HESI-PSYCHIATRIC
The client states to the nurse during 1:1 therapy, "I have been having trouble sleeping the last few nights." What is the nurse's best response? (Select all that apply.)
"I have seen you up very early in the morning." "Help me understand what 'having trouble' means."
The nurse is reviewing a treatment plan with a client who just attempted suicide. Which client statement is most reassuring to the nurse?
"I have signed the contract that I will not hurt myself again."
The nurse is reviewing techniques of therapeutic communication with a student nurse. Which of the student's statements will the nurse indicate as therapeutic? (Select all that apply.)
"Am I correct in restating that you are feeling less anxious today?" "In looking back at what you said, you stated you are feeling better." "Help me understand what you are feeling today?"
A client on the behavioral health states, "I hear angles singing. They are calling me home." What is the nurse's best statement in response to this hallucination?
"Are you thinking of hurting yourself so you can join the angles?"
A 25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." What is the nurse's best response?
"Come with me to your room, and I will sit with you."
The nurse is caring for a client who was admitted after being stabilized for swallowing 10 sleeping tablets. What is the most important question for the nurse to ask?
"Do you still feel like harming yourself?"
A client of the Jewish faith is readmitted to the behavioral treatment unit with a diagnosis of depression. Which nurse's statement would the manager need to correct?
"Have you been saved by accepting Christ into your life?"
A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." What is the nurse's best response?
"How can I help you? Tell me more about your problems."
A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask?
"How much alcohol do you consume daily?"
The emergency department nurse is assigned to a client with a blood alcohol level of 0.14%. What questions will the nurse include in the assessment? (Select all that apply.)
"How much alcohol have you consumed today?" "When did you last consume alcohol?" "How long have you been drinking alcohol?"
A schizophrenic client who is taking fluphenazine decanoate is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching?
"I am going to have lots of fun at the beach and plenty of time in the sun."
A colleague of an inpatient client on a behavioral unit approaches a nurse and asks, "How is my friend doing?" What is the nurse's best response to the colleague? (Select all that apply.)
"I appreciate you asking, but I cannot share that information." "It is best to reach out to your colleague yourself."
A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best?
"I know these treatments must seem like torture to you, but we want to help you recover."
The nurse convenes a new group of clients who were in an abusive relationship. Which client statements does the nurse assess as appropriate for the first meeting? (Select all that apply.)
"I work at a local car dealership." "I have three children that live with me fulltime." "I attend worship services at the community church."
A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic?
"I'll leave your tray here. I am available if you need anything else."
The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression?
"I'm not very pretty or likeable."
The clinic nurse notes bruises in various stages of healing on the client's back and legs. What questions must the nurse include in the client's assessment? (Select all that apply.)
"Is anyone hurting your back and legs?" "When you and your spouse disagree, what happens to you?" "Has your spouse ever threatened you verbally or with violence?"
The nurse recognizes a client is rationalizing the outburst that just occurred in the dayroom. Which statement best reflects the nurse's assessment?
"It was okay that I broke the chairs; they were old anyway."
During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization?
"No matter what I do, I cannot make the voices go away."
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. What is the nurse's best response?
"Others have had similar thoughts when under stress."
One of the clients on the behavioral health unit states, "I am the savior and I am here to take all of you to heaven with me." What statements will the nurse include in this client's plan of care? (Select all that apply.)
"Please describe what you are seeing now." "Tell me what you are feeling at this moment." "You see yourself as the savior. I see you as my client."
A client states to the new nurse, "I can't tell you something important because you will tell the other nurses." What is a therapeutic response by the new nurse? (Select all that apply.)
"Since the information you have is important to you; I encourage you to share." "I urge you to tell me what is on your mind; you have something to disclose."
Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate?
"Tell me more about these accidents that your child has been having."
A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." What is the nurse's best response?
"What has worked for you in the past?"
A client reports to the nurse a profound feeling of sadness after the loss of a close parent. What is the nurse's best response?
"What you are feeling is a part of the grieving process."
At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make?
"Yes, I will be leading this group. What would you like to accomplish?"
The nurse on the behavioral health unit is concerned a new admission will develop withdrawal delirium. During which timeframe will the nurse pay particular attention to this client?
48 to 72 hours after last consumption
A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client?
A manic client who has started lithium carbonate treatment
Which activity will the nurse plan for the client in a manic phase of bipolar disorder?
Aerobics class
Based on the premise that those with like experiences can help each other, which groups will the nurse select for referral for clients with similar circumstances? (Select all that apply.)
Alcoholics anonymous Codependents anonymous Gamblers anonymous Overeaters anonymous Debtors anonymous
Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?
Allow the group to handle the problem.
When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.)
Oxygen Suction equipment Crash cart
A client believes that the health care provider is an FBI agent and that the agent's apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to be prescribed for this client?
Antipsychotic
The clinic nurse suspects a new client is suffering from posttraumatic stress disorder. Which assessments will the nurse include in the client's plan of care? (Select all that apply.)
Anxiety Sleep disturbances Flashbacks of stressful event
The emergency department nurse is concerned a client may develop signs of alcohol withdrawal. What assessments will the nurse include when providing care to this client? (Select all that apply.)
Anxiety Tachycardia Irritability Tremors
A 34-year-old client presents to the clinic with a 4 month old for routine well-baby care. The client is a long-term patient in the clinic, and the child has not been seen there before. Upon review of the client's chart, no pregnancy was ever confirmed or treated in the past. What are the nurse's best actions? (Select all that apply.)
Ask a coworker to alert the authorities for a potential child abduction. Perform routine care for the infant. Remain in the examination room and play with the newborn.
A client mumbles out loud regardless if anyone else is talking, and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which action should the nurse take first?
Ask the client how she has previously managed the voices.
Which actions will the nurse take for the client in a depressive phase? (Select all that apply.)
Ask the client, "Are you thinking of harming yourself?" Have the client sit in the day area and fill cups with bird feed. Encourage the client to take frequent rest periods. Stay with the client when performing daily hygiene and mouth care.
The nurse observes a newly admitted client stepping in and out of the dayroom multiple times. The client repeatedly states during the observed behavior, "I must not step on the crack between the hall and the dayroom." What are the nurse's next actions? (Select all that apply.)
Ask the client, "What were you thinking right before you stepped into the dayroom?" Provide the client with a protein bar and milkshake. State, "I see you repeatedly stepping in an out of the dayroom." Quietly ask the client, "Please come and sit with me so we can talk about your feelings."
The nurse is talking to a client with heightened anxiety. What actions will the nurse include when providing care for this client? (Select all that apply.)
Ask, "Do you have any idea what happened to increase your anxiety level?" Have the client review recent events that may have triggered the change. State, "Tell me what you are thinking and feeling now."
The nurse is assigned to a client admitted with paranoia. Which actions will the nurse include in the client's plan of care? (Select all that apply.)
Assess for suicide risk. Plan to care for the client when on duty. Provide a nonthreatening environment.
Which actions will the nurse take for the client admitted with mania? (Select all that apply.)
Assign the client to a private room. Assist the client with sweeping the floor of the unit. Provide the client with a chicken leg and carrot sticks.
A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam. When developing the nursing care plan for this client, which action would be most important for the nurse to include?
Assist client to focus on personal strengths.
The nurse is conducting a small group of overeaters anonymous. What characteristics will the nurse assess for in these clients? (Select all that apply.)
Binge overeating occurs without purging. The clients report feelings of helplessness about their weight.
The nurse is planning care for a client in the depressed phase of bipolar disorder. What foods will the nurse include in the client's plan of care? (Select all that apply.)
Celery filled with peanut butter A mixture of nuts and dried fruit Greek yogurt with mixed berries and granola
Two nurses are working together on a medical-surgical unit on the 1900 to 0700 shift. One nurse is showing signs of working impaired. What is the other nurse's next action?
Call the nursing supervisor
A client on the behavioral health unit is newly admitted with schizophrenia, and appears to be in a stupor. What is the nurse's best action?
Calmly sit with the client in five-minute intervals.
A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of confusion related to ICU psychosis. Which nursing action is best for this client's behavior?
Cluster care to allow for brief rest periods during the day.
An 84-year-old who lives alone reports to the clinic nurse the lack of transportation to buy food and an uncertainty of how bills are paid. What nursing actions will the nurse include in this client's plan of care? (Select all that apply.)
Compare the height and weight to previous findings Ask about the frequency of eating and how food is provided. Ask about the presence of family or close friends in the area.
The nurse assesses a new client admitted to an eating disorders unit in a behavioral health facility. The assessment reveals a female client, 18 years old, height 5′6″/167 cm and weight 108 pounds/49 kg. Temperature, blood pressure, and pulse are all below the anticipated findings for a client at this age. Which additional outward findings will the nurse look for in this client? (Select all that apply.)
Complaints of constipation Gum deterioration Scaly skin
A 24-year-old female presents to the emergency department with her best friend. She states to the intake nurse, "My husband forces me to have sex with him 2 to 3 times every day. Sometimes I tell him I don't want to, but then he gets mean with me, forces me on my stomach and has anal sex with me." What are the nurse's next actions? (Select all that apply.)
Contact a S.A.N.E. nurse. Assist the client into a private exam room.
A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression?
Depressed clients may be unaware of guilt feelings and should be encouraged to increase self-awareness.
The nurse manager is working with architects and child abduction specialists to design a state-of-the-art maternal-infant care unit. What safety features will the nurse manager request of the design team? (Select all that apply.)
Design the nurse's station so all exits are visible. Install an infant security monitoring system with sensor infant bands. Require all access points to the unit are monitored by a security camera. All doors must have electronic locks that can only be opened by approved personnel.
Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first?
Determine if the client still needs constant observation.
The nurse is working with family members of a client with advanced Alzheimer's disease. What client behaviors will the nurse include in the discussion with the family? (Select all that apply.) Rationale:
Difficulty walking independently Inability to eat independently Switching days and nights Bowel and urinary incontinence Unaware if surroundings
Which behavior indicates to the nurse that a client with paranoid ideas is improving?
Discusses his feelings of anxiety with the nurse.
What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam? (Select all that apply.)
Do not combine this medication with alcohol. This medication is typically used for short-term treatment. Avoid driving or operating equipment while taking this drug.
The nurse arrives to the unit at 2300 hours to start an 8-hour shift. A coworker scheduled to work with the nurse who started at 1900, appears to be under the influence of a central nervous system depressant. Which assessment findings, in combination with each other, lead the nurse to this conclusion? (Select all that apply.)
Drowsiness Irritability Unsteady gait Slurred speech
A client who has been hospitalized for 2 weeks for paranoia reports continuously to the staff that some clothing is missing from the closet. What is the correct action for the nurse to take based on the client's complaints?
Enroll the client in an exercise class to promote positive activities.
What is the primary goal of the nurse in the initial inpatient treatment for the client with anorexia nervosa?
Establish a trusting relationship.
hat is the priority nursing action three days after the admission of a client diagnosed with obsessive-compulsive disorder?
Establish a written contract with the client to gradually decrease the compulsive behaviors.
The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is impaired social interactions related to inability to trust. Which action is most important for the nurse to take first?
Greet the client by first name during each social interaction.
The nurse is in a 1:1 session with a client who reportedly drinks 750 mL of vodka per day. What questions will the nurse include in the initial client assessment? (Select all that apply.)
Have you ever wanted to drink less vodka in a day? Have you ever gotten angry with someone who points out to you how much vodka you drink? Have you ever had a drink early in the morning to get yourself up and moving? Have you ever felt guilty after the fact about behaviors displayed when drinking vodka?
The nurse is providing instructions for disulfiram therapy. Which client statement indicates an understanding of the instructions?
I will not drink alcohol during and after the therapy.
A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
Identification
Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.)
Importance of adherence to medication regimen Signs and symptoms of an exacerbation Chronic grief associated with long-term illness
The nurse cares for an adolescent with a history of violence who now exhibits signs of sublimation. Which behavior by the adolescent best represents sublimation?
Joined a competitive boxing team
The nurse is reviewing signs and symptoms of Alzheimer's disease with a new nurse to the unit. Which definition indicates the new nurse understands the term aphasia?
Language disturbance in understanding and stating words.
The nurse is caring for a client who is taking valproic acid. Which laboratory finding is most important to include in this client's record?
Liver function test results
Which activities will the nurse include in the care plan for the client admitted with depression? (Select all that apply.)
Low aerobic exercise class with others Walking the unit with an aide Making snack mix with one other client
A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse of poisoning attempts. The client's delusions are most likely related to which factor?
Low self-esteem
The nurse is performing in-service training on bullying to a group of elementary school teachers. The nurse indicates that the teachers must be alert to the signs a child is being bullied. What signs will the nurse share with the teachers? (Select all that apply.)
Low self-esteem Depression Social withdrawal
A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important?
Maintain a balanced diet and adequate exercise.
The nurse is attempting to communicate with a client newly admitted with Alzheimer's disease. What actions will the nurse include in the client's plan of care? (Select all that apply.)
Maintain eye contact when talking with the client. Call the client by name with each new interaction.
A client who was admitted two days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement?
Manipulation is being used to achieve the client's personal goals.
A unit employee receives a blow to the face when attempting to deescalate a client on the behavioral health unit. Physical restraints are placed on the client, and then the client is put into a seclusion room. What actions must the nurse take in the next hour? (Select all that apply.)
Meet the physical needs of the client. Obtain a prescription for the restraints. Objectively document the client's behaviors.
The nurse is developing a plan of care for a client on disulfiram therapy. Which products will the nurse include in the plan as items that must be avoided while taking this medication? (Select all that apply.)
Mouthwash Aftershave products Cough medicines
A client is admitted with a diagnosis of depression. Which characteristic is most indicative of depression?
Negative self-image
A newly admitted client to the behavioral health unit states, "I think my own mother is out to kill me. I saw her yesterday in the kitchen cutting up vegetables. I know that knife was meant for me." The nurse will initiate a plan of care based on which most likely medical diagnosis?
Paranoid disorder
The nurse is providing care to a client with Alzheimer's disease. Which actions will the nurse include in the client's plan of care? (Select all that apply.)
Place a picture of the client's family on the bedroom door. Walk with the client for 15 minutes at the same time every day.
For the client with an altered thought process, what will the nurse include in the client's plan of care? (Select all that apply.)
Place items from home in the client's room. Place a calendar on the wall across from the client's bed. Place a clock on the client's bedside table.
A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take first?
Prior to giving the next dose, notify the health care provider of these symptoms.
The nurse is conducting a teaching session with parents of school-age children. What information will the nurse plan on including in the teaching plan to help prevent against child abduction? (Select all that apply.)
Promote a play-pal, so the child does not go anywhere alone. Establish a code word that is only known between the parents and the child. Instruct the child to never accept a ride from a stranger or unapproved relative.
A 6-year-old learns of the recent death of a grandparent. The child and grandparent spent weekends together for the past four years. The parent notes the child has difficulty concentrating and seeks the advice of a healthcare provider. What will the nurse include in the parent's teaching plan? (Select all that apply.)
Promote activities that the child enjoys. Encourage the child to express feelings through coloring. Answer the child's questions honestly. Hold and cuddle the child to reinforce closeness.
A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which action should the nurse include in this client's plan of care?
Provide a structured environment with little stimuli.
On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to take?
Provide a well-balanced liquid diet for the client.
A client on the behavioral health unit admits to the nurse that a plan for suicide has been developed. What is the nurse's priority action?
Provide one-on-one supervision.
The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal?
Psychomotor agitation
On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorders?
Psychotic disorders
The client with Stage 3 Alzheimer's disease suddenly becomes agitated. What actions will the nurse take to settle the client? (Select all that apply.)
Reassure the client. Approach the client slowly. Speak to the client using a calm tone of voice.
A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take?
Redirect the client by offering an activity such as playing card games.
An adult client who lives in a residential facility is mentally delayed and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently engages in exposure to other residents. Which action should the nurse take first?
Redirect the client to physically demanding activities.
After a 20-day stay, the nurse is preparing the client for discharge from the behavioral therapy unit. What will the nurse include in the client's plan of care? (Select all that apply.)
Refer the client to an outpatient therapist. Determine the progress the client thus far. Evaluate if the client has met the projected outcomes.
While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position?
Reinforce reality to the client on the floor and remove him to a quiet space.
A client on the behavioral health unit bursts out in a verbal tirade in the dayroom. The client has a history of poor impulse control. What is the nurse's priority action?
Remove any other clients from the day room.
A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?
Report any case of suspected child abuse.
An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement?
Report as suspected child abuse.
A spouse reveals to the clinic nurse that physical abuse is occurring in the home. However, the client feels the need to remain in the home environment. What actions must the nurse take on behalf of this client? (Select all that apply.)
Report the physical abuse to the proper authorities. Provide the client with a hotline number for abuse victims. Work with the client to initiate a safety plan.
The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge?
Reports feeling better and less depressed
The client states to the therapy nurse, "I cannot remember a thing about any of the times my parent would burn me with a cigarette. I know it happened because I have the scars and my family tells me of those times." When developing the client's plan of care, which defense mechanism will the nurse include?
Repression
The emergency department nurse assesses a new client and finds constricted pupils, drowsiness, impaired memory, and slurred speech. Which vital sign would be most concerning to the nurse?
Respirations 10 breaths/min
An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens?
Restlessness and confusion
The client states to the nurse on the behavioral unit, "I do not want to stay in treatment any longer. I am feeling better, and I want to go home." What is the nurse's next action?
Review the client's chart for the type of admission to the unit.
The nurse on the behavioral unit notices a change in the client's behavior. When voluntarily admitted, the client appeared sad with mournful eyes, and frequent sighing. Upon the morning assessment, the client is noncommunicative and displays continuous rocking motions. What is the nurse's next action?
Review the client's medication list.
The nurse encounters a client with bipolar disorder in an aggressive state. What is the priority nursing action for this client?
Say, "If you throw that lamp you will need to stay in your room for 1 hour."
The nurse observes a client with Alzheimer's disease wandering. What actions will the nurse take for this client? (Select all that apply.)
Secure all doors to stairwells and outdoors. Walk with the client. Provide the client a clear path.
A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements?
She is projecting her feelings onto the nurse.
The nurse is conducting an intake interview for a new client. The client states, "My spouse was just diagnosed with pancreatic cancer. I do not know what to do." The client's plan of care will reflect which type of crisis?
Situational
A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he is being treated for dissociative disorder. Which data are consistent with this diagnosis? (Select all that apply.)
Sleepwalking Unable to remember who he is Exhibits multiple personalities
The therapy nurse is working with a group of nine veterans who observed traumatic death and violence on a daily basis while on duty. What actions will the nurse include in the veterans' plan of care? (Select all that apply.)
Speak using a calm nonaccusatory tone of voice, and do not pass judgment. With each subsequent session, explore each traumatic experience more deeply. Encourage each veteran to express current feelings to survival of the traumatic event.
The nurse assess a client on an inpatient behavioral unit is becoming increasingly anxious. What initial actions should the nurse take for this client? (Select all that apply.)
Stay by the client's side. Escort the client to a quiet place. Use a comforting tone of voice when speaking to the client.
The clinic nurse notes in a new client a spontaneous onset of hyperventilation, tremulousness, and an inability to concentrate. What is the nurse's priority action?
Stay with the new client.
The nurse is assigned to a client admitted with paranoia. Which assessments will the nurse include in the client's plan of care? (Select all that apply.)
Suspiciousness Distrusting Argumentative Grandiosity
The parent and a 6-year-old present to the clinic for routine well-child care. The child weighs 35 pounds 15.9 kg; is wearing torn and dirty clothing; and, sits quietly with an apparent subtle rocking motion. What are the nurse's next actions? (Select all that apply.)
Take the child's height, and vital signs. Assess the child for any bruising, or lacerations. Ask the accompanying parent to leave the room. Ask the child about attendance at school. Stay with the child during the healthcare provider's assessment.
A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate?
Take the client's vital signs and notify the health care provider immediately.
A client is admitted with a medical diagnosis of dissociative identity disorder. The nurse will build the client's care plan based on which understanding of the personalities?
The alternate personalities are aware of the host
The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority?
The child will be protected from further harm.
The nurse at an adult day care center is assessing a new client. The nurse is concerned the client has dementia. Which characteristics support the nurse's concern? (Select all that apply.)
The client cannot remember what was served for breakfast 30 minutes ago. The client thinks it is permissible to drive without a license.
Which actions leads the nurse to assess the client is in a manic phase? (Select all that apply.)
The client is quickly angered. A flight of ideas is displayed by the client.
The therapy nurse is working with a client admitted with an erratic type of personality disorder. Which client behaviors indicate to the nurse that the therapy is beginning to be effective? (Select all that apply.)
The client no longer wishes to do self-harm. The client no longer displayed manipulative behaviors. Attention seeking behaviors are no longer evident.
The nurse is providing care to four clients. Which client will the nurse assess for symptoms of withdrawal?
The client who consumes 800 mL of grain alcohol every day for 3 years
The nurse is working to establish a contract with a client with anorexia nervosa. What measurable goals will the nurse include in the contract? (Select all that apply.)
The client will not lose any more than 1/2 pound a week. The client will exercise no more than 15 minutes a day. The client will select 1 each of dairy, protein, carbohydrate and fruit/vegetable for each meal. The client will eat no less than 50% of the requested meal at each mealtime.
The clinic nurse includes in the client's plan of care the number for Al-Anon. Which client will benefit most from this information?
The spouse whose partner drinks 5 to 8 mixed drinks per day.
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?
The usual activity patterns of each group member
