Mental Health & Psych Nursing #1-NurseLabs
6. During postprandial monitoring, a female client with bulimia nervosa tells the nurse, "You can sit with me, but you're just wasting your time. After you had sat with me yesterday, I was still able to purge. Today, my goal is to do it twice." What is the nurse's best response? A. "I trust you not to purge." B. "How are you purging and when do you do it?" C. "Don't worry. I won't allow you to purge today." D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat."
D. "I know it's important for you to feel in control, but I'll monitor you for 90 minutes after you eat." This response acknowledges that the client is testing limits and that the nurse is setting them by performing postprandial monitoring to prevent self-induced emesis. Clients with bulimia nervosa need to feel in control of the diet because they feel they lack control over all other aspects of their lives.
16. Nurse Harry is developing a plan of care for a client with anorexia nervosa. Which action should the nurse include in the plan? A. Restrict visits with the family until the client begins to eat B. Provide privacy during meals C. Set up a strict eating plan for the client D. Encourage the client to exercise, which will reduce her anxiety
C. Set up a strict eating plan for the client Establishing a consistent eating plan and monitoring the client's weight are important for this disorder.
14. A 24-year old client with anorexia nervosa tells the nurse, "When I look in the mirror, I hate what I see. I look so fat and ugly." Which strategy should the nurse use to deal with the client's distorted perceptions and feelings? A. Avoid discussing the client's perceptions and feelings B. Focus discussions on food and weight C. Avoid discussing unrealistic cultural standards regarding weight D. Provide objective data and feedback regarding the client's weight and attractiveness
D. Provide objective data and feedback regarding the client's weight and attractiveness By focusing on reality, this strategy may help the client develop a more realistic body image and gain self-esteem.
45. A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous
A. Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism.
1. Flumazenil (Romazicon) has been ordered for a male client who has overdosed on oxazepam (Serax). Before administering the medication, nurse Gina should be prepared for which common adverse effect? A. Seizures B. Shivering C. Anxiety D. Chest pain
A. Seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose.
28. Nurse Fey is aware that the drug of choice for treating Tourette syndrome? A. Fluoxetine (Prozac) B. Fluvoxamine (Luvox) C. Haloperidol (Haldol) D. Paroxetine (Paxil)
C. Haloperidol (Haldol) Haloperidol is the drug of choice for treating Tourette syndrome.
48. Macoy and Helen seek emergency crisis intervention because he slapped her repeatedly the night before. The husband indicates that his childhood was marred by an abusive relationship with his father. When intervening with this couple, nurse Gerry knows they are at risk for repeated violence because the husband: A. Has only moderate impulse control B. Denies feelings of jealousy or possessiveness C. Has learned violence as an acceptable behavior D. Feels secure in his relationship with his wife
C. Has learned violence as an acceptable behavior Family violence usually is a learned behavior, and violence typically leads to further violence, putting this couple at risk.
5. A male client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is Nurse Alice most likely to administer to reduce the symptoms of alcohol withdrawal? A. Naloxone (Narcan) B. Haloperidol (Haldol) C. Magnesium sulfate D. Chlordiazepoxide (Librium)
D. Chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal.
24. Eighteen hours after undergoing an emergency appendectomy, a client with a reported history of social drinking displays these vital signs: temperature, 101.6° F (38.7° C); heart rate, 126 beats/minute; respiratory rate, 24 breaths/minute; and blood pressure, 140/96 mm Hg. The client exhibits gross hand tremors and is screaming for someone to kill the bugs in the bed. Nurse Melinda should suspect: A. A postoperative infection B. Alcohol withdrawal C. Acute sepsis. D. Pneumonia.
B. Alcohol withdrawal The client's vital signs and hallucinations suggest delirium tremens or alcohol withdrawal syndrome.
20. When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority? A. Client's physical needs B. Client's safety needs C. Client's psychosocial needs D. Client's medical needs
B. Client's safety needs The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily.
30. A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks one (1) qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness
D. Diaphoresis, tremors, and nervousness Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.
23. A female client with anorexia nervosa describes herself as "a whale." However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should nurse Angel be included in the plan of care? A. Asking the client to compare her figure with magazine photographs of women her age B. Assigning the client to group therapy in which participants provide realistic feedback about her weight C. Confronting the client about her actual appearance during one-on-one sessions, scheduled during each shift D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy
D. Telling the client of the nurse's concern for her health and desire to help her make decisions to keep her healthy A client with anorexia nervosa has an unrealistic body image that causes consumption of little or no food. Therefore, the client needs assistance with making decisions about health.
10. For a female client with anorexia nervosa, nurse Rose plans to include the parents in therapy sessions along with the client. What fact should the nurse remember to be typical of parents of clients with anorexia nervosa? A. They tend to overprotect their children B. They usually have a history of substance abuse C. They maintain emotional distance from their children D. They alternate between loving and rejecting their children
A. They tend to overprotect their children Clients with anorexia nervosa typically come from a family with parents who are controlling and overprotective. These clients use eating to gain control of an aspect of their lives.
25. Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal
C. Opiate withdrawal Clonidine is used as adjunctive therapy in opiate withdrawal.
46. A female client is admitted to the psychiatric clinic for treatment of anorexia nervosa. To promote the client's physical health, nurse Tair should plan to: A. Severely restrict the client's physical activities B. Weigh the client daily, after the evening meal C. Monitor vital signs, serum electrolyte levels, and acid-base balance D. Instruct the client to keep an accurate record of food and fluid intake
C. monitor vital signs, serum electrolyte levels, and acid-base balance An anorexic client who requires hospitalization is in poor physical condition from starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid-base balance is crucial.
4. Which of the following drugs should Nurse Mary prepare to administer to a client with a toxic acetaminophen (Tylenol) level? A. Deferoxamine mesylate (Desferal )B. Succimer (Chemet) C. Flumazenil (Romazicon) D. Acetylcysteine (Mucomyst)
D. Acetylcysteine (Mucomyst) The antidote for acetaminophen toxicity is acetylcysteine. It enhances conversion of toxic metabolites to nontoxic metabolites.
31. When monitoring a female client recently admitted for treatment of cocaine addiction, nurse Aaron notes sudden increases in the arterial blood pressure and heart rate. To correct these problems, the nurse expects the physician to prescribe: A. Norepinephrine (Levophed) and Lidocaine (Xylocaine) B. Nifedipine (Procardia) and Lidocaine. C. Nitroglycerin (Nitro-Bid IV) and Esmolol (Brevibloc) D. Nifedipine and Esmolol
D. Nifedipine and Esmolol This client requires a vasodilator, such as nifedipine, to treat hypertension, and a beta-adrenergic blocker, such as esmolol, to reduce the heart rate.
3. A female client who's at high risk for suicide needs close supervision. To best ensure the client's safety, Nurse Mary should: A. Check the client frequently at irregular intervals throughout the night B. Assure the client that the nurse will hold in confidence anything the client says C. Repeatedly discuss previous suicide attempts with the client D. Disregard decreased communication by the client because this is common with suicidal clients
A. Check the client frequently at irregular intervals throughout the night Checking the client frequently but at irregular intervals prevents the client from predicting when observation will take place and altering behavior in a misleading way at these times.
8. For a female client with anorexia nervosa, Nurse Jimmy is aware that which goal takes the highest priority? A. The client will establish adequate daily nutritional intake B. The client will make a contract with the nurse that sets a target weight C. The client will identify self-perceptions about body size as unrealistic D. The client will verbalize the possible physiological consequences of self-starvation
A. The client will establish adequate daily nutritional intake According to Maslow's hierarchy of needs, all humans need to meet basic physiological needs first. Because a client with anorexia nervosa eats little or nothing, the nurse must first plan to help the client meet this basic, immediate physiological need.
13. Nurse Mary is assigned to care for a suicidal client. Initially, which is the nurse's highest care priority? A. Assessing the client's home environment and relationships outside the hospital B. Exploring the nurse's own feelings about suicide C. Discussing the future with the client D. Referring the client to a clergyperson to discuss the moral implications of suicide
B. Exploring the nurse's own feelings about suicide The nurse's values, beliefs, and attitudes toward self-destructive behavior influence responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse initially must explore personal feelings about suicide to avoid conveying negative feelings to the client.
49. A client whose husband just left her has a recurrence of anorexia nervosa. Nurse Vic caring for her realizes that this exacerbation of anorexia nervosa results from the client's effort to: A. Manipulate her husband B. Gain control of one part of her life C. Commit suicide D. Live up to her mother's expectations
B. Gain control of one part of her life By refusing to eat, a client with anorexia nervosa is unconsciously attempting to gain control over the only part of her life she feels she can control.
41. Nurse Amy is aware that the client is at highest risk for suicide? A. One who appears depressed frequently thinks of dying and gives away all personal possessions B. One who plans a violent death and has the means readily available C. One who tells others that he or she might do something if life doesn't get better soon D. One who talks about wanting to die
B. One who plans a violent death and has the means readily available The client at highest risk for suicide is one who plans a violent death (for example, by gunshot, jumping off a bridge, or hanging), has a specific plan (for example, after the spouse leaves for work), and has the means readily available (for example, a rifle hidden in the garage).
32. A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle B. The client will work with the nurse to remain safe C. The client will drink plenty of fluids daily D. The client will make a personal inventory of strength
B. The client will work with the nurse to remain safe The priority goal in alcohol withdrawal is maintaining the client's safety.
43. Kellan, a high school student is referred to the school nurse for suspected substance abuse. Following the nurse's assessment and interventions, what would be the most desirable outcome? A. The student discusses conflicts over drug use B. The student accepts a referral to a substance abuse counselor C. The student agrees to inform his parents of the problem D. The student reports increased comfort with making choice
B. The student accepts a referral to a substance abuse counselor All of the outcomes stated are desirable; however, the best outcome is that the student would agree to seek the assistance of a professional substance abuse counselor
18. A male client is hospitalized with fractures of the right femur and right humerus sustained in a motorcycle accident. Police suspect the client was intoxicated at the time of the accident. Laboratory tests reveal a blood alcohol level of 0.2% (200 mg/dl). The client later admits to drinking heavily for years. During hospitalization, the client periodically complains of tingling and numbness in the hands and feet. Nurse Gian realizes that these symptoms probably result from: A. Acetate accumulation B. Thiamine deficiency C. Triglyceride buildup. D. A below-normal serum potassium level
B. Thiamine deficiency Numbness and tingling in the hands and feet are symptoms of peripheral polyneuritis, which results from inadequate intake of vitamin B1 (thiamine) secondary to prolonged and excessive alcohol intake. Treatment includes reducing alcohol intake, correcting nutritional deficiencies through diet and vitamin supplements, and preventing such residual disabilities as foot and wrist drop.
50. A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy
B. Total abstinence Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.
27. A 14-year-old client was brought to the clinic by her mother. Her mother expresses concern about her daughter's weight loss and constant dieting. Nurse Kris conducts a health history interview. Which of the following comments indicates that the client may be suffering from anorexia nervosa? A. "I like the way I look. I just need to keep my weight down because I'm a cheerleader." B. "I don't like the food my mother cooks. I eat plenty of fast food when I'm out with my friends." C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." D. "I do diet around my periods; otherwise, I just get so bloated."
C. "I just can't seem to get down to the weight I want to be. I'm so fat compared to other girls." Low self-esteem is the highest risk factor for anorexia nervosa. Constant dieting to get down to a "desirable weight" is characteristic of the disorder. Feeling inadequate when compared to peers indicates poor self-esteem.
42. Nurse Penny is aware that the following medical conditions is commonly found in clients with bulimia nervosa? A. Allergies B. Cancer C. Diabetes mellitus D. Hepatitis A
C. Diabetes mellitus Bulimia nervosa can lead to many complications, including diabetes, heart disease, and hypertension.
2. Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to: A. Avoid shopping for large amounts of food B. Control eating impulses C. Identify anxiety-causing situations D. Eat only three meals per day
C. Identify anxiety-causing situations Bulimic behavior is generally a maladaptive coping response to stress and underlying issues. The client must identify anxiety-causing situations that stimulate the bulimic behavior and then learn new ways of coping with the anxiety.
44. A male client who reportedly consumes one (1) qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, Dr. Smith is most likely to prescribe which drug? A. Clozapine (Clozaril) B. Thiothixene (Navane) C. Lorazepam (Ativan) D. Lithium carbonate (Eskalith)
C. Lorazepam (Ativan) The best choice for preventing or treating alcohol withdrawal symptoms is lorazepam, a benzodiazepine.
26. A male client with a history of cocaine addiction is admitted to the coronary care unit for evaluation of substernal chest pain. The electrocardiogram (ECG) shows a 1-mm ST-segment elevation the anteroseptal leads and T-wave inversion in leads V3 to V5. Considering the client's history of drug abuse, nurse Greg expects the physician to prescribe: A. Lidocaine (Xylocaine). B. Procainamide (Pronestyl) .C. Nitroglycerin (Nitro-Bid IV). D. Epinephrine.
C. Nitroglycerin (Nitro-Bid IV). The elevated ST segments in this client's ECG indicate myocardial ischemia. To reverse this problem, the physician is most likely to prescribe an infusion of nitroglycerin to dilate the coronary arteries.
40. Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mmHg D. Blood pressure of 140/80 mmHg
A. Heart rate of 120 to 140 beats/minute Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.
17. Nurse Taylor is aware that the victims of domestic violence should be assessed for what important information? A. Reasons they stay in the abusive relationship (for example, lack of financial autonomy and isolation) B. Readiness to leave the perpetrator and knowledge of resources C. Use of drugs or alcohol D. History of previous victimization
B. Readiness to leave the perpetrator and knowledge of resources Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready.
35. A female client with borderline personality disorder is admitted to the psychiatric unit. Initial nursing assessment reveals that the client's wrists are scratched from a recent suicide attempt. Based on this finding, the nurse Lenny should formulate a nursing diagnosis of: A. Ineffective individual coping related to feelings of guilt. B. Situational low self-esteem related to feelings of loss of control C. Risk for violence: Self-directed related to impulsive mutilating acts D. Risk for violence: Directed toward others related to verbal threats
C. Risk for violence: Self-directed related to impulsive mutilating acts The predominant behavioral characteristic of the client with borderline personality disorder is impulsiveness, especially of a physically self-destructive sort. The observation that the client has scratched wrists doesn't substantiate the other options.
29. A male client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from nurse Julia? A. "Why didn't you get someone else to drive you?" B. "Tell me how you feel about the accident." C. "You should know better than to drink and drive." D. "I recommend that you attend an Alcoholics Anonymous meeting."
B. "Tell me how you feel about the accident." An open-ended statement or question is the most therapeutic response. It encourages the widest range of client responses, makes the client an active participant in the conversation, and shows the client that the nurse is interested in his feelings.
15. Nurse Alice is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese
B. Aftershave lotion Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions.
37. A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink six (6) hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to: A. Begin after seven (7) days B. Not occur at all because the time period for their occurrence has passed C. Begin anytime within the next one (1) to two (2) days D. Begin within two (2) to seven (7) days
C. Begin anytime within the next one (1) to two (2) days Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.
33. A male client is admitted to a psychiatric facility by court order for evaluation for antisocial personality disorder. This client has a long history of initiating fights and abusing animals and recently was arrested for setting a neighbor's dog on fire. When evaluating this client for the potential for violence, nurse Perry should assess for which behavioral clues? A. A rigid posture, restlessness, and glaring B. Depression and physical withdrawal C. Silence and noncompliance D. Hypervigilance and talk of past violent acts
A. A rigid posture, restlessness, and glaring Behavioral clues that suggest the potential for violence includes: a rigid posture, restlessness, glaring, a change in usual behavior, clenched hands, overtly aggressive actions, physical withdrawal, noncompliance, overreaction, hostile threats, recent alcohol ingestion or drug use, talk of past violent acts, inability to express feelings, repetitive demands and complaints, argumentativeness, profanity, disorientation, inability to focus attention, hallucinations or delusions, paranoid ideas or suspicions, and somatic complaints.
21. The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? A. Accept responsibility for own behaviors B. Be able to verbalize own needs and assert rights. C. Set firm and consistent limits with the client D. Allow the child to establish his own limits and boundaries
A. Accept responsibility for own behaviors Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child.
47. Kevin is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with: A. Antisocial personality disorder B. Borderline personality disorder C. Obsessive-compulsive personality disorder D. Narcissistic personality disorder
A. Antisocial personality disorder The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others.
36. A male client recently admitted to the hospital with sharp, substernal chest pain suddenly complains of palpitations. Nurse Ryan notes a rise in the client's arterial blood pressure and a heart rate of 144 beats/minute. On further questioning, the client admits to having used cocaine recently after previously denying use of the drug. The nurse concludes that the client is at high risk for which complication of cocaine use? A. Coronary artery spasm B. Bradyarrhythmias C. Neurobehavioral deficits D. Panic disorder
A. Coronary artery spasm Cocaine use may cause such cardiac complications as coronary artery spasm, myocardial infarction, dilated cardiomyopathy, acute heart failure, endocarditis, and sudden death. Cocaine blocks reuptake of norepinephrine, epinephrine, and dopamine, causing an excess of these neurotransmitters at postsynaptic receptor sites.
38. Nurse Helen is assigned to care for a client with anorexia nervosa. Initially, which nursing intervention is most appropriate for this client? A. Providing one-on-one supervision during meals and for one (1) hour afterward B. Letting the client eat with other clients to create a normal mealtime atmosphere C. Trying to persuade the client to eat and thus restore nutritional balance D. Giving the client as much time to eat as desired
A. Providing one-on-one supervision during meals and for one (1) hour afterward Because the client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 hour afterward.
9. When interviewing the parents of an injured child, which of the following is the strongest indicator that child abuse may be a problem? A. The injury isn't consistent with the history or the child's age B. The mother and father tell different stories regarding what happened C. The family is poor D. The parents are argumentative and demanding with emergency department personnel
A. The injury isn't consistent with the history or the child's age When the child's injuries are inconsistent with the history given or impossible because of the child's age and developmental stage, the emergency department nurse should be suspicious that child abuse is occurring.
7. A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"
B. "You told me you got fired from your last job for missing too many days after taking drugs all night." Confronting the client with the consequences of substance abuse helps to break through denial.
11. In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? A. Remaining with the client and staying calm B. Calling a security guard and another staff member for assistance C. Telling the client's husband that he must leave at once D. Determining why the husband feels so angry
B. Calling a security guard and another staff member for assistance The health care worker who witnesses this scene must take precautions to ensure personal as well as client safety but shouldn't attempt to manage a physically aggressive person alone. Therefore, the first priority is to call a security guard and another staff member.
12. Nurse Mary is caring for a client with bulimia. Strict management of dietary intake is necessary. Which intervention is also important? A. Fill out the client's menu and make sure she eats at least half of what is on her tray. B. Let the client eat her meals in private. Then engage her in social activities for at least 2 hours after each meal C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal D. Let the client eat food brought in by the family if she chooses, but she should keep a strict calorie count.
C. Let the client choose her own food. If she eats everything she orders, then stay with her for 1 hour after each meal Allowing the client to select her own food from the menu will help her feel some sense of control.
39. A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time? A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes
C. Providing a quiet environment and administering medication as needed and prescribed Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment for reducing stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing oversedation.
19. A parent brings a preschooler to the emergency department for treatment of a dislocated shoulder, which allegedly happened when the child fell down the stairs. Which action should make the nurse suspect that the child was abused? A. The child cries uncontrollably throughout the examination B. The child pulls away from contact with the physician. C. The child doesn't cry when the shoulder is examined D. The child doesn't make eye contact with the nurse.
C. The child doesn't cry when the shoulder is examined A characteristic behavior of abused children is the lack of crying when they undergo a painful procedure or are examined by a health care professional. Therefore, the nurse should suspect child abuse.
34. A male client is brought to the psychiatric clinic by family members, who tell the admitting nurse that the client repeatedly drives while intoxicated despite their pleas to stop. During an interview with the nurse Linda, which statement by the client most strongly supports a diagnosis of psychoactive substance abuse? A. "I'm not addicted to alcohol. In fact, I can drink more than I used to without being affected." B. "I only spend half of my paycheck at the bar." C. "I just drink to relax after work." D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me."
D. "I know I've been arrested three times for drinking and driving, but the police are just trying to hassle me." According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, diagnostic criteria for psychoactive substance abuse include a maladaptive pattern of such use, indicated either by continued use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem caused or exacerbated by substance abuse or recurrent use in dangerous situations (for example, while driving).
22. A male client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, he sits staring blankly at his bleeding wrists while staff members call for an ambulance. How should Nurse Anuktakanuk approach her initially? A. Enter the room quietly and move beside him to assess his injuries B. Call for staff back-up before entering the room and restraining him C. Move as much glass away from him as possible and sit next to him quietly D. Approach him slowly while speaking in a calm voice, calling him name, and telling him that the nurse is here to help him
D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her Ensuring the safety of the client and the nurse is the priority at this time. Therefore, the nurse should approach the client cautiously while calling her name and talking to her in a calm, confident manner.
