretation and misinformation about Pap tests.

A woman feels a lump in her breast. She anxiously says to her spouse, "I have cancer. It probably has spread all over my body." Which nursing diagnosis and etiology best apply to this situation?

Fear related to misinterpretation and misinformation about breast self-exams.

Which observation indicates to the nurse that a client is at risk for codependent behavior?

Feeling guilt for a family member's drug use. Rationale: Codependence involves overresponsible behavior and performing activities for others that they could perform on their own. Codependence is common among friends and family members of individuals with substance-related and addictive disorders. Feeling guilt for someone else's drug us is an example of a codependent behavior. Promising to change one's own behavior, lack of empathy, and family history of tobacco use are not risk factors for codependent behaviors.

Which outcome indicates that the individual is demonstrating a commonly observed but negative coping strategy after a crisis event?

Gaining 10 lb over a 6-week period of time, losing one's driver's license for driving drunk, and offering numerous excuses for not socializing. Rationale: Common coping mechanisms may be overeating, drinking, smoking, withdrawing, yelling or fighting. Counseling and reasonable exercise would not be considered negative coping strategies.

Which interventions by the nurse are best associated specifically with care provided for a client diagnosed with paranoid disorder?

Giving the client a copy of the daily routine he or she is expected to follow and explaining why the scheduled therapy session will be delayed 30 minutes. Rationale: The paranoid client is suspicious and mistrustful, and he or she may develop perceptional distortions. Giving clear instructions and explanations will help minimize these tendencies. This can be done by giving the client a copy of a daily routine and explaining any scheduling delays. Monitoring for psychotic behavior is appropriate for any client with a risk for cognitive or perceptual distortions; it is not specific to paranoid disorder. The narcissistic client is associated with thoughtless, disparaging comments such as calling the nurse fat or making hurtful statements about others on the unit.

Which nursing intervention is most helpful to support improvement in an anxious individual's sense of control and competence?

Help the individual identify several stress situations that he or she successfully managed. Rationale: Positive self-concepts result from positive experiences, leading to perceived competence and acceptance. Assisting the client in identifying such situations that he or she successfully managed will aid in building confidence. Being praised for successes is appropriate, but praise should be reserved for situations that the individual recognizes as meaningful. Although stress management techniques are important, they are not linked directly to a sense of competence. Describing how one demonstrates control and competence is applicable but has limited favor in actually assisting the client to feel competent.

Which abnormalities in brain structure and function have been found to be associated with borderline personality disorder?

Hippocampus size, frontal lobe function, and amygdala size. Rationale: In people with borderline personality disorder, abnormal brain structure and function have been found. Findings include abnormalities in the size of the hippocampus, in the size and functioning of the amygdala, and in the functioning of the frontal lobes. Individuals with antisocial personality disorder have shown altered metabolism in the prefrontal regions of the brain. An image study identified reduced prefrontal gray matter within areas of the brain implicated in empathic processing, moral reasoning, and the processing of emotions such as guilt and embarrassment.

A nurse notices that a client behaves in a melodramatic way and acts flirtatiously. With which personality disorder does the nurse expect the client to be diagnosed?

Histrionic personality disorder. Rationale: People diagnosed with histrionic personality disorder have emotional, attention-seeking behaviors. They are often melodramatic and act flirtatiously. People diagnosed with paranoid personality disorder are extremely suspicious and often believe others will harm them. People diagnosed with schizoid personality disorder exhibit emotional detachment and are viewed as loners. People diagnosed with narcissistic personality disorder are arrogant and need constant admiration.

A client who is dramatic, charming, and seductive has traits of which personality disorder?

Histrionic. Rationale: Individuals with histrionic personality disorder are dramatic, charming, and seductive. They are excessively emotional and always the center of attention. Individuals with narcissistic personality disorder have a grandiose sense of their personal achievements. Individuals with antisocial personality disorder are callous, deceitful, and impulsive. Individuals with borderline personality disorder are emotionally unstable and impulsive and have feelings of emptiness.

When a client in an outpatient program scores a 7 on the SAD PERSONS scale, what action should the nurse take?

Hospitalization of the client. Rationale: A score of 7 to 10 on the SAD PERSONS scale indicates hospitalization or commitment, because the person would be considered a high risk for suicide. Closely following up refers to a score of 3 to 4. Sending home with follow-up refers to a score of 0 to 2. Strongly considering hospitalization refers to a score of 5 to 6.

A 70-year-old male client lost a spouse 3 months ago, has no children, and lives alone. The client had depression at the age of 25, started drinking alcohol then, and has been treated with antidepressants. The client reports disturbed sleep and decreased appetite. On assessment the nurse finds that the client is demonstrating behaviors associated with dementia and is unable to think rationally. What would be the most appropriate intervention for the nurse according to the SAD PERSONS scale?

Hospitalize the client. Rationale: The nurse should evaluate the client for the risk of suicide according to the SAD PERSONS scale. According to this scale, the client's total score is 7, with 1 point each for age (1), gender (1), lack of spouse (1), lack of social support (1), use of alcohol (1), episode of depression (1), and loss of ability to think rationally (1). Therefore, the nurse should immediately hospitalize the client, because there is high risk for suicide. The psychiatrist can be contacted once the client is hospitalized. The client should not be sent home and asked to come for follow-up, because the client is at high risk of suicide.

Cocaine exerts which of the following effects on a client?

Increased metabolism. Rationale: Cocaine exerts a stimulant effect on metabolism and may cause extreme weight loss. Cocaine does not cause drowsiness. Imbalanced emotions and paranoia may occur during cocaine withdrawal.

Which scenario describes a client in phase IV of a crisis response?

Individual comes to the crisis clinic complaining of depression and expresses that he or she does not want to go on living. Rationale: The individual coming to the crisis clinic complaining of depression and expressing that he or she does not want to go on living describes phase IV, when, if coping is ineffective, may lead to depression, confusion, violence, or suicide. The other options describe phase II (extreme distress), phase III (panic attack), and phase I (anxiety) in phases of crisis.

How does the counselor integrate motivational interviewing as a tool in the treatment plan of a client with a substance use disorder?

It helps the counselor use strategies to resolve ambivalence and evoke internally motivated change. Rationale: A counselor first understands the change that is occurring in the individual as it relates to the client's substance use disorder. Then, the counselor assists the client in correlating the change in the individual with the treatment process. A counselor works as a part of the treatment process rather than introducing an alternative plan. A counselor assists the client to develop coping skills and motivates the client to follow the treatment plan. The evaluation of the treatment plan is not a part of counseling. The assessment of substance use disorder and comorbidities is done after the screening and counseling is based on that assessment.

Which behavior is most characteristic of a client diagnosed with antisocial personality disorder?

Justifying taking another client's dessert by stating, "I deserve two desserts." Rationale: An entitled attitude is a characteristic demonstrated by clients diagnosed with antisocial personality disorder. Poor impulse control as demonstrated by throwing a book is a hallmark of borderline personality disorder. Schizotypal personality disorder is associated with eccentric behavior while intense jealousy is characteristic of paranoid personality disorder.

Research has indicated that an individual diagnosed with an antisocial personality may present with which characteristic?

Lack of remorse. Rationale: Individuals with an antisocial personality exhibit a lack of remorse when confronted with the results of their thoughtless, irresponsible behavior toward others. Social isolation, learning difficulties, and difficulty with reality generally are not associated with antisocial personality disorder.

A client on an acute psychiatric unit removed the cap from the ceiling sprinkler, resulting in rapid flooding of the unit. After attending to the safety of the clients and staff, which action should the nurse take to address client needs?

Lead a group session with clients to discuss feelings associated with the event. Rationale: Because everyone is physically safe, the nurse should lead a group session with clients to discuss feelings associated with the event so that clients can process the stress from the event in a safe, constructive way. Because the clients experienced the flood as a group, a group session is preferable and so individual sessions regarding the experience would not be the correct choice. Attempting to distract clients from the event does not help the clients to address their feelings and the stress that the even caused, so this is not the correct response. Implementing psychomotor activity to reduce anxiety associated with the event is not the first step the nurse should take, so this is an incorrect response.

Which event can lead to the development of a situational crisis in clients?

Loss of a job. Rationale: A situational crisis arises from external events such as loss of a job or an abortion. An adventitious crisis results from accidental events that are unplanned, which may be human-made or caused by nature. This crisis arises from situations such as physical assaults and natural disasters like floods and earthquakes. A maturational crisis arises from developmental changes in a person's life such as the birth of a child or death of parents.

Which neurobiological factor is the greatest predictor of suicide?

Low levels of 5-hydroxyindoleacetic. Rationale: Low levels of 5-hydroxyindoleacetic in cerebral spinal fluid are associated with impulsive suicide-like violence. Low levels of 5-hydroxyindoleacetic can predict future attempts and future completed suicides. A dizygotic twin is a genetic factor with lower suicide concordance rates. Overactivity of the noradrenergic system is associated with higher suicidal risk. Abnormalities of the hypothalamic-pituitary-adrenal axis are associated with major depression and suicide victims.

A new client is diagnosed with generalized anxiety disorder. It is most important for the nurse to assess this client for which additional problem?

Major depressive disorder. Rationale: Clinicians and researchers have shown clearly that anxiety disorders frequently co-occur with other psychiatric problems. Several studies suggest that other major depressive disorder commonly coexists with generalized anxiety or panic disorder. Although conduct disorder, alcohol use disorder, and obsessive-compulsive disorder are possibilities, the most likely comorbid problem is depression.

What is the primary goal of milieu therapy for clients diagnosed with personality disorders?

Managing the affect of the entire group. Rationale: The primary goal of milieu therapy is affect management in a group context. One-on-one therapy is not a goal of milieu management. Helping the client remain uninvolved is not therapeutic. The staff would not be able to effectively manage the milieu if they adopted a laissez-faire attitude.

Which form of crises may occur as an individual moves from one developmental level to another?

Maturational. Rationale: Maturational crises are normal states in growth and development in which specific new maturational tasks must be learned when old coping mechanisms are no longer effective. A situational crisis arises from events that are extraordinary, external rather than internal, and often unanticipated. An adventitious crisis is not a part of everyday life; it results from events that are unplanned and may be accidental, caused by nature, or human-made. Reactive is not a term used to identify a type of crisis.

Which provision should the nurse include in a client's no-suicide contract?

Not to attempt suicide in the next 24 hours. Rationale: A no-suicide contract is quite straightforward in seeking a client's promise not to attempt to harm oneself within a specified period. When that time expires, a new contract is negotiated. The contract does not involve the promises of never attempting suicide, alerting someone if an attempt is planned, and discussing why the client feels suicidal.

A client has been diagnosed with narcissistic personality disorder. Which aspect of the nursing assessment is most important?

Nutritional status. Rationale: Anorexia nervosa and substance use disorders are often comorbidities for clients diagnosed with narcissistic personality disorder; therefore, it is important for the nurse to assess the client's nutritional status, because these disorders compromise this. Whereas it's important to assess pain in all clients, the greater risk in this scenario applies to the client's nutritional status. Anxiety is associated with antisocial, avoidant, and obsessive-compulsive personality disorders rather than narcissistic personality disorder. Attention deficit hyperactivity disorder is more often a comorbidity of borderline personality disorder.

A nurse is teaching high school students about commonly abused drugs and their effects. Which common substances are abused via swallowing?

Opium, alcohol, and marijuana. Rationale: Substances that are abused by swallowing include opium, alcohol, and marijuana. Opium is an opioid which can be swallowed and smoked. Alcohol is found in liquor, beer, and wine and is abused through swallowing. Marijuana is a cannabinoid and can be swallowed and smoked. Nicotine is the main ingredient in tobacco and is smoked, snorted, or chewed (but not swallowed). Heroin is an opioid and can be injected, snorted, and smoked.

Which states have legalized physician assisted suicide (PAS)/physician aid in dying (PAD)?

Oregon, Vermont, California, and Washington. Rationale: In the United States, as of February 2016, only four states have legalized PAS/PAD. These states include Oregon, Vermont, California, and Washington. Florida and Michigan have not legalized PAS/PAD.

A nurse observes that a client behaves rudely to the staff and refuses treatment. On inquiry, the nurse learns that The client says to the nurse, "I think that all staff members are planning to harm and deceive me." Which diagnosis does the nurse expect to see in the client's medical record?

Paranoid personality disorder. Rationale: Clients diagnosed with paranoid personality disorder are suspicious and believe that others want to exploit, harm, and deceive them. They develop a defense system and try to counterattack the other person and reject the treatment, often behaving rudely. Clients diagnosed with schizoid personality disorder have reduced emotional attachment and depression. In narcissistic personality disorder, clients are extremely worried about their prestige; they feel intense shame and fear of abandonment by others. Clients diagnosed with obsessive-compulsive personality disorder exhibit repetitive behaviors.

During which crisis phase does a client exhibit serious personality disorganization, depression, and confusion?

Phase 4. Rationale: Caplan was the first person who conducted an extensive study on individual behavior. He proposed four stages based on the emotional status of a client during a crisis. Patients with high personality disorganization, depression, and confusion are categorized under phase 4. These clients also exhibit suicidal thoughts. Increased level of anxiety caused by external stimuli is experienced by a client during phase 1. If the anxiety level grows to a level of extreme discomfort, the client has reached the phase 2 level of crisis. Phase 3 is characterized by an increased level of panic due to grief and loss.

A nurse who cared for a client who completed suicide has begun exhibiting signs of guilt, shock, anger, shame, and decreased self-esteem. This nurse is exhibiting symptoms of which type of trauma?

Posttraumatic stress disorder. Rationale: Health care workers are similarly traumatized by suicide. Staff may experience signs of posttraumatic stress disorder including guilt, shock, anger, shame, and decreased self-esteem. Health care workers are also subject to feelings of burnout and depression if feelings are not expressed in a healthy environment. Adaptive grief process refers to healthy reactions to trauma to prevent self-defeating behaviors.

The nurse is assessing a client diagnosed with anxiety who is a victim of intimate partner abuse. Which nursing intervention will help in reducing the anxiety levels of the client?

Provide knowledge of problem-solving techniques.

An adult client is currently experiencing amphetamine withdrawal. Which assessment finding is a common characteristic of this process?

Psychomotor retardation. Rationale: Withdrawal from amphetamines is commonly associated with symptoms of depression. Psychomotor retardation commonly accompanies depression. Dilated pupils, dry oronasal cavity, irregular heart rate, and excessive motor activity are symptoms of amphetamine intoxication.

A primary health care provider instructs a nurse to document cognitive-behavioral therapy as part of the care plan for a client with social phobia. What intervention does the nurse know is appropriate for the client during the cognitive-behavior therapy?

Re-evaluate the client's situation. Rationale: Cognitive behavioral therapy helps clients learn to control negative feelings. The nurse should re-evaluate the situation realistically and develop a positive insight in the client by replacing the negative thoughts. The nurse should not support the client's negative beliefs. The nurse should not give his or her own opinion on the client's thoughts, because doing so may make the client feel rejected. The nurse should not isolate the client from peers, because doing so could cause withdrawal and aggression in the client.

The nurse is discussing crisis intervention with a depressed client who lost a child in an accident. The client is self-blaming and has expressed suicidal ideation. What is the primary nursing intervention for the client?

Recommend hospitalization of the client. Rationale: Because the client has suicidal ideation, the client should be constantly monitored to ensure safety. Thus, the nurse should recommend hospitalizing the client. The nurse should later help the client to stop blaming him- or herself. Once the client stops having suicidal ideation and is safe, the nurse can advise the client to take part in religious services to relieve stress. When the client is admitted to the hospital the nurse can redefine the situation in a consoling manner by conducting cognitive therapy with the client.

The nurse is assessing a client for a possible personality disorder. Which finding does the nurse identify as feature of paranoid personality disorder?

Reluctance to answer any questions. Rationale: A person diagnosed with paranoid personality disorder generally views others with suspicion and may be reluctant to answer any questions. A person with diagnosed borderline personality disorder may have dichotomous thinking. People diagnosed with histrionic personality disorder may exhibit excessive emotionality to the extent of being considered melodramatic. A person diagnosed with dependent personality disorder may have low self-esteem and therefore be dependent on others for minor issues like answering questions. exemplified by splitting or an inability to view both the positive and negative aspects as a part of the whole.

A client experiences extreme anxiety in social situations and seems to have some intellectual and perceptual distortions but can be made aware of the misinterpretations of reality. With which disorder does the nurse expect the client to be diagnosed?

Schizotypal personality disorder. Rationale: People diagnosed with schizotypal personality disorder have severe social and interpersonal deficits. They experience anxiety in social situations. They may have some intellectual and perceptual distortions but can be made aware of reality, unlike those with schizophrenia. Schizoid personality disorder can be a precursor to schizophrenia or delusional disorder. People diagnosed with this disorder are emotionally detached loners who do not seek out or enjoy close relationships. People diagnosed with paranoid personality disorder tend to be afraid that others will harm or deceive them, so they are hostile and view others with suspicion. People diagnosed with obsessive-compulsive disorder have a fear of imminent catastrophe. They tend to rehearse over and over how they will respond in a social circumstance.

Which behavior is demonstrated by a client who engages in splitting with dichotomous thinking?

Sees things as divided into "all good" or "all bad." Rationale: Splitting demonstrates the failure to integrate the positive and negative into a cohesive whole. An individual is not seen as a person with good and bad traits, but rather as all good or all bad. Unconsciously repressing undesirable aspects of self, placing responsibility for behavior outside the self, or demonstrating a lack of personal boundaries are not behaviors considered part of splitting.

Which neurotransmitter has been implicated as playing a part in the decision to commit suicide?

Serotonin. Rationale: Low serotonin levels have been noted among individuals who have committed suicide. While γ-aminobutyric acid, dopamine and acetylcholine are neurotransmitters, they are not believed to be associated with suicidal ideations.

A client frantically reports to the nurse, "You have got to help me! Something terrible is happening. I can't think. My heart is pounding, and my head is throbbing." At what level should the nurse assess the client's anxiety?

Severe. Rationale: Severe anxiety is characterized by feelings of falling apart and impending doom, impaired cognition, and severe somatic symptoms such as headache and pounding heart. Mild to moderate anxiety would not involve a pounding heart and throbbing head. Panic-level anxiety would render a client unable to ask the nurse for help.

An adult with a family history of colon cancer has screening colonoscopies every 5 years. At age 55, the colonoscopy reveals a malignant tumor in the ascending colon. The nurse should assess this adult for which type of crisis?

Situational. Rationale: A situational crisis may occur after the loss or change of a job, the death of a loved one, an abortion, change in financial status, divorce, or severe illness. In this scenario, a situational crisis may occur despite the adult's predisposition to colon cancer. An adventitious crisis results from events that are unplanned and may be accidental, caused by nature, or human-made (natural disaster, a national disaster, or a crime of violence). A maturational crisis may occur associated with leaving home during late adolescence, marriage, birth of a child, retirement, or death of a parent. Each developmental stage represents a maturational crisis that is a critical period of increased vulnerability and, at the same time, heightened potential.

What is the most likely potential problem for a client diagnosed with severe obsessive-compulsive disorder?

Sleep disturbance. Rationale: Clients who must engage in compulsive rituals for anxiety relief rarely are afforded relief for any prolonged period. The high anxiety level and need to perform the ritual may interfere with sleep. Excessive socialization, command hallucinations, and altered states of consciousness are not typically associated with obsessive-compulsive disorder.

The nurse is assessing a client with a history of attempted suicide. Which method used by the client in the previous suicide attempt would put the client at higher risk?

Staging a car crash. Rationale: A method can be considered high or low risk based on the lethality, that is, how quickly a person can die using that particular method. Therefore, staging a car crash would put the client at higher risk. Ingesting pills, inhaling natural gas, and slashing one's wrists are considered low-risk methods. If the client uses these methods to commit suicide, there may be time to rescue the client from dying.

Which stage of critical incident stress debriefing includes acknowledgement of expressed symptoms?

Teaching phase. Rationale: Critical incident stress debriefing is a form of tertiary intervention for crisis and disaster management. It is a type of group therapy that consists of seven phases in which the clients share their thoughts, feelings, and ideas. In the teaching phase the clients acknowledge the normality of their symptoms. They are also taught about the symptoms of stress that they may anticipate in the future. The thought phase includes the sharing of ideas and thoughts between the clients of the group. In the reaction phase the participants talk about the painful events associated with the crisis incident. In the symptom phase participants describe their cognitive, physical, emotional, or behavioral experiences of the incident.

Which statements are true regarding tertiary crisis care?

The care may be provided on an outpatient basis, a goal is to have the client regain optimum function, a goal is the prevention of further crisis-related emotional disruption, and care focuses on recovery from a disabling mental state resulting from a crisis. Rationale: Tertiary care provides support for those who have experienced a severe crisis and are now recovering from a disabling mental state. Social and community facilities that offer tertiary intervention include rehabilitation centers, sheltered workshops, day hospitals, and outpatient clinics. Primary goals are to facilitate optimal levels of functioning and prevent further emotional disruptions.

The nurse is helping a client through deep breathing exercises when the client is experiencing severe anxiety. Which sign after performing this exercise would indicate that the client's anxiety has decreased?

The client demonstrates selective inattention. Rationale: In the client with severe anxiety, learning may be impaired because of inattention. The individual can focus on only one particular detail and has difficulty noticing what is going on in the environment, even if another person points it out. A client with moderate anxiety demonstrates selective inattention, wherein the client can perceive stimuli in the environment when it is pointed out. Therefore, for a client with severe anxiety, selective inattention indicates improvement. Being confused is an indicator of severe anxiety. Pacing, running, shouting, and false sensory perceptions would not be seen in a client with severe anxiety; these are manifestations of panic attack.

If a client's SAD PERSONS score is 5, what does this indicate regarding care?

The client should be strongly considered for hospitalization. Rationale: If the SAD PERSONS score for a client is 5, then the client should be strongly considered for hospitalization. If the score is 7 to 10, then the client should be immediately hospitalized. If the score is 3 to 4, then the client should be strictly followed up with on a regular basis. If the score is 0 to 2, then the client can be asked to go home and return for a follow-up.

In the absence of a previous suicide attempt, the nurse is most concerned about a risk for self-harm when the client shares which information?

The client was diagnosed with major depression 10 years ago. Rationale: Although previous suicide attempts indicate risk, the longer the time one spends depressed is also a major factor in determining the long-term risk of suicide. Divorce triggers depression in some individuals but is not the greatest risk factor among those provided. A history of depression in an immediate family member is considered a risk factor but is not the greatest risk factor provided, because it does not affect the client directly. Social isolation is considered a risk factor but is not the greatest risk factor among those provided. Episodic solitude may be normal in this individual.

In a teaching session, the nurse uses strategies that will induce a slight degree of anxiety for the clients attending the session. What is the nurse's intention for this action?

The clients will be more focused during the session. Rationale: Mild anxiety causes clients to see, listen, and grasp more information. This helps the clients to focus more on whatever is taught during the teaching session. Mild anxiety is unlikely to improve the clients' expression, comfort level, or willingness to participate.

Which principles related to crisis resolution direct the care provided by a crisis intervention nurse?

The goal of crisis intervention is for the client to regain pre-crisis level functioning, early intervention probably increases the chances for coping that is effective, and during a crisis, people often are more receptive than usual to outside intervention. Rationale: The goal of crisis intervention is to return the client to at least the pre-crisis level of functioning. During a crisis, people often are more receptive than usual to outside intervention. With intervention, the client can learn different adaptive means of problem solving to correct inadequate solutions. The nurse must be willing to take an active, even directive, role in intervention. Early intervention probably increases the chances for a good prognosis.

Which assumption serves as a foundation for the use of crisis intervention?

The individual is mentally healthy but in a state of disequilibrium. Rationale: The individual is mentally healthy but in a state of disequilibrium is the only true statement. Crisis intervention cannot address long-term dysfunctional adjustment. An anxious person is not likely to try new strategies. Crisis intervention nurses take an active role in working with the client.

The nurse assessing a client who survived a terrorist attack finds that the client is demonstrating impaired thinking and severe anxiety. Which strategy should the nurse implement while conducting crisis intervention for the client?

The nurse focuses on the present situation of the client, the nurse encourages the client to express feelings in a nondestructive manner, and the nurse assists the client to identify past coping skills. Rationale: While conducting the crisis intervention, the nurse should focus on the present situation of the client. It helps to plan an effective treatment plan. The nurse should encourage the client to express feelings in a nondestructive manner. It helps to ensure safety of others and the client. The nurse should assist the client to identify past coping skills. It helps the client to develop problem-solving and decision-making skills. The nurse should not give false assurance that the client will be fine within 2 days. It usually takes 4 to 6 weeks for the client to recover from a crisis. The nurse should encourage the client to focus on one implication at a time to avoid stress and confusion.

A nurse is planning crisis intervention for a client who has been diagnosed with acute stress and panic episodes. Which nursing intervention does the nurse implement while giving primary care to the client?

The nurse teaches relaxation techniques to the client. Rationale: Crisis interventions consist of three levels of care, including primary care, secondary care, and tertiary care. Primary care is intended to reduce stress and promote the mental health of the client. At this level the nurse teaches relaxation techniques to the client to reduce the stress. Secondary care is established during an acute crisis to prevent prolonged anxiety in the client. The nurse plans the crisis interventions based on the coping styles and support systems of the client. Tertiary care is provided to those clients who have experienced a severe crisis and are now recovering from a disabling mental state. At this level the nurse learns more about the clients' support systems and may suggest other support options that are available. The nurse might suggest such clients join a rehabilitation center, for instance.

A nurse observes a client's parents at an intensive care unit. The nurse determines that the client's parents have moderate anxiety. Which symptoms of anxiety did the nurse assess in the client's parents?

The parents were talking in trembling voices and the parents were having increased rates of respiration. Rationale: People having moderate anxiety have voice tremors and tend to talk in a trembling voice. They show increased pulse rate and respiratory rate. In severe anxiety, people are usually confused and are unable to make decisions. They cannot make decisions to solve problems at an optimum level. People with mild anxiety exhibit mild tension-relieving behavior such as foot or finger tapping and lip chewing.

Which statement is descriptive of clients diagnosed with personality disorders?

They are resistant to behavioral change. Rationale: Personality disorders are deeply ingrained and pervasive. Clients diagnosed with personality disorders find it very difficult, if not impossible, to change. Because they are so resistant to change, these clients do not often seek help. This makes a client easily frustrated and intolerant of pain. They have difficulty establishing and maintaining intimate relationships that are satisfying.

A 72-year-old client is diagnosed with Parkinson's disease and anxiety. The health care provider prescribes a benzodiazepine. The nurse knows to double-check this prescription based on what fact related to this classification of medications?

This medication would increase the client's risk for falls. Rationale: An important nursing intervention is to monitor for side effects of the benzodiazepines, including sedation, ataxia, and decreased cognitive function. In older adults who may have a higher risk of falls, a benzodiazepine may be contraindicated. There is no evidence to suggest that older adults become addicted faster than younger clients. Medication and other therapies are used congruently with all age levels. This classification of medications generally is not associated with nonadherence.

The nurse must initially assess a client in crisis for which equilibrium-focused behavior?

Unrealistic report of a crisis-precipitating event. Rationale: A person's equilibrium may be affected adversely by one or more of the following: an unrealistic perception of the precipitating event, inadequate situational supports, and inadequate coping mechanisms. These factors must be assessed when a crisis situation is evaluated because data gained from the assessment are used as guides for both the nurse and the client to set realistic and meaningful goals, as well as to plan possible solutions to the problem situation. Feelings of depression or anxiety and admission of drug use are important to the crisis management process, but they are secondary to assessing the client's report of the event.

A female client diagnosed with panic disorder is prescribed chlordiazepoxide. What is the most appropriate suggestion by the nurse?

Use contraceptive methods. Rationale: Chlordiazepoxide belongs to the benzodiazepine class of antianxiety drugs. It causes congenital anomalies in the fetus; therefore, the client should avoid becoming pregnant. Abruptly stopping the medication can cause withdrawal symptoms like dry mouth, tremors, and convulsions. The nurse should suggest discontinuing the medication after 3 to 4 months. Because caffeine decreases the efficacy of the benzodiazepines, the nurse should suggest the client avoid drinking coffee and tea.

Which situation supports the fact that a client has a lethal suicide plan?

Woods are behind the house is where the suicide will take place, client plans to activate the plan on the anniversary of the client's divorce, and client plans to jump from a bridge when the voices command him or her to do so. Rationale: The evaluation of a suicide plan is extremely important in determining the degree of suicidal risk. Three main elements must be considered when evaluating lethality: Is there a specific plan with details? How lethal is the proposed method? Is there access to the planned method? People who have definite plans for the time, place, and means are at high risk. Methods that include overdose and wrist slashing are considered soft or low-risk methods, thus decreasing the lethality of the plan.

A young woman reports that although she has no memory of the event, she believes that she was raped. This raises suspicion that she unknowingly ingested what drug?

γ-hydroxybutyrate (GHB). Rationale: The drugs most frequently used to facilitate a sexual assault (rape) are flunitrazepam (Rohypnol, "roofies") and GHB and its congeners. These drugs are odorless, tasteless, and colorless, mix easily with drinks, and can render a person unconscious in a matter of minutes. Perpetrators use these drugs because they rapidly produce disinhibition and relaxation of voluntary muscles; they also cause the victim to have lasting anterograde amnesia for events that occur. Cathinone is an amphetamine-like stimulant. Naltrexone is an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence. Clonidine is a centrally acting alpha-agonist hypotensive agent.