Mental Health - Archer Review (1/2)

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Admission - - Involuntary Medications - - Valproic acid Monitoring - - Enhanced observation

The client is exhibiting manifestations consistent with __________ personality disorder. The nurse should prioritize assessing the client for _________ When developing a plan of care for this client, it is strongly recommended that the nurse obtain a prescription for ________

Boarderline, Suicide, Outpatient therapy

The nurse is caring for a client who has a factitious disorder. The client reports chest pain. Which of the following actions should the nurse take? Select all that apply. Provide reassurance that this is part of the disorder Notify the primary healthcare physician (PHCP) Obtain a 12-lead Electrocardiogram Disregard the symptom as it may be unreliable Assess vital signs

Choices B, C, and E are correct. Chest pain is a worrisome manifestation as it may be a clinical finding associated with myocardial infarction, pulmonary embolism, or other pathology. Despite the client having factitious disorder, which is characterized by the client feigning their symptoms, the nurse should intervene by notifying the PHCP, obtaining a 12-lead Electrocardiogram, and assessing vital signs. This is the standard of care for any client reporting an acute change such as angina.

The nurse reviews the physician's progress note The nurse is providing discharge education regarding the prescribed valproic acid. Which statement, if made by the client, requires follow-up? - "I will need follow-up laboratory work while taking this medication." - "I may need to take a multivitamin while taking this medication." - "It is okay for me to skip a dose of this medication if I get nausea." - "I should notify my physician if I notice any yellowing of my eyes."

- "It is okay for me to skip a dose of this medication if I get nausea."

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Hypomania - - Talkative and able to still go to work Mania - - Impairment in insight and judgement - Worsening of symptoms leading to work absenteeism - Visual hallucinations

Drag one (1) prescription and one (1) nurse's note finding to complete the sentence Based on the client's clinical data, the nurse should immediately ______ based on the client's ______

Initiate 0.9% saline infusion, Severe dehydration

A nurse is caring for a child who has autism. Which of the following actions should the nurse take? Select all that apply. Withhold prescribed vaccines Have a family member bring in the child's favorite toys Dim the lights in the room Seclude the child for any misconduct Maintain consistent caregivers

Choices B, C, and E are correct. Clients with autism do well with an established routine; thus, having familiar objects from home is effective nursing care. Further, a low-stimulation environment with dim lights and low noise is more conducive for a client with autism. Finally, consistent caregivers may decrease the anxiety associated with change.

The nurse is preparing to administer a dose of valproic acid to the client. The nurse should be prepared to monitor which laboratory data while the client takes this medication? Select all that apply Complete blood count Liver function tests Arterial blood gas Urine electrolytes Valproic acid level

Complete blood count Liver function tests Valproic acid level

The nurse assesses the client and reviews the history and physical. Which client finding has the nurse most concerned? The client's expansive affect. impaired judgment. medication adherence. inability to stay on topic.

impaired judgment.

Drag words from the choices below to fill the blank in the following sentence The client most likely has ________ The client is at greatest risk for _______

mania, self-harm

The nurse is assessing a client with possible bipolar I disorder. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which laboratory testing? A. Thyroid Stimulating Hormone (TSH) B. Complete Metabolic Panel (CMP) C. Glycated Hemoglobin A1C (HbA1c) D. C-Reactive Protein (CRP)

Choice A is correct. A TSH is the standard of care before diagnosing a mood disorder such as bipolar disorder or major depressive disorder. While this test does not confirm the presence of a mood disorder, it excludes alterations of the thyroid, which could alternatively explain the client's symptoms.

The nurse educator is talking to a group of students regarding anorexia nervosa. Which statement by the students indicates an understanding of the condition? A. "Impulsivity and perfectionism are personality traits highly associated with anorexia nervosa." B. "Clients with anorexia nervosa display a binge-purge behavior." C. "Clients with anorexia nervosa have poor dental conditions." D. "Clients with anorexia nervosa have esophagitis, esophageal erosions, or ulcers."

Choice A is correct. Clients with anorexia nervosa have the desire to please others; thus, impulsivity and perfectionism are personality traits highly associated with anorexia nervosa. These clients often feel the need to be "perfect" to cope with stress or other self-perceived concerns.

The nurse has established a support group for individuals with major depressive disorder (MDD). The nurse recognizes that this support group is A. tertiary prevention. B. primary prevention. C. secondary prevention. D. essential prevention.

Choice A is correct. Establishing a support group for individuals with a disease or disorder to maximize their functioning is tertiary prevention.

A 12-year-old client with chronic asthma exacerbations has decided to try guided imagery as a way to manage the anxiety that is contributing to frequent asthma attacks. Which statement by the client indicates an understanding of this stress-reduction technique? A. "I can do this anytime and anywhere when I feel anxious." B. "I must be lying down to practice guided imagery." C. "My mom will have to be with me any time I try this." D. "I will play music every time I do my guided imagery to make sure it works."

Choice A is correct. Guided imagery is a stress-reduction technique that can be done in any place at any time. In fact, this is one of the biggest advantages of this technique. Anytime the patient begins to feel anxious, they can practice guided imagery.

Which type of care environment is the most therapeutic and conducive for treating clients with emotional and behavioral issues? A. A milieu therapy B. A locked environment C. One employing mindfulness therapy D. One employing universal seclusion

Choice A is correct. Milieu refers to a physical and social environment. Milieu therapy is a psychiatric philosophy that involves a secure environment, including people, settings, structure, and a specific emotional climate to support client recovery. Milieu therapy takes advantage of the naturally occurring events in the client's environment to utilize these events as learning opportunities for clients. A consistent routine and structure are maintained to give clients predictability and trust.

The nurse in the emergency department is triaging a client with multiple burns and bruises to the upper and lower extremities. The client states that her spouse gave her these injuries during an argument. The nurse should take which initial action? A. Assess and treat the injuries B. Consult a social worker for discharge planning C. Establish a therapeutic rapport D. Report the alleged abuse to authorities

Choice A is correct. The initial concern for the client is her physical stability. The nurse should always put physical needs first; in this case, the nurse should initially assess and treat the wounds. By addressing the client's bodily injuries, the nurse can move on to keep the client safe by providing reassurance, establishing a therapeutic rapport, and reporting the alleged domestic violence incident to authorities.

The school nurse assesses a 12-year-old boy who came into her office for a nosebleed. She notices several bruises on his back and forearms in various healing stages. When she asks the boy about them, he is very deceptive. The nurse notifies child protective services of her suspicion. The next day, the boy's mother comes to the nurse's office and yells at her for calling child protective services. Which of the following responses is most appropriate? A. "I am required by law to report any suspected violence." B. "You should have thought about this before you abused your son." C. "I'm so sorry. Please don't take this out on me." D. "Don't talk to me about this. I don't want to see you."

Choice A is correct. The nurse is a mandatory reporter of any suspected violence and is required by law to report her suspicions. Parents may become upset and confront the nurse when these allegations come to light, but that should not stop the nurse from saying what she has seen. The nurse should remain calm when the parent confronts her and state that she is required to report any suspected violence.

Which of the following patients is at greatest risk for sensory deprivation? A. An older man who is confined to bed at home following a stroke. B. An adoterm-80lescent in an oncology unit who is working on homework supplied by her friends. C. A woman in active labor. D. A toddler in a playroom awaiting same-day surgery.

Choice A is correct. The patient in this option is confined to bed and has visits/interactions with others that may be limited leading to sensory deprivation. The reticular activating system (RAS) is a network of neurons located in the brain stem that projects anteriorly to the hypothalamus to mediate behavior. Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. With decreased sensory input, the RAS is no longer able to project a normal level of activation to the brain. As a result, the person may hallucinate simply to maintain an optimal level of arousal.Factors that place patients at a higher risk for sensory deprivation may include: An environment that has decreased stimuli Impaired ability to receive environmental stimuli (impaired vision or hearing) Inability to process environmental stimuli (patients with spinal cord injuries, brain damage, or confused/disoriented patients)

The nurse supervises a novice nurse interviewing a client with a borderline personality disorder. Which client statement would demonstrate the client using transference? A. "You are just like my mother bothering me with these questions." B. "Instead of breaking objects, I have joined a kickboxing class." C. "I cannot be an alcoholic because I still go to work every day." D. "I told my boyfriend if he leaves me, I will kill myself."

Choice A is correct. This is an example of transference. In transference, the client's unconscious feelings toward a healthcare worker come to the surface that originally stems from someone else. For instance, if a client starts to have hostility towards the healthcare worker because they remind them of a family member with whom they had (or have) a negative relationship. The client bringing up their mother and pinning it on the healthcare worker exemplifies transference.

The nurse is caring for a client who is receiving prescribed varenicline. Which of the following statements would indicate a therapeutic response if made by the client? A. "I am not smoking cigarettes anymore." B. "My depression has gotten better." C. "I am sleeping eight hours a night." D. "I can focus on one task at a time."

Choice A is correct. Varenicline is a medication intended to reduce nicotine withdrawal symptoms and cravings. Following the initiation of varenicline, the client's comments that they are not smoking cigarettes anymore indicate varenicline has been therapeutically effective. Clients go back to resuming tobacco smoking if the withdrawal symptoms are not appropriately treated.

The nurse plans care for a client with moderate Alzheimer's disease (AD). Which of the following interventions should the nurse include? A. Provide a low-stimulation environment with adequate lighting B. Quiz the client with orientation questions C. Change assigned staff to avoid burnout D. Provide a broad range of choices

Choice A is correct. When caring for a client with moderate Alzheimer's disease, the nurse should provide a low-stimulated environment with adequate lighting. The rationale for giving a low-stimulated environment is to allow the client to cognitively process one task at a time and not become distracted.

A client in the primary healthcare provider (PHCP) office is observed getting yelled at by their spouse. When the nurse interviews the client, the client is hostile and shouts at the nurse. This client is exhibiting which defense mechanism? A. Identification B. Displacement C. Undoing D. Compensation

Choice B is correct. Displacement is the ego defense mechanism that a client will most likely employ to cope with the stressors associated with lashing out at a target with socially unacceptable hostility. For example, a client under attack by another individual does not react and displaces their reaction (which is often intensified) on someone else. In this case, the spouse shouted at the client, which led to the client unloading their reaction to that conflict by being hostile to the nurse.

Which statement about behavior management is accurate? A. Negative feedback is not ethically appropriate when the client exhibits poor behavior. B. Skinner's theory scientifically supports behavior management techniques and procedures. C. Orem's theory scientifically supports behavior management techniques and procedures. D. Negative feedback is contraindicated because it is not scientifically sound and beneficial.

Choice B is correct. According to Skinner's theory, changes in behavior result from an individual's response(s) to the specific events, or stimuli, which occur in their respective environment. According to Skinner's research, everything we do and are shaped by our experience of punishment and reward. More specifically, when a stimulus-response pattern is rewarded, the individual is conditioned to respond similarly in the future. The key to Skinner's theory is reinforcement, or, more specifically, anything that strengthens the desired response. The central tenet of Skinner's work is that positively reinforced behavior will reoccur. When an individual is rewarded for a specific behavior, that individual is more likely to repeat the behavior due to positive reinforcement. Conversely, under Skinner's theory, negative reinforcement involves removing an undesirable stimulus to increase a behavior (not to be confused with a "negative punishment," where one would remove a pleasant stimulus to decrease a behavior). Despite Skinner's operant conditioning findings dating back to publications from the 1960s, many of these scientific theories continue to be implemented today. While Skinner's research and findings greatly influence countless fields, education is one of the most notable. Education appears to have been affected by Skinner's theories at all educational levels, having been integrated into all aspects of classroom management by instructors, instructional designers, administrators, etc., continuing to this day. Skinner's theories relating to behavior management techniques and procedures continue to be cited and implemented today.

The clinic nurse notices bruising at multiple stages of healing on a two-year-old. The nurse also sees two burns on the toddler's trunk. What would be the most appropriate action for the nurse to take? A. Confront the child's parent(s)/caregiver(s) B. Call the local authorities or the designated state-specific child abuse hotline C. Recheck the child after two weeks D. Call the health care provider (HCP)

Choice B is correct. Bruises and/or burns present on a child are indicative of child abuse. Once the nurse suspects child abuse, the nurse is legally obligated to notify the local authorities or the designated state-specific child abuse hotline. Typically, following the alert made to local authorities or the designated state-specific child abuse hotline, referrals usually go to the state child welfare department and are assigned to a caseworker in an agency, such as Child Protective Services. After a referral has been made, a caseworker is assigned to investigate the report. Based on the investigation findings, the child is left in the home or temporarily removed.

A client is admitted due to anorexia nervosa. Which assessment parameter should the nurse prioritize? A. The client's height B. The client's electrolyte levels C. The concerns of the client's family D. The client's medical history

Choice B is correct. Clients with anorexia nervosa often experience electrolyte abnormalities, specifically hypokalemia and/or hyponatremia. These electrolyte abnormalities may predispose the client to tachyarrhythmias or sudden death due to ventricular tachyarrhythmias. Therefore, the nurse should prioritize assessing the client for electrolyte abnormalities. Additionally, a client with electrolyte abnormalities will be unable to receive medical clearance from a health care provider (HCP), preventing the client from being placed in a psychiatric ward to receive the psychiatric treatment necessary for anorexia nervosa.

The nurse is reviewing eating disorders with a group of students. It would be correct for the nurse to identify that the primary differential between anorexia nervosa and bulimia nervosa is a client's A. dentition. B. body mass index (BMI). C. binging and purging patterns. D. distorted perception of body weight.

Choice B is correct. Clients with anorexia nervosa often present with a body mass index (BMI) of < 18.5 (i.e., underweight). This is due to the severe caloric restriction anorexia nervosa clients implement on themselves. Conversely, the body weight of clients with bulimia nervosa tends to fluctuate around normal, periodically going above this range (i.e., the majority of bulimia nervosa clients have a BMI between 18.5 and 30). This higher BMI is due to the binging and purging of high-calorie foods by clients with bulimia nervosa. Binging and purging are clinical features of both bulimia and anorexia nervosa. It cannot be used to determine the client's condition. The key distinguishing feature of anorexia nervosa is abnormally low body weight, as indicated by a body mass index <18.5 kg/m2.

Which form of therapy would most likely be used to treat a group of clients affected by phobias? A. Behavioral psychotherapy B. Cognitive behavioral psychotherapy C. Psychoanalysis D. Cognitive psychotherapy

Choice B is correct. Cognitive-behavioral therapy (CBT) is a treatment that combines cognitive psychotherapy and behavioral psychotherapy. CBT is recommended as a first-line treatment approach for specific phobias. Thebehavioral component of CBT involves repeated exposure to the feared situations and thereby promotes fear reduction. For example, a virtual reality exposure strategy using computer technology can be used to simulate real-life situations (e.g. treating fear of flying with repeated exposure in a flight simulator). The cognitive component of CBT facilitates the client to identify the maladaptive thoughts relating to stressors and replace them with realistic thoughts. For example, a client with a specific phobia of elevators may incorrectly believe there is an extremely high chance of getting stuck while in an elevator. This distorted belief can be addressed with cognitive therapy and thereby reduce fear. CBT is also used for generalized anxiety disorder, panic disorder, eating disorders (anorexia nervosa, bulimia), and obsessive-compulsive disorder (OCD).

The nurse is performing an admission assessment on a client admitted to the behavioral health unit. The client is reporting new-onset blindness after witnessing a traumatic motor vehicle accident. The nurse suspects that this client is using which defense mechanism? A. suppression B. conversion C. displacement D. dissociation

Choice B is correct. Converting anxiety into physical symptoms with no organic cause best explains this defense mechanism this client is experiencing. Conversion is a pathological defense that may manifest as a disorder if it continues to recur. The accident traumatized this client and converted his anxiety into a physical symptom (blindness). His new-onset blindness has no organic origin; thus, this exemplifies conversion.

The nurse is caring for a client in the emergency department (ED) experiencing delirium tremens. The nurse should take which initial action? A. assess the client's pain level B. implement seizure precautions C. obtain a prescription for chlordiazepoxide D. assess the client using the Glasgow Coma Scale (GCS)

Choice B is correct. Delirium Tremens (DTs) is a medical emergency that may result in seizure activity. The nurse should always put the client's safety at the forefront and provide seizure precautions. This includes padding the side rails, ensuring that intravenous access has been established, oxygen is at the bedside, and suction is available.

The nurse is talking with a widower who is complaining of insomnia, shortness of breath, extreme anxiety, and a sense of impending doom. Which response by the nurse is most appropriate? A. "Just relax. You're in a safe place now. You have nothing to worry about." B. "Has anything happened recently, or is there anything in the past that could have triggered these feelings?" C. "The medication that I have given you will help decrease these feelings of anxiety." D. "Why don't you take some deep breaths to help you calm down?"

Choice B is correct. Of the available options this is the best choice. While it's important to approach the situation with sensitivity, this response still allows for the exploration of potential triggers, but it does so in a more open-ended and non-confrontational manner. It invites the individual to share if they are comfortable doing so, while also acknowledging the possibility of past experiences contributing to their current distress. This response promotes open communication and understanding without placing undue pressure on the individual during their moment of distress.

A nursing student is currently learning about domestic violence and wonders why the abused individual cannot "just quickly get out of the relationship." Which theoretical model helps in explaining the cyclical and progressive nature of domestic and spousal abuse? A. The Cycle of Abuse and Neglect B. The Cycle of Violence C. The Cycle of Impaired Couples D. The Duluth Model

Choice B is correct. The cycle of violence is a model developed in 1979 by Lenore Walker to explain the co-existence of disorder with love. It may be tough for those who have never experienced domestic abuse to understand why it is difficult for an abused individual to "just quickly leave" the relationship. Understanding the cycle of violence may help plan appropriate interventions to break the cycle and stop domestic violence. Violence often occurs in a repetitive cycle and usually consists of three phases: (1) the Tension phase, (2) the Acute explosion phase (Crisis phase), and (3) the Honeymoon Phase (calm phase). In the first phase (tension-building), the abuser gets angry, argumentative, and starts threatening. Minor fights may occur. In this phase, victims often report a feeling of walking on eggshells. As the period progresses, tension continues to build. In the second phase (explosion/crisis), significant verbal or physical abuse will occur. Major violent acts such as physical or sexual attacks will follow and may result in injury. In the third phase (Calm phase or Honeymoon period), the abuser expresses sorrow and feelings of guilt. The abuser shows love and promises to change and get himself/herself help. The victim feels like things are getting much better, but the phase does not last. The cycle starts all over again and the three steps repeat over time. It is, therefore, hard to end an abusive relationship since the three phases of love, hope, and fear, keep the cycle moving. The cycle is progressive as well. With every period, the abuse may get worse during the explosion phase.

The nurse is working with a woman who is five months pregnant and attending her first prenatal appointment after completing the client's history. The nurse suspects that she is a victim of domestic violence. Which of the following is not a sign of domestic violence? A. Depression B. Weight gain C. Unexplained bruising D. Late initiation of prenatal care

Choice B is correct. Weight gain is an expected finding in pregnancy and is not a symptom that requires investigation into possible abuse. A woman's risk of becoming a victim of domestic violence increases when pregnant. The health care team should be diligent in watching for signs of violence and abuse in the prenatal client.

While working in the emergency department, the nurse sees each of the following clients. As a mandated reporter, the nurse knows which client is at highest risk for elder abuse? A. A 70-year old female with orthostatic hypotension. B. An 86-year old female with glaucoma. C. A 92-year old male with late-stage Alzheimer's disease. D. A 75-year old male with leukemia.

Choice C is correct. A 92-year old male with late-stage Alzheimer's disease is at very high risk for elder abuse. This can include both physical and psychological abuse. Elders with late-stage Alzheimer's disease are at very high risk because of the memory loss and confusion that occurs with this disease.

The nurse assesses a client with schizophrenia who appears to be demonstrating neologisms in their speech. Which of the following would be the expected finding? A. Words that rhyme or have a similar beginning sound B. Reduction in speech; short-worded replies C. Words or phrases with meaning only for the client D. Going off on tangents and never reaching the point

Choice C is correct. A neologism is when a client invents words or phrases that only have meaning for themselves. This is a positive symptom associated with schizophrenia.

The nurse is caring for a client who is receiving prescribed acamprosate. Which of the following statements, if made by the client, would indicate a therapeutic response? A. "I no longer hear voices." B. "I have more motivation during the day." C. "I am not drinking alcohol anymore." D. "My anxiety has lessened in public."

Choice C is correct. Acamprosate is a medication used to support alcohol abstinence in individuals who have recently stopped drinking. A therapeutic response to acamprosate would be a significant reduction or cessation of alcohol consumption. Option C indicates a positive therapeutic outcome, as the client reports not drinking alcohol anymore, which aligns with the intended effect of the medication.This medication may be combined with naltrexone to increase the chance of sobriety.

A client in a psychiatric clinic tells the nurse, "I want to kill my wife. The moment I see her, I am going to kill her." Which of the following should be the nurse's next action? A. Respect the client's right to privacy and confidentiality B. Document the client's statements C. Notify the client's psychiatrist of the comments D. Explore the client's feelings about his wife

Choice C is correct. Confidentiality plays a critical role in client care; however, there may be certain circumstances where confidentiality must be breached to not only ensure the safety of the client, but also to protect a third party (or parties). This concept is referred to as the 'duty to warn' or 'duty to protect.' These types of situations most often arise when a client reports suicidal ideation (SI), homicidal ideation (HI), or when the client makes a threat against an identifiable third party, even if the threat was made during a private therapy session.

The nurse is performing an assessment on a client. The client tells the nurse, "You people are part of the government plotting to destroy me." The nurse should document this statement as a A. Delusion of grandeur B. Somatic delusion C. Delusion of persecution D. Delusion of reference

Choice C is correct. Exploring the content of the client's delusion is important because this assessment will determine if the delusion has any logic (unlikely) and will help foster a therapeutic relationship with the client. This client expressing that they are being falsely term-60targeted is a persecutory delusion. This is when a client believes they are being threatened or harrassed by some sort of force.

The nurse is assessing a client with intermittent explosive disorder (IED). Which of the following findings would support a diagnosis of IED? A. predatory violence B. inattention C. impulsivity D. deceptive behavior

Choice C is correct. IED is characterized by exhibiting episodic aggressiveness grossly disproportionate to any stressors that may have helped elicit the episodes. The symptoms, which may be spells or attacks, appear within minutes or hours and remit spontaneously and quickly regardless of duration. After each episode, the client may express remorse. The client with IED often resorts to physical or verbal assault during the episodes and may damage property, people, or animals.

The nurse is assessing a client suspected of having the early stages of dementia. Which defense mechanism would the nurse expect? A. Identification B. Projection C. Denial D. Conversion

Choice C is correct. In the early stages of dementia, it is quite common for family members and the client to exhibit denial. Denial is utilized to avert the unpleasant emotions surrounding the diagnosis of dementia which is progressive in terms of its symptom intensity. Typically, symptoms that may be concerning for dementia are noticed by family or friends. This individual (an informant) usually brings this concern forward to the primary healthcare provider (PHCP).

A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. The client's behavior is disruptive and interfering with the unit's therapeutic environment. Which action should the nurse take to promote a therapeutic milieu? A. Assign a staff member to stay with the client at all times B. Isolate the client in a separate room until the manic episode subsides C. Develop a structured daily schedule with clear expectations and goals D. Encourage the client to engage in group therapy sessions with peers

Choice C is correct. Individuals experiencing manic episodes may benefit from structure and routine to help manage their symptoms. By establishing a structured daily schedule, the nurse can provide stability, maintain boundaries, and promote a sense of control for the client. Clear expectations and goals can help the client focus and redirect their energy in a positive way.

A nurse is talking to new volunteers at an elderly community club regarding elder abuse. The nurse identifies which of the volunteer's clients as the one that is most vulnerable to abuse? A. A 75-year-old man that has diabetes B. A 79-year-old man with cataracts C. An 87-year-old woman with Parkinson's disease D. A 64-year-old woman with psoriasis

Choice C is correct. Most elder abuse victims are females of advanced age and have at least one physical or mental impairment that limits their ability to perform activities of daily living. The client described in choice C is a woman who has Parkinson's disease, which impairs her cognitively. She is also of advanced age, which further makes her susceptible to abuse.

The nurse in the mental health unit is preparing to establish a new group therapy session. Which client would be most appropriate for group therapy? A client A. in the acute phase of schizophrenia. B. with bipolar I disorder experiencing a mixed episode of depression and mania. C. with post-traumatic stress disorder having difficulty sleeping because of night terrors. D. experiencing delirium tremens associated with alcohol withdrawal.

Choice C is correct. Post-traumatic stress disorder is most effectively treated with therapy. Therapy modalities such as cognitive-behavior therapy and therapy performed by individuals skilled in traumas are strongly recommended. Group therapy is also a modality that may be employed, especially if it contains others with PTSD. Significant advantages of group therapy are that it instills hope and provides comfort to others as they realize they are not alone.

A client is scheduled to undergo electroconvulsive therapy (ECT). The nurse understands which of the following actions must be performed before the client's electroconvulsive therapy (ECT) procedure? A. Assess the client for contrast dye allergy B. Administer an anticonvulsant medication C. Apply a blood pressure cuff to the client D. Check if the client is currently on metformin

Choice C is correct. Standard American Society of Anesthesiologists (ASA) recommends monitoring the client's heart rate, blood pressure, ECG, capnography, and temperature during any electroconvulsive therapy (ECT) procedure, as clients undergoing an ECT procedure often experience a temporary rise in blood pressure during treatment.

The nurse is performing discharge teaching to a client who is alert and fully oriented but appears unable to comprehend the teaching. Additionally, the client presents signs of anxiety, including a pulse rate of 104, forehead sweating, and reports of impending doom. The nurse suspects that the client is experiencing. A. moderate anxiety. B. psychosis. C. severe anxiety. D. mild anxiety.

Choice C is correct. The client's inability to comprehend any information signals that the client is experiencing severe anxiety. A critical difference between moderate and severe anxiety is that the client with severe anxiety has such a narrow perceptual field that the thought process is grossly impaired, and learning and problem-solving cannot occur. When a client has moderate anxiety, the thought process is slightly scattered, but can still engage in learning and problem-solving. The increase in pulse and beads of sweat support both moderate and severe anxiety.

A nurse educator is shadowing a student nurse caring for a psychiatric client. The nurse educator should instruct the student that a therapeutic nurse-client relationship starts with: A. A sincere desire to help others B. Acceptance C. Understanding and self-awareness D. Knowledge of psychiatric nursing

Choice C is correct. The foundation for a robust nurse-client relationship must begin with the student's thorough understanding and self-awareness of their own beliefs, biases, feelings, values, etc.

Which of the following represents appropriate nursing documentation of a patient with a normal mood? A. Sad and tearful during conversation B. Grandiose or strongly confident C. Pleasant or appropriate to the situation D. Tearful but mildly humble and meek

Choice C is correct. The mood is a sustained emotion. Nurses should assess the intensity, depth, and duration of an altered climate. Patients may describe feeling happy, excited, sad, tearful, depressed, angry, anxious, or fearful. When assessing a patient's climate, it is essential to listen to verbal cues but also observe for nonverbal cues. For example, if the patient states, "I am happy," but she seems nervous or is crying, the nurse should document the objective data, as well.

A nurse is speaking with the mother of a 3-year-old in the emergency department. After an assessment, the mother is suspected of abusing the toddler. Following a conversation between the nurse and the mother, which finding would most support the suspicion of maternal child abuse? A. The mother exhibits a healthy level of self-esteem. B. The mother describes the happy childhood she experienced. C. The mother complains her toddler seems to be different from others. D. The mother complains that her child seems to be growing up too quickly.

Choice C is correct. The physical and emotional demands placed on the parent(s) of an unwanted, cognitively impaired, hyperactive, physically disabled, or any other child perceived as "different" may overwhelm the parent(s), resulting in abuse.

The nurse in the outpatient clinic is triaging a 19-year-old client with reports of auditory hallucinations, paranoia, and alterations in speech. The nurse's assessment shows the client is apathetic, and she reports quitting her job from a lack of motivation. The nurse suspects that this client is at highest risk for A. bipolar disorder. B. paranoid personality disorder. C. schizophrenia. D. obsessive-compulsive disorder.

Choice C is correct. These signs and symptoms are highly suggestive of schizophrenia. If not already done, the nurse should speak with the healthcare team about the concerns and request a psychiatric consultation. The client is demonstrating both positive and negative manifestations of schizophrenia. The positive features the client has includes hallucinations and paranoia (delusion). The negative symptoms the client is exhibiting include avolition (lack of motivation) and apathy.

An LPN is working in a group home for adolescents who are recovering from substance abuse. She is assigned to work with a 16-year-old girl who is trying to quit smoking marijuana. While talking with the girl, she uses motivational interviewing to help her work towards her goals. Which of the following statements by the LPN would be the best? A. "Would it be alright if we talk about your pot use now?" B. "What good things do you have going for you in your life?" C. "What changes can you make in your marijuana use this week?" D. "Who can help you quit marijuana?"

Choice C is correct. This is a direct, open-ended question that addresses the patient's substance abuse. Motivational interviewing maintains direct communication with open items, as does this question. By using motivational interviewing, the patient should be empowered and encouraged to make positive changes. The nurse will help to facilitate the patient in seeing the need to change, but the patient will make their own decision to work for that change.

The school nurse has performed an assessment on a 6-year-old child who has been sent to the office after a teacher developed concerns for his safety. Which findings will lead the nurse to investigate other signs of neglect? A. The child has a difficult time paying attention during class. B. The child always finishes his meal at lunch time and is hungry again a few hours later. C. The child is more shy than many of his classmates. D. The child is frequently absent from school and is tired when he does attend.

Choice D is correct. A child who is frequently absent from school and fatigued should be further investigated for neglect at home. Other signs may be poor dental hygiene, lack of appropriate seasonal clothing, or a tendency towards theft.

While rounding in the mental health unit, you are learning about specific phobias. You should be aware that ailurophobia is an unreasonable fear of: A. Social interactions B. Clowns C. Crowds D. Cats

Choice D is correct. Ailurophobia is best described as an unreasonable fear of cats. The psychiatric mental health treatment interventions for phobias are based on the specific type of phobia. For example, ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear.

The nurse is interviewing a client in the clinic looking to establish care. The nurse determines the client is demonstrating altruism by A. justifying illogical ideas, actions, or feelings by developing acceptable explanations. B. reverting to an earlier, more primitive, and childlike pattern of behavior. C. channeling anger from an unacceptable activity to one that is acceptable. D. a largely unconscious motivation to feel caring and concern for others.

Choice D is correct. Altruism is generally a positive defense mechanism that, when utilized appropriately, causes an individual to feel caring and concern for others and act for the well-being of others. Although this defense mechanism is generally regarded as a positive one, it may be maladaptive if a client threatens the health or safety of themselves or others (for example, a client adopts several stray animals, but it threatens the health of others in the household).

The home health nurse is performing a follow-up visit on a child recently relocated to a new home following child abuse. The nurse anticipates that the child will likely demonstrate A. a willingness to explore new places. B. rapid social engagement with others. C. increased scholastic performance. D. reluctance or avoidance in social interactions.

Choice D is correct. Children subjected to abuse often have immediate psychosocial adverse effects such as acting aloof, being withdrawn, guarded, distrustful, and having difficulty engaging and maintaining social relationships.

Crisis helplines are highly important due to which of the following? A. Facilitates the ability of the nurse to visit the home. B. Allows the caller and the call center to plan follow-up care. C. Serves as a cost free way to develop new coping strategies. D. Often saves lives when a person is in a severe crisis.

Choice D is correct. Crisis helplines are highly relevant because these helplines often save lives when a person is in a severe crisis. These helplines are staffed with people who use somewhat scripted verbal communication that addresses the here and now of the crisis. The caller can remain anonymous if they choose to do so. They are also allowed to solve their immediate problem and be able to cope with their stressors in the crisis.

The nurse is caring for a client experiencing delirium tremens. The nurse anticipates a prescription for which medication? A. Disulfiram B. Naloxone C. Methadone D. Clonidine

Choice D is correct. DTs can be fatal if untreated. DTs result from florid alcohol withdrawal causing the client to experience hallucinations, hypertension, agitation, nystagmus, and potential seizure activity. Clonidine is an alpha-agonist and is primarily used in the treatment of hypertension. Clonidine is helpful during DTs because it lowers the client's blood pressure and gives the client some drowsiness which is useful if they are agitated.

A nurse is caring for a client who will undergo electroconvulsive therapy (ECT) for the first time. The client's spouse asks the nurse about visiting the client on ECT treatment days and expresses concern regarding what to expect after the initial treatment. The best response by the nurse is: A. "Are you sure you'd like that? Clients are pretty sick after the first treatment, and you'll have to get permission from the health care provider (HCP) to visit." B. "Visitors are prohibited. We will just telephone you to update you to inform you of the progress." C. "Clients are asleep for several hours after the treatment, so there's really no need to stay." D. "Yes, you may visit. After each session, clients may have temporary drowsiness, confusion, or memory loss."

Choice D is correct. For clients undergoing electroconvulsive therapy (ECT) treatments, visitors, especially family members, are allowed and encouraged. "Yes, you may visit. After each session, clients may have temporary drowsiness, confusion, or memory loss," is the best response for the nurse to utilize. This response allows the nurse to alleviate the concerns expressed by the client's spouse by explaining the temporary nature of certain side effects. Some of the most common side effects of electroconvulsive therapy sessions include nausea, headache, drowsiness, confusion, and slight memory loss, which may last minutes to hours.

While working in the emergency department, the nurse is taking care of a client who has overdosed on morphine. Which of the following medications does she expect the healthcare provider will order? A. Sodium bicarbonate B. Flumazenil C. Diphenhydramine D. Naloxone

Choice D is correct. Naloxone is the antidote for opioid overdose. Naloxone would be used in the overdose of morphine, fentanyl, oxycodone, or other opioid medications.

Which of the following statements indicates body image distortion in a patient with anorexia nervosa? A. "I wish I looked like my mom." B. "I hate how my body looks." C. "I wish I could wear tank tops." D. "I'm so overweight."

Choice D is correct. Patients with anorexia perceive themselves to look differently than they do. Many of these patients see someone in the mirror who weighs more than their desired weight. Despite being too thin, this client will not eat in hopes of getting the perfect body.

The emergency department nurse (ED) prepares to care for a client with severe anxiety. The nurse anticipates that the client will demonstrate A. limited problem solving and decreased attentiveness. B. heightened perceptual field and is aware of the anxiety. C. narrowed perceptual field and able to discuss past coping mechanisms. D. the inability to problem solve and has a sense of impending doom.

Choice D is correct. Severe anxiety may lead to physical exhaustion if prompt intervention is not obtained. Severe anxiety is marked by - Greatly reduced and distorted perceptual field Focuses on details or one specific detail Attention is scattered Inability to problem solve The feeling of impending doom

The nurse is caring for a client with a history of aggressive and violent behavior. When caring for this client, the nurse should initially take which action? A. Restrain the client B. Place the client in seclusion C. Get an order for a sedating medication D. Establish trust with the client

Choice D is correct. The first thing the nurse should do to prevent violence is to establish trust with the client. The first step in the nurse-client relationship is to build confidence in this therapeutic relationship. Without trust, future collaboration, interventions, and client outcomes cannot facilitate appropriate and safe behaviors.

The nurse in the psychiatric unit notes that a client with paranoid schizophrenia is yelling and blocking the television. Other psychiatric clients around the yelling client are now becoming agitated. What is the most appropriate action for the nurse? A. Restrain the client B. Escort the other clients from the room C. Administer haloperidol via intramuscular (IM) injection to the client causing a disruption D. Approach the client causing a disruption calmly while accompanied by two additional staff members

Choice D is correct. The initial intervention is to approach the client calmly, attempt to de-escalate the situation, and remove this client from the room (preferably on the client's own accord). For the safety of staff and all other individuals in the room, staff members should never make face-to-face contact with an agitated psychiatric client without being accompanied by other trained healthcare personnel.

The nurse is developing group therapy sessions on substance use disorders. The nurse develops weekly topics and plans to host the sessions in a community center. The nurse is in which phase of therapeutic group development? A. Working B. Orientation C. Termination D. Planning

Choice D is correct. The nurse is in the planning phase, and the crux of this phase is to identify the purpose of the group, its objectives, individuals who may attend, and weekly topics.

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up? A. "These sores in my mouth hurt." B. "When can I weigh myself?" C. "I hate my life and wish it was over." D. "I feel really dizzy right now."

Choice D is correct. The physical (basic) needs of the client with a mental health disorder are prioritized over psychosocial needs. Frequent episodes of vomiting and laxative use, common behaviors in individuals with bulimia nervosa, can lead to significant fluid loss and dehydration. Dehydration can result in dizziness, lightheadedness, and a drop in blood pressure, which can contribute to the feeling of being dizzy.

The nurse is leading a group therapy session on substance use disorders. The nurse observes that a client is monopolizing the session. The nurse should take which appropriate action? A. Ask the client to leave the therapy session B. Stop the session to review the rules with the group C. Allow the client to express themselves uninterrupted D. Ask the group if they would like to share their feelings about the monopolization

Choice D is correct. This is an appropriate action because it addresses the problem and allows the group to engage in problem-solving, which is the crux of group therapy. The nurse should solicit feedback from other group members on how they feel the group is going or share observations. This tactic, while challenging, promotes problem-solving and reflection, both of which are essential in therapy.

The nurse is caring for a client who has been diagnosed with chronic pancreatitis secondary to alcohol abuse. Which of the following is the most appropriate tertiary prevention expected outcome for this client? A. Altered digestion is secondary to pancreatitis. B. Altered coping secondary to alcoholism. C. The client will be free of insomnia during hospitalization. D. The client will have the opportunity to participate in a 12-step recovery program

Choice D is correct. This option represents the most appropriate tertiary prevention outcome for a client with chronic pancreatitis secondary to alcohol abuse. Participating in a 12-step recovery program is essential for addressing the root cause (alcoholism) and preventing further complications related to pancreatitis. It focuses on long-term recovery and sobriety, which are crucial for the client's overall well-being. It's important to note that tertiary prevention includes rehabilitation, and a 12-step recovery program is a form of rehabilitation.

A nurse is caring for a client with schizophrenia who is experiencing delusions and hallucinations. The nurse understands which of the following therapeutic communication techniques is appropriate for establishing a therapeutic relationship. A. Offering reassurance and substantiating the client's delusions B. Challenging the client's beliefs and encouraging reality testing C. Encouraging the client to avoid discussing their delusions and hallucinations to prevent reinforcing them. D. Active listening and empathy, acknowledging the client's feelings

Choice D is correct. When working with clients diagnosed with schizophrenia who experience delusions and hallucinations, establishing a therapeutic relationship is essential. The most appropriate therapeutic communication technique in this situation is active listening and empathy, acknowledging the client's feelings. This technique helps build trust and rapport with the client by showing understanding and validating their emotional experiences. It also provides an opportunity for the client to express their thoughts and feelings without judgment.

The nurse is assessing a client with Dependent Personality Disorder. Which of the following would be an expected finding? Select all that apply. - Difficulty with decision-making - Flamboyant behaviors - Intense and unstable relationships - Avoiding social relationships - Feels helpless when alone

Choices A and E are correct. Individuals with Dependent Personality Disorder manifest difficulty with decision-making and initiating projects.

The nurse is developing a safety plan for a client experiencing domestic violence. The nurse should recommend which elements are included in the plan? Select all that apply. Safe family, friends, and places to stay Phone numbers to call for assistance A bag in a safe place containing clothes and important documents Money or a credit card that cannot be traced Annual testing of smoke detectors

Choices A, B, C, and D are correct. The nurse should establish a safety plan before discharge for a client suffering from intimate partner violence or domestic violence. The safety plan should include a concealed bag containing clothes, important documents, money, a credit card that cannot be traced, spare car keys, and phone numbers for nearby shelters and services. An interactive safety plan may be developed by visiting the National Domestic Violence Hotline website (https://www.thehotline.org/plan-for-safety/create-a-safety-plan/#gf_1).

The nurse has provided medication instruction to a client prescribed methadone for intravenous (IV) opioid use disorder. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply. - "I will need counseling while taking this medication." - "I will need periodic blood tests while on this medication." - "This medication may lower my risk for Hepatitis C." - "This medication will send me into opioid withdrawals." - "I may get drowsy while taking this medication."

Choices A, B, C, and E are correct. Methadone is an efficacious medication used in the treatment of opioid use disorder, chronic pain, and in the treatment of neonatal abstinence syndrome. This medication requires close monitoring and counseling for opioid use disorder. Periodic blood tests are required as this medication may be hepatotoxic. This medication has decreased the transmission of bloodborne pathogens such as HIV and Hepatitis C. This is because reducing intravenous drug use decreases the risk of transmitting these pathogens. Drowsiness is a common side effect of this medication as it is an opioid agonist.

The nurse is caring for a client who reports a sexual assault. Which actions should the nurse take? Select all that apply. - Interview the client in a private room - Refer the client to support groups - Allow the client to be alone to promote problem-solving - Record verbatim statements in the medical record - Repeat questions previously answered

Choices A, B, and D are correct. When caring for a client who has been sexually assaulted, the nurse must maintain a private environment to allow the client to be forthcoming with their answers. Support groups are quite influential in the recovery process, and it would be wise for the nurse to provide these at discharge. Recording verbatim statements in the medical record are necessary because the nurse must construct an accurate nursing note. The nursing note may also be subject to legal proceedings, reinforcing the necessity for accurate documentation.

The nurse is caring for a client experiencing a manic episode with delusions of grandeur. Which of the following nursing interventions is appropriate for this client? Select all that apply. Maintain a calm environment Set clear, consistent limits Limit the amount of finger food and snacks provided to the client Ignore the client's behavior until the delusion passes Promote safety measures

Choices A, B, and E are correct. A is correct. Reducing stimuli can help decrease the client's hyperactivity and distractibility. B is correct. Due to impulsivity during manic episodes, the client may benefit from clear, consistent boundaries. This should be done respectfully and firmly. E is correct. Due to impulsive behaviors and poor judgment, the client may be at risk for harm. Ensure a safe environment to prevent injury.

The nurse is teaching a group of students about using reminiscence therapy. Which statements should the nurse include in the teaching? Select all that apply. This approach helps support self-esteem This is an effective intervention in a group setting This intervention focuses on looking forward Establishing future goals is important part of this intervention Reminiscing is a way to express personal identity

Choices A, B, and E are correct. Reminiscence helps support self-esteem by having an individual look back on past accomplishments and positive life experiences. This strategy may be used one-on-one or in a group setting, facilitating rapport building with other individuals. Finally, reminiscence is a way for an individual to express their personal identity by reflecting on past accomplishments (college work, occupations, marriage, etc.).

The nurse understands that which of the following types of grief are not considered normal and require some interventions from the members of the healthcare team? Select all that apply. Complicated grief Anticipatory grief Unresolved grief Grief as the result of a perceived loss Dysfunctional grief

Choices A, C and E are correct. Complicated grief and unresolved grief are not considered normal. Both types, therefore, require some interventions from the healthcare team members. Complicated grief is defined as pathological grief; it is characterized by maladaptive coping methods with the loss and the loss of normal functioning six months after the event. Unresolved grief is characterized by an exaggerated and prolonged period of mourning. Dysfunctional grief is characterized by unhealthy coping mechanisms and a lack of resolution.

The nurse is teaching a group of students about the concept of a crisis. It would be appropriate for the nurse to state that a crisis Select all that apply. - can be triggered by an external event, such as a natural disaster. - maintains homeostasis or equilibrium. - is a disturbance caused by a stressful event or threat. - causes normal coping mechanisms to fail. - may exacerbate concurrent medical and psychiatric disorders.

Choices A, C, D, and E are correct. A crisis triggered by an external event is an adventitious crisis (natural disaster, mass shooting). These events may have little to no warning. A crisis causes a significant disturbance in homeostasis, which causes an individual's coping mechanisms to fail. The failure of these coping mechanisms may cause a client to feel powerless. If the client has an underlying medical or psychiatric disorder, it may exacerbate these disorders. For example, a crisis may cause a hypertensive emergency if the client has hypertension.

The nurse is putting together a community health presentation about the signs and symptoms of depression to promote awareness of the disease and educate the public. Which of the following signs and symptoms should the nurse include? Select all that apply. Social withdrawal or isolation Flight of ideas Looseness of associations Sleep disturbances Persistent sadness or low mood

Choices A, D, and E are correct. A is correct. Withdrawing from social activities, avoiding friends or family, or isolating oneself can be a symptom of depression. Anhedonia is a common symptom of depression. It is defined as the loss of pleasure in usually pleasurable things. D is correct. Sleep disturbances are a common symptom of depression. Clients can experience a range of sleep disturbances, such as disrupted sleep continuity, difficulty sleeping, or sleeping too much. Any change in sleep patterns can be a symptom of both mental and physical health problems, and symptoms of depression frequently manifest with sleep disruption of some kind. E is correct. Feeling down or hopeless most of the day, nearly every day, for an extended period is a joint presentation of depression.

The nurse is caring for a 45-year-old client who has undergone electroconvulsive treatment (ECT) for severe depression. Which of the following nursing interventions is appropriate following the treatment? Select all that apply. Position the client supine with the head of the bed at 30 degrees. Reorient the client frequently. Remain with the client at all times. Promote bedrest for 12-24 hours. Ambulate the client as soon as possible.

Choices B and C are correct. B is correct. It will be a critical nursing intervention to frequently reorient the client who has just received electroconvulsive therapy (ECT). This is because temporary memory loss is associated with this procedure, so they will likely be confused and disoriented. Due to this disorientation, they will probably be scared; the nurse must frequently reorient them to their place and situation to make them feel safe and secure. C is correct. It will be a critical nursing intervention to remain with the client who has just received electroconvulsive therapy. A side effect of electroconvulsive treatment is temporary memory loss. They will be disoriented and confused, so the nurse must remain with them to keep them safe.

The nurse cares for a client with major depressive disorder (MDD). Which of the following would indicate that the client is achieving the treatment goals? Select all that apply. Reporting a decreased appetite. Engaging in daily exercise. Increasing social ties. Drinking alcohol with friends. Not attending therapy sessions.

Choices B and C are correct. A client engaging in daily exercise and increasing their social ties are significant strides in meeting the treatment goals. A client engaging in exercise decrease their neurological inflammation and exposes themselves to light, which is quite helpful in treating MDD. Loneliness is a significant risk factor for depression and by a client increasing their social ties, they are engaging with others and strengthening their ability for self-expression.

The nurse is caring for a client experiencing an acute episode of severe anxiety. The nurse should plan to take which appropriate action? Select all that apply. Discuss previous coping skills Stay and observe the client Maintain an environment with low stimuli Plan to ambulate with the client in the hallway Instruct the client to identify what triggered the event Assess the client for possible hypoventilation Obtain a prescription for haloperidol

Choices B and C are correct. Severe anxiety causes an individual to experience a narrow perceptual field, an inability to problem-solve, and somatic symptoms such as dizziness, palpitations, diaphoresis, and a feeling of impending doom. Staying with the client provides an assurance and enables the nurse to give the client simple and short directions, if necessary.

The nurse is assessing a client with schizophrenia. Which of the following would be an expected finding? Select all that apply. Apraxia Anhedonia Avolition Delusions Bradykinesia

Choices B, C, and D are correct. Clinical features of schizophrenia include positive and negative symptoms. Anhedonia, avolition, and delusions are all associated with this psychiatric disorder.

The nurse is attending to a client who was just diagnosed with terminal cancer. He continues to claim the "cancer is just going to disappear on its own." Knowing that this is an acceptable response by the client, please arrange the following stages of the Kübler-Ross model of grieving in the correct ordered sequence: Acceptance Denial Depression Bargaining Anger

The correct ordered sequence is Denial, Anger, Bargaining, Depression, and Acceptance ("DABDA"). Denial: Refuses to believe that loss is happening. The client is unready to deal with practical problems, i.e. prosthesis after the loss of a leg. May assume artificial cheerfulness to prolong denial. This client is currently in denial. Anger: The client or family may direct anger at nurses or staff about matters that generally would not bother them. Bargaining: Seeks to bargain to avoid loss (e.g. "let me just live until ___ and then I will be ready to die"). Depression: Grieves over what has happened and what cannot be. May talk freely (e.g. reviewing past losses such as money or a job), or may withdraw. Acceptance: Comes to terms with the loss. May have decreased interest in surroundings and support people. May wish to begin making plans (e.g. will, prosthesis, altered living arrangements).