Mental health exam 3 practice

A nurse is assessing a client who has an anxiety disorder and is taking a benzodiazepine. For which of the following adverse effects should the nurse monitor the client? A. Seizures B. Dizziness C. Polyuria D. Insomnia

Correct Answer: B. Dizziness Dizziness is a common adverse effect of benzodiazepines. Other common adverse effects are drowsiness and sedation. Incorrect Answers: A. Benzodiazepines are often prescribed for the treatment of seizure disorder. However, the sudden withdrawal of benzodiazepines can be associated with the development of seizures. C. Polyuria is an adverse effect of lithium, not benzodiazepines. D. Drowsiness is a common adverse effect of benzodiazepines.

A nurse is assessing a client who has a history of methamphetamine use. Which of the following findings indicates that the client is currently under the influence of this drug? A. Paranoia B. Slurred speech C. Marked lethargy D. Bradycardia

A Acute effects of methamphetamine use include increased heart rate and metabolism, mental alertness, reduced appetite, and paranoia. Incorrect Answers: B. C. Clients who are under the influence of methamphetamine exhibit increased energy and mental alertness. Clients who are under the influence of alcohol exhibit slurred speech. D. Clients who are under the influence of methamphetamine exhibit increased heart rate and blood pressure.

A nurse is caring for a client with obsessive-compulsive disorder (OCD) who has been taking fluoxetine for 3 months. The client states, "This medication isn't working. I want to stop taking it." Which of the following responses should the nurse make? A. "It is best to discontinue the medication slowly over 1 or 2 months." B. "If the medication hasn't helped you in 3 months, it's not going to." C. "You will likely gain weight if you stop taking the medication." D. "This medication is the only treatment available for your condition."

A The nurse should respond by telling the client that withdrawing from the medication should be done slowly to reduce any manifestations of withdrawal. This can be achieved by reducing the dosage by 25% every 1 to 2 months. Incorrect Answers: B. The nurse should respond by telling the client that the effects of fluoxetine take several months to peak and that therapy should continue for a year before discontinuation. C. The nurse should not indicate that weight gain is likely with the withdrawal of fluoxetine. An adverse effect of taking the medication is weight gain. D. The nurse should not indicate that fluoxetine is the only treatment for OCD. Other SSRI medications are effective for the disorder. Some clients benefit from behavioral therapy and deep-brain stimulation.

Which symptom indicates a moderate level of anxiety? Select all that apply. One, some, or all responses may be correct. A. Talking in trembling voices B. Increased rates of respiration C. Confused and unable to make any decisions D. Effectively making decisions to solve problems E. Tapping foot and chewing lip

A, B Rationale People having moderate anxiety have voice tremors and tend to talk in a trembling voice. They show increased pulse rate and respiratory rate. In severe anxiety, people are usually confused and are unable to make decisions. They cannot make decisions to solve problems at an optimum level. People with mild anxiety exhibit mild tensionrelieving behavior such as foot or finger tapping and lip chewing. p. 135

Which consideration must the nurse make before lithium can be started when planning care for a patient who has mania? A. The physical examination and laboratory tests are analyzed. B. The initial doses of antipsychotic medication have brought behavior under control. C. Seclusion has proven ineffective as a means of controlling any assaultive behavior. D. Electroconvulsive therapy can be scheduled to coincide with lithium administration.

Answer: A Rationale Lithium may need to be given with caution to patients with impaired renal or thyroid function. A thorough physical examination and various laboratory tests are necessary to rule out other organic causes for the behavior and to ensure that the lithium can be excreted normally. Lithium is a first-line treatment, so it is not likely that the patient would receive antipsychotic medication before being treated with lithium. The use of seclusion is not relevant to the use of lithium, and seclusion should be limited. Electroconvulsive therapy may be considered for patients who have not responded to lithium treatment. pp. 240-241

Which phrase describes a likely potential problem for a patient diagnosed with severe obsessive-compulsive disorder? A. Sleep disturbance B. Excessive socialization C. Command hallucinations D. Altered state of consciousness

Answer: A Rationale: Patients who must engage in compulsive rituals for anxiety relief rarely are afforded relief for any prolonged period. The high anxiety level and need to perform the ritual may interfere with sleep. Excessive socialization, command hallucinations, and altered states of consciousness are not typically associated with obsessive-compulsive disorder. pp. 146, 147

Which symptoms are associated with opioid withdrawal? A. Lacrimation, rhinorrhea, dilated pupils, and muscle aches B. Illusions, disorientation, tachycardia, and tremors C. Fatigue, lethargy, sleepiness, and convulsions D. Synesthesia, depersonalization, and hallucinations

Answer: A Rationale: Symptoms of opioid withdrawal resemble symptoms of the flu; they include lacrimation, rhinorrhea, dilated pupils, muscle aches, diaphoresis, cramps, chills, and fever. Illusions, disorientation, tachycardia, tremors, fatigue, lethargy, sleepiness, convulsions, synesthesia, depersonalization, and hallucinations are not characteristic symptoms of opioid withdrawal. p. 314

Which action taken by the patient with depression and a family history of suicide would lead the nurse to implement suicide precautions? Select all that apply. One, some, or all responses may be correct. A. Gave personal belongings to friends B. Wrote feelings down in a daily journal C. Developed durable power of attorney D. Reported sleeping 10 hours most nights E. Began taking a shower or bath every night

Answer: A Rationale: When patients with depression begin to give away their personal belongings to friends, this can be a sign of increased suicidal risk. The patient would be encouraged to write feelings down in a journal as part of therapy. A durable power of attorney would be a person who makes health care decisions when the person is unable and is not a sign of suicidal risk. A person who creates a will along with other signs would be a behavioral clue of suicide. Insomnia, not sleeping 10 hours a night, is a behavioral clue for suicidal risk. Neglecting personal hygiene, not bathing daily, would be a behavioral clue for increased suicide risk. pp. 367, 369

Which assessment finding is a primary risk factor for depression? Select all that apply. One, some, or all responses may be correct. A. Male gender B. History of physical abuse as a child C. Middle-class socioeconomic status D. History of alcohol abuse E.Married

Answer: B, D Rationale Primary risk factors of depression include early childhood trauma and history of alcohol or other substance abuse. Female gender, low socioeconomic class, and unmarried are other primary risk factors. Box 15.1,p. 201

Which side effects of lithium can be expected when the medication is at therapeutic levels? A. Increased thirst and nausea B. Ataxia and hypotension C. Fine hand tremors and polyuria D. Coarse hand tremors and gastrointestinal upset

Answer: C Rationale Fine hand tremors, polyuria, and mild nausea and thirst are present at therapeutic levels of lithium treatment. Increased nausea and thirst are early signs of toxicity. Ataxia, hypotension, coarse hand tremors, and gastrointestinal upset are advanced signs of toxicity.

Which intervention by the nurse will foster hope and connectedness for a patient in palliative care and the family who is at the bedside and having a difficult time with the diagnosis? Select all that apply. One, some, or all responses may be correct. Some correct answers were not selected A. Encouraging legacy-building B. Encouraging uplifting memories C. Discouraging humor D. Encouraging reminiscence E. Encouraging life review for patients

Answers: A, B, D, E Rationale: Families need to have hope as long as the dying person is present, and sources of hope for terminally ill patients and families include legacy-building, uplifting memories, reminiscence, and life review for patients. Discouraging humor is incorrect because humor is a source of hope for terminally ill patients and families. pp. 399-400

A nurse is assessing a client who has major depressive disorder. Which of the following questions should the nurse prioritize when speaking with the client? A. "Do you have any close friends?" B. "Can you describe how you feel about what's happening?" C. "Have you thought about hurting yourself?" D. "How are you dealing with being away from your family?"

C The greatest risk to the client at this time is suicide. Therefore, the priority question the nurse should ask is if the client has any intent to self-harm. Incorrect Answers: A. Exploring the client's interpersonal relationships is an intervention the nurse should perform to help develop a therapeutic relationship. However, another question is the nurse's priority at this time. B. Asking about how the client feels is an ongoing intervention that can help the nurse develop and strengthen the therapeutic relationship. However, another question is the nurse's priority at this time. D. Asking how the client is dealing with being in the hospital and away from family is an ongoing intervention that can help the nurse develop and strengthen the therapeutic relationship. However, another question is the nurse's priority at this time.

A nurse is caring for a client who has end-stage lung cancer. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of Kübler-Ross' stages of grief? A. "I would give anything to live to see my grandchild born." B. "Can you make sure there hasn't been a mistake with my test results?" C. "I feel so sad that I will be leaving my partner all alone." D. "What have I done to deserve this death sentence?"

Correct Answer: A. "I would give anything to live to see my grandchild born." Kübler-Ross identified common responses of clients who experience any form of loss. These responses are divided into 5 stages. While each of these stages is experienced by clients, they are not necessarily experienced in a linear fashion or in the exact same order. Some clients can experience a stage more than once. This response shows that the client is in the bargaining stage and might be trying to make a deal with a higher power to prolong life. Incorrect Answers: B. The denial stage provides psychological protection to the client against the pain of the loss and gives the client time to regroup and accept the diagnosis. This response shows that the client is in disbelief or shock about the diagnosis, indicating denial. C. During the depression stage, the client mourns the actual or anticipated loss. During this stage, the client confronts the emotions and realization of the loss. Manifestations can include regression as well as social isolation and withdrawal. D. The anger stage occurs following the acceptance of the diagnosis or the reality of the loss. During this stage, the client can experience anxiety along with self-blame or blame toward others. Anger is often projected onto those around the client such as family and members of the health care team It is important for the nurse to inform the family members that this is an expected response

A nurse is caring for a client who has been unable to leave the house for the past 10 years without accompaniment. When attempting to go out alone, the client becomes anxious and must quickly return inside. The nurse should identify that the client is exhibiting which of the following disorders? A. Agoraphobia B. Post-traumatic stress disorder C. Panic disorder D. Obsessive-compulsive disorder

Correct Answer: A. Agoraphobia Agoraphobia is the fear and subsequent avoidance of places or situations from which escape might be difficult. The most common manifestations of this disorder are a fear of leaving home and avoiding open public places, such as shopping malls. Incorrect Answers: B. Post-traumatic stress disorder (PTSD) is a trauma-related disorder in which the client experiences flashbacks, distressing memories, and dreams of a traumatic event. The client tries to avoid distressing memories but does not become anxious from leaving the residence. C. Panic disorder is an anxiety disorder in which recurrent panic attacks that are not associated with any specific stimulus or situation seem to occur spontaneously. D. Obsessive-compulsive disorders are characterized by recurrent obsessional thoughts or ritual behaviors.

A nurse is caring for a client who has obsessive-compulsive disorder. Which of the following actions should the nurse take when dealing with the client's ritualistic behaviors? A. Plan the client's schedule to allow time to perform rituals B. Verbalize disapproval of ritualistic behavior C. Place the client in protective isolation D. Increase stimuli in the client's immediate surroundings

Correct Answer: A. Plan the client's schedule to allow time to perform rituals The nurse should allow sufficient time for the client to perform rituals early in the treatment. This will help keep anxiety levels manageable and prevent the precipitation of panic anxiety. Incorrect Answers: B. Negative reinforcement decreases the client's self-esteem and could increase the repetition of negative behaviors C. There is no indication that the client is at risk of harm. Isolation would increase the likelihood of a panic attack . D. The nurse should ensure the client's immediate surroundings involve minimal stimuli to avoid increasing the client's level of anxiety.

A nurse is caring for a client who has anxiety disorder. The client states that she forgot her partner's birthday after they had an argument. The nurse recognizes this action as which of the following defense mechanisms? A. Repression B. Splitting C. Conversion D. Projection

Correct Answer: A. Repression The nurse should identify that the client forgetting her partner's birthday following an argument is an example of repression. Repression is an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. Incorrect Answers: B. Splitting is a pathological defense mechanism in which clients have an inability to accept positive and negative qualities of themselves or others in a cohesive image. C. Conversion is a pathological defense mechanism in which clients unconsciously transform anxiety or stress into a physical manifestation with no organic cause. D. Projection is an immature defense mechanism in which clients unconsciously reject emotionally unacceptable features in themselves and attribute them to others.

A nurse is caring for a client who has severe anxiety disorder and is in a state of panic in the dayroom. Which of the following actions should the nurse take? A. Speak to the client in a calm voice B. Leave the client alone to regain control C. Encourage the client to express her feelings D. Place the client in restraints

Correct Answer: A. Speak to the client in a calm voice The initial goal for a client who is in a state of panic is to obtain relief. The nurse should stay with the client and speak in a calm manner. Incorrect Answers: B. A client who is in a state of panic should never be left alone, as this could place her at risk for injury. C. A client who is in a state of panic will not be able to express her feelings coherently until her level of anxiety is lower. Encouraging her to express her feelings while in a state of panic could cause her anxiety to increase. D. Placing the client in restraints could result in injury, and there is no indication that she is a safety risk to herself

A patient has a death in the family. Which of the following situations should the nurse identify as a risk factor for maladaptive grieving? A. The death was a result of violence. B. The client expresses anger over the loss. C. This is the client's first experience of the loss of a family member. D. The client demonstrates reorganization of behavior.

Correct Answer: A. The death was a result of violence. When death is a result of violence, is traumatic, or is unexpected, the loss can result in maladaptive grieving for those left behind. This type of grief is complicated by the survivors not having an opportunity to prepare for the death or to say goodbye. Incorrect Answers: B. Anger is an expected response during the grieving process. It is a phase that mourners often experience in the adaptive process of grieving. C. The loss of family members is a maturational loss that occurs in all families. It is a necessary loss that occurs across the lifespan. D. Reorganization of behavior is a healthy, adaptive response to the grieving process in which the mourner accepts the death, takes on new roles, and moves forward in life.

A newly admitted client who has major depressive disorder states to the nurse, "I'm a failure. I can't even cope with little things anymore." Which of the following responses should the nurse provide? A. "What happened in your life to make you feel like such a failure?" B. "It sounds as if you are feeling pretty overwhelmed right now." C. "Do you feel like you don't deserve to feel good about yourself?" D. "I know you feel like that now, but you'll feel differently when you get better."

Correct Answer: B. "It sounds as if you are feeling pretty overwhelmed right now." This response by the nurse acknowledges the client's feelings and attempts to convey the ability to understand them. This promotes a trusting relationship between the client and the nurse. Incorrect Answers: A. This response is nontherapeutic and does not acknowledge the client's feelings. It assumes the client suffered a major life event that caused feelings of failure. C. This response is nontherapeutic and could be a misinterpretation of the client's feelings. D. This nontherapeutic response by the nurse provides false reassurance to the client and implies sympathy rather than empathy

A nurse is providing teaching to a client who has social anxiety disorder and a new prescription for paroxetine. Which of the following statements should the nurse include in the teaching? A. "You can take this medication when needed." B. "The medication takes a few weeks to build up in your system." C. "You should plan to take this medication for 6 months." D. "Relapsing after withdrawing from this medication is rare."

Correct Answer: B. "The medication takes a few weeks to build up in your system." The nurse should inform the client that initial effects of paroxetine take about 4 weeks to develop. Optimal effects of the medication can be seen in 8 to 12 weeks. Incorrect Answers: A. The nurse should inform the client that paroxetine, an SSRI, takes 4 weeks to convey initial effects and 8 to 12 weeks to convey optimal effects. Therefore, this medication should not be taken PRN. C. The nurse should inform the client that treatment should continue for at least 1 year. After that, the provider can prescribe gradual withdrawal if necessary. D. The nurse should inform the client that withdrawal from paroxetine frequently results in a relapse of the

A nurse is providing teaching to a client who has obsessive-compulsive disorder and performs hand hygiene to decrease anxiety. Which of the following actions by the nurse implements modeling as a behavioral intervention strategy? A. Setting a time limit between episodes of hand hygiene B. Demonstrating performance of hand hygiene at scheduled times C. Telling the client to shout "stop" each time an urge to perform hand hygiene arises D. Instructing the client to practice muscle relaxation when experiencing the urge to perform hand hygiene

Correct Answer: B. Demonstrating performance of hand hygiene at scheduled times This action is an example of modeling, which is a behavioral intervention strategy that allows the client to see the expected behaviors performed by the nurse. Incorrect Answers: A. This action is an example of response prevention, which instructs the client to set time limits between each episode of the compulsive ritual. C. This action is an example of thought stopping, which is a strategy the client uses to interrupt obtrusive thoughts or actions. D. This action is an example of relaxation training, which is a behavioral intervention the client can use to counteract stress and anxiety.

A nurse is caring for a client with bipolar disorder who is experiencing mania. Which of the following actions is the nurse's priority? A. Offer the client finger foods every 2 hours B. Determine if the client is a danger to herself C. Monitor the client's vital signs every 2 hours D. Move the client to a quiet area

Correct Answer: B. Determine if the client is a danger to herself The greatest risk to this client is an injury from hyperactivity or life-threatening exhaustion. Therefore, the priority action is to determine if the client has feelings of suicide or if the client is showing manifestations of exhaustion. Incorrect Answers: A. The nurse should offer the client finger foods frequently to encourage nutritional intake. However, another action is the priority. C. The nurse should monitor the client's vital signs every 1 to 2 hours to ensure the client is not experiencing physical exhaustion that stresses the cardiovascular system. However, another action is the priority. D. The nurse should stay with the client and move her to a quiet area with minimal stimulation, which can decrease excitability. However, another action is the priority.

A nurse is caring for a child who has a diagnosis of terminal brain cancer. The mother states, "I feel numb and can't believe this is happening to us." Which of the following interventions by the nurse is the first priority? A. Explore effective ways of family coping B. Encourage the family's expression of their feelings C. Discuss the disease and its manifestations with family members D. Instruct the family about anticipatory grieving

Correct Answer: B. Encourage the family's expression of their feelings The first action the nurse should take using the nursing process is to assess the family by encouraging them to express their feelings about their child's illness. This assessment will allow the nurse to understand the particular needs of the family better as they prepare to face their child's death. Incorrect Answers: A. The nurse should explore effective ways of family coping to help the family with their grief; however, there is another action the nurse should take first. C. The nurse should discuss the disease and its symptoms with family members to help the family deal with the child's illness; however, there is another action the nurse should take first. D. The nurse should instruct the family about anticipatory grieving to help the family cope with the upcoming loss of their child; however, there is another action the nurse should take first

A nurse is reviewing the plan of care for a client who has bipolar disorder. Which of the following is an effect of using cognitive behavioral therapy (CBT) for a client who has bipolar disorder? A. Prevents the need for mood-stabilizing medications B. Helps the client deal with distorted thought processes C. Aids communication among family members D. Replaces the need for lifestyle interventions

Correct Answer: B. Helps the client deal with distorted thought processes CBT assists the client with recognizing distorted thought processes that are maladaptive with regards to recovery. When experiencing mania, the client tends to view the future unrealistically as highly favorable. CBT assists the client in recognizing and challenging such unrealistic or "automatic" thoughts and can help the client and the health care team recognize early trends toward mania. Incorrect Answers: A. CBT improves adherence to a medication regimen, but it does not replace medication. C. Family-focused therapy can improve communication among family members. CBT is an individual therapy. D. CBT does not replace the need for lifestyle interventions such as proper rest and nutrition, which aid in the treatment of bipolar disorder.

An emergency room nurse is assessing a client who has anxiety disorder. The client is flushed, perspiring profusely, and experiencing palpitations. The client begins to scream, "I am going to die! This is it! I am having a heart attack!" The nurse should determine the client's level of anxiety to be which of the following? A. Moderate B. Panic C. Severe D. Mild

Correct Answer: B. Panic This client's manifestations indicate the panic level of anxiety and are manifestations of a panic disorder. Incorrect Answers: A. In moderate anxiety, the perceptual field narrows, but the client is able to cope with some assistance. This client's manifestations indicate a higher level of anxiety. C. In severe anxiety, the perceptual field is scattered, and the client is not able to focus on anything except relieving the anxiety. This client's manifestations indicate a high level of anxiety. D. Mild anxiety allows the client to perceive reality in sharp focus, and actual problem-solving becomes more effective. This client's manifestations indicate a higher level of anxiety.

A nurse is assessing a client who is experiencing moderate-level anxiety. Which of the following findings should the nurse expect? A. The client has a heightened perceptual field. B. The client has difficulty concentrating. C. The client reports shortness of breath. D. The client reports a sense of impending doom

Correct Answer: B. The client has difficulty concentrating. The nurse should expect a client who has moderate-level anxiety to have difficulty concentrating and focusing. This lack of concentration increases as the anxiety level escalates. Incorrect Answers: A. The nurse should expect a client who is experiencing mild anxiety to have a heightened perceptual field; however, the perceptual field becomes narrowed as the anxiety increases to a moderate level. C. The nurse should expect severe somatic complaints, such as shortness of breath, from a client who is experiencing a panic level of anxiety. D. The nurse should expect a sense of impending doom from a client experiencing a severe level of anxiety.

A nurse is caring for a client who has obsessive-compulsive disorder and feels compelled to pace the floor for a specific number of times each day or "something bad will happen." Which of the following responses should the nurse make? A. "Nothing terrible is going to happen to you. Please stop this behavior." B. "Are you seeking attention with this behavior?" C. "It may help if we talked about why you find it necessary to pace the floor." D. "Are you pacing to work off excess energy?"

Correct Answer: C. "It may help if we talked about why you find it necessary to pace the floor." This response is therapeutic and encourages the client to discuss the underlying thoughts and feelings that are causing anxiety. Incorrect Answers: A. This statement is nontherapeutic and does not allow exploration of the client's feelings. B. This statement is nontherapeutic and offers a personal judgment, which does not allow exploration of the client's feelings. D. This statement is nontherapeutic because it makes an assumption about the client's behavior

A nurse is assessing a client who has major depressive disorder. The client states, "I might as well be dead. I have always been a failure." Which of the following responses should the nurse make? A. "Why do you think you feel this way?" B. "You have a great deal to offer in life." C. "Let's discuss these feelings further." D. "Feeling like a failure is expected with depression.

Correct Answer: C. "Let's discuss these feelings further." The nurse is using the therapeutic technique of exploring the client's feelings. The client's comments indicate a risk for self-harm, and the nurse should further explore to confirm this. Incorrect Answers: A. This is a nontherapeutic communication technique of asking a "why" question that can cause the client to feel defensive and criticized. The client's comments indicate a risk for self-harm and should be explored further. B. This is a nontherapeutic communication technique of invalidating and minimizing the client's feelings. The client's comments indicate a risk for self-harm and should be explored further. D. This is a nontherapeutic communication technique of invalidating and minimizing the client's feelings. The client's comments indicate a risk for self-harm and should be explored further.

A nurse is planning a menu for a client who has bipolar disorder and is experiencing an acute manic episode. Which of the following meals should the nurse provide for this client? A. Spaghetti with meatballs, a salad, and apple pie B. Beef and vegetable stew, rice, and vanilla pudding C. Chicken nuggets, crackers with cheese sticks, and a cookie D. Broiled fish fillets, stewed tomatoes, and ice cream

Correct Answer: C. Chicken nuggets, crackers with cheese sticks, and a cookie . A client who is in the manic phase of bipolar disorder should receive high-calorie finger foods that can be carried and are relatively easy to manipulate. This meal is a good choice for a client who is hyperactive, has a short attention span, and might not sit down to eat. Incorrect Answers: A. A client who is in the manic phase of bipolar disorder has a short attention span and might not be able to manipulate this meal; therefore, the client might give up before finishing. B. A client who is in the manic phase of bipolar disorder will not be able to sit and concentrate on this type of meal. In addition, a client who has a short attention span and low frustration tolerance might not eat this meal. D. A client who is in the manic phase of bipolar disorder is hyperactive and has a limited attention span. This client will do better with foods that are easy to manipulate and require little concentration to eat

A nurse is providing teaching to a client who has generalized anxiety disorder and a new prescription for buspirone. Which of the following manifestations is a common adverse effect of this medication? A. Confusion B. Bradycardia C. Dizziness D. Insomnia

Correct Answer: C. Dizziness The nurse should inform the client that dizziness is a common adverse effect of buspirone. The nurse should instruct the client to avoid driving and operating heavy machinery until the presence of adverse effects has been determined. Incorrect Answers: A. Confusion is not an adverse effect of buspirone, although the client might experience decreased concentration and headaches. B. Tachycardia and palpitations are possible adverse effects of buspirone. D. Drowsiness, not insomnia, is an adverse effect of buspirone

A nurse is providing teaching about stress management to a client who is experiencing anxiety. Which of the following techniques should the nurse recommend to assist the client in identifying his stressors? A. Biofeedback B. Intellectualization C. Journaling D. Cognitive reframing

Correct Answer: C. Journaling Journaling is a technique that can be used to identify stressors. By recording feelings and responses to events, the client can find the source of everyday stressors and begin the process of stress reduction. Incorrect Answers: A. Biofeedback is a mind-body relaxation technique that uses instrumentation to monitor physiological responses such as heart rate, blood pressure, and skin temperature. B. Intellectualization is a defense mechanism that uses facts to examine events rather than responding with emotion. The technique can be adaptive or maladaptive. D. Cognitive reframing is a relaxation technique that replaces negative self-talk with positive responses. Also known as cognitive restructuring, this technique is designed to reduce stress by giving the client a sense of better control over situations.

A nurse on an inpatient rehabilitation unit is assessing a client who has a history of opioid use disorder and is experiencing withdrawal. Which of the following manifestations should the nurse expect? A. Hyperactivity B. Headache C. Rhinorrhea D. Tremulousness

Correct Answer: C. Rhinorrhea Rhinorrhea, lacrimation, pupillary dilation, yawning, and piloerection are classic manifestations of opioid withdrawal. Incorrect Answers: A. Hyperactivity is a manifestation of sedative, hypnotic, and anti-anxiety medication withdrawal. B. A headache is a manifestation of cannabis withdrawal and caffeine withdrawal. D. Tremulousness is a manifestation of alcohol withdrawal.

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. Which of the following medications may be administered safely while the client is taking lithium? A. Ibuprofen B. Haloperidol C. Valproic acid D. Hydrochlorothiazide

Correct Answer: C. Valproic acid Valproic acid and lithium are both indicated for the treatment of bipolar disorder. The nurse may safely administer both of these medications to the client. Incorrect Answers: A. Ibuprofen is not safe to administer to a client who is taking lithium because it can increase kidney absorption of lithium, which can lead to lithium toxicity. B. Haloperidol is not safe to administer to a client who is taking lithium because the combination increases the client's risk of extrapyramidal adverse effects and tardive dyskinesia. D. Hydrochlorothiazide is not safe to administer to a client who is taking lithium because it promotes sodium loss, which can lead to lithium toxicity.

A nurse is assessing a client who has a new diagnosis of major depressive disorder. Which of the following questions is the priority for the nurse to ask? A. "How would you describe your mood?" B. "How are you sleeping?" C. "Do you drink alcohol or use other substances?" D. "Do you ever think about suicide?"

Correct Answer: D. "Do you ever think about suicide?" The diagnosis of major depressive disorder indicates that the greatest risk for this client is suicide. Therefore, the priority for the nurse to ask is about suicidal ideation. Research shows that clients who have depressive disorders are at high risk for suicide due to the common presence of recurring thoughts of death. Incorrect Answers: A. Asking about the client's mood can indicate the client's current emotional status. However, another question is the priority for the nurse to ask. B. The nurse should ask about the client's ability to sleep since insomnia is a common finding in clients who are depressed. However, another question is the priority for the nurse to ask. C. The nurse should ask the client about the use of alcohol or other substances because depression can occur with substance use. However, another question is the priority for the nurse to ask.

A nurse is talking with a client who has major depressive disorder. Which of the following client statements should the nurse identify as a covert statement of suicidal ideation? A. "I don't want to be alive any longer." B. "I think every day about killing myself." C. "My parents will be happier when I'm dead." D. "I won't have to deal with things much longer."

Correct Answer: D. "I won't have to deal with things much longer." The nurse should listen closely for overt and covert statements that indicate a client's intent to commit suicide. Covert statements, such as this example, can implicate a client's plan for suicide or wish not to be alive. Covert statements are more difficult to identify because they do not openly express the client's suicidal thoughts. The nurse should assess the client further for suicidal ideation and implement interventions to reduce the risk of a suicide attempt. Incorrect Answers: A. B. C. This is an overt statement because it openly expresses the client's plan to commit suicide or wish to no longer be alive

A nurse is providing teaching to a client who recently completed detoxification from alcohol and has a new prescription for acamprosate. Which of the following statements should the nurse make? A. "You will get very sick if you drink alcohol while taking this medication." B. "The medication will be administered as a subcutaneous injection." C. "You should take this medication on an empty stomach." D. "The medication might cause you to have episodes of diarrhea."

Correct Answer: D. "The medication might cause you to have episodes of diarrhea." The nurse should instruct the client that an adverse effect of acamprosate is diarrhea. Incorrect Answers: A. The nurse should instruct the client that acamprosate reduces the unpleasant feelings associated with abstinence such as anxiety, dysphoria, and tension. Unlike disulfiram, acamprosate does not function as aversion therapy. B. The nurse should instruct the client that acamprosate is administered orally in delayed-released tablets. C. The nurse should instruct the client to take 2 tablets of acamprosate 3 times daily with meals. Taking the medication at mealtimes helps promote compliance.

A nurse is providing teaching to the family of a client who is scheduled for electroconvulsive therapy (ECT). Which of the following statements made by the family indicates an understanding of ECT? A. "We are so glad there are no physical side effects of shock treatment." B. "Thank goodness there is no permanent memory loss." C. "Cardiac dysrhythmias can persist for several weeks." D. "We won't be alarmed if there is some confusion after the

Correct Answer: D. "We won't be alarmed if there is some confusion after the treatment." It is common following ECT for a client to experience confusion and disorientation. Incorrect Answers: A. The nurse should explain to the family that confusion and disorientation often occur following ECT. Memory deficits might also be present. In rare cases, death has occurred from acute myocardial infarction or cerebrovascular accident. B. The nurse should explain to the family that memory deficits do not always recover following ECT. C. Persistent cardiac dysrhythmias are not an adverse effect of ECT.

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan? A. Discourage the client from taking naps during the day. B. Allow the client to choose which items of clothing to wear each day. C. Encourage the client to participate in group therapy. D. Provide the client frequently with high-calorie finger-foods

Correct Answer: D. Provide the client frequently with high-calorie finger-foods. The nurse should provide the client with frequent, high-calorie snacks and meals during a manic episode to provide the calorie replacement needed due to excessive physical energy and activity. Providing finger-foods increases the client's intake by making eating easier when mania creates difficulties with sitting down and concentrating on a meal. Incorrect Answers: A. The nurse should encourage the client to take naps and frequent rest periods during the day to avoid physical exhaustion due to mania. B. The nurse should closely supervise the client's choice of clothing to maintain dignity and promote positive selfesteem during a manic episode. C. The nurse should encourage one-on-one therapy during the manic phase. Group therapy can cause anxiety and agitation for the client

A nurse is caring for a client who has major depressive disorder and is severely withdrawn. Which of the following techniques should the nurse use to facilitate communication with the client? A. Continue to talk if the client does not provide an immediate verbal response B. Use platitudes when talking with the client C. Ask the client direct questions D. Speak to the client using simple and concrete terminology

Correct Answer: D. Speak to the client using simple and concrete terminology The nurse should use simple and concrete terminology when communicating with this client. A client who is severely withdrawn has impaired comprehension and difficulty concentrating; therefore, this technique facilitates communication. Incorrect Answers: A. The nurse should give the client additional time to respond. Clients who are severely withdrawn might take longer to comprehend what is being said and formulate a response. B. The nurse should avoid using platitudes because this technique minimizes the client's feelings and promotes feelings of worthlessness in clients who are severely withdrawn. C. The nurse should avoid asking direct questions to a client who is severely withdrawn because this technique can increase anxiety.

A nurse in a mental health clinic is caring for a client who states, "I think I might have a problem with alcohol." Which of the following actions should the nurse take first? A. Provide the client with information about a 12-step recovery program B. Encourage the client to accept responsibility for his alcohol use C. Teach the client alternate coping mechanisms to use in place of alcohol D. Ask the client to complete the CAGE questionnaire

D The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the client's alcohol use. Completing a CAGE questionnaire can help determine the impact of alcohol use on the client's life. Incorrect Answers: A. The nurse should provide the client with information about a 12-step recovery program, such as Alcoholics Anonymous; however, there is another action that the nurse should take first. B. The nurse should encourage the client to accept responsibility for his alcohol use, which encourages acceptance of the alcohol use problem and promotes recovery; however, there is another action that the nurse should take first. C. The nurse should teach the client coping mechanisms to use in response to stress besides alcohol; however, there is another action that the nurse should take first

A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following medications should the nurse prepare to administer? a. Carbamazepine b. Clonidine c. Propranolol d. Lorazepam

D The nurse should expect to administer lorazepam, a benzodiazepine, as the first treatment for acute alcohol withdrawal. Along with decreasing symptoms of acute alcohol withdrawal, these medications can also maintain vital signs and prevent seizures and delirium tremens. Incorrect Answers: A. Carbamazepine is an antiepileptic medication that can be used with a benzodiazepine for acute alcohol withdrawal. However, benzodiazepines such as lorazepam are the first choice for acute alcohol withdrawal. B. Clonidine is a central alpha-adrenergic agonist medication that can be used with a benzodiazepine for acute alcohol withdrawal. However, benzodiazepines are the first choice for acute alcohol withdrawal. C. Propranolol is a beta-adrenergic blocker medication that can be used with a benzodiazepine for acute alcohol withdrawal. However, benzodiazepines are the first choice for acute alcohol withdrawal. Many clients who have alcohol use disorder have poor diets, which renders them malnourished. Because of this poor nutritional state, these clients need foods with a high nutritional value such as fat and protein. This can be achieved through dietary modification, not fluid-replacement therapy

A nurse is reviewing the health history of a young adult client who has a depressive disorder. Which of the following factors increases the client's risk of depression? A. The client is an only child. B. The client lives in an urban setting. C. The client is married. D. The client is female

D The nurse should identify female gender as a primary risk factor for depression. The incidence of depressive disorders is greater in women than in men by a ratio of almost 2 to 1. Incorrect Answers: A. The client's status as an only child is not a risk factor for depression. B. Living in an urban setting does not increase the client's risk for depression. A low socioeconomic status is a risk factor for depression. C. Clients who are not married are at a greater risk for depression than clients who are married