Mental Health Exam 3 practice

Nurse Vicky is assessing a newly admitted client for symptoms of post-traumatic stress disorder (PTSD). Which symptoms are typically seen with this diagnosis? Select all that apply. A. Anger with numbing of other emotions B. Exaggerated startle response C. Feeling that one is having a heart attack D. Frequent thoughts about contamination E. Frequent nightmares F. Survivor's guilt

A, B, E, F These are common symptoms of PTSD. Option C is common in panic disorder, and option D is characteristic of obsessive-compulsive disorder.

Which outcome is most appropriate for Francis who has a dissociative disorder? A. Francis will deal with uncomfortable emotions on a conscious level. B. Francis will modify stress with the use of relaxation techniques. C. Francis will identify his anxiety responses. D. Francis will use problem-solving strategies when feeling stressed.

A. Francis will deal with uncomfortable emotions on a conscious level. Dissociative disorders occur when traumatic events are beyond an individual's recall because these memories have been "blocked" from conscious awareness. Bringing the feelings associated with these events into conscious awareness and coping with these feelings will decrease the need for dissociation.

A client is admitted to the psychiatric unit with a diagnosis of alcohol intoxication and suspected alcohol dependence. Other assessment findings include an enlarged liver, jaundice, lethargy, and rambling, incoherent speech. No other information about the client is available. After the nurse completes the initial assessment, what is the first priority? A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output B. Checking the client's medical records for health history information C. Attempting to contact the client's family to obtain more information about the client D. Restricting fluids and leaving the client alone to "sleep off" the episode

A. Instituting seizure precautions, obtaining frequent vital signs, and recording fluid intake and output A nurse who lacks adequate information to determine which level of care a client requires must take all possible precautions to ensure the client's physical safety and prevent complications. To do otherwise could place the client at risk for potential complications. Options B and C: After taking all possible precautions, the nurse can begin seeking health history information and, as needed, modify the plan of care. Option D: Fluids are typically increased unless contraindicated by a preexisting medical condition.

The community nurse visits the home of George, a child recently diagnosed with autism. The parents express feelings of shame and guilt about having somehow caused this problem. Which statement by the nurse would best help alleviate parental guilt? A. "Autism is a rare disorder. Your other children shouldn't be affected." B. "The specific cause of autism is unknown. However, it is known to be associated with problems in the structure of and chemicals in the brain." C. "Sometimes a lack of prenatal care can be cause of autism." D. "Although autism is genetically inherited if you didn't have testing you could not have known this would happen."

B. "The specific cause of autism is unknown. However, it is known to be associated with problems in the structure of and chemicals in the brain." This statement is factual and does not cast blame on anything the parents did or did not do.

When planning care for a client who has ingested phencyclidine (PCP), nurse Wayne is aware that the following is the highest priority? A. Client's physical needs B. Client's safety needs C. Client's psychosocial needs D. Client's medical needs

B. Client's safety needs The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. Options A, C, and D: After safety needs have been met, the client's physical, psychosocial, and medical needs can be met

During a community visit, volunteer nurses teach stress management to the participants. The nurses will most likely advocate which belief as a method of coping with stressful life events? A. Avoidance of stress is an important goal for living. B. Control over one's response to stress is possible. C. Most people have no control over their level of stress. D. Significant others are important to provide care and concern.

B. Control over one's response to stress is possible. When learning to manage stress, clients find it helpful to believe that they have the ability to control their response to it. It is impossible to avoid stress, which is a normal life experience.

Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is: A. Displacement B. Denial C. Projection D. Compensation

B. Denial Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.

A 25 -year old client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle B. The client will work with the nurse to remain safe C. The client will drink plenty of fluids daily D. The client will make a personal inventory of strength

B. The client will work with the nurse to remain safe The priority goal in alcohol withdrawal is maintaining the client's safety. Options A, C, and D: Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority

Joy has entered the chemical dependency unit for treatment of alcohol dependency. Which of the following client's possession will the nurse most likely place in a locked area? A. Toothpaste B. Shampoo C. Antiseptic wash D. Moisturizer

C. Antiseptic wash Antiseptic mouthwash often contains alcohol & should be kept in a locked area, unless labeling clearly indicates that the product does not contain alcohol.

Clonidine (Catapres) can be used to treat conditions other than hypertension. Nurse Sally is aware that the following conditions might the drug be administered? A. Phencyclidine (PCP) intoxication B. Alcohol withdrawal C. Opiate withdrawal D. Cocaine withdrawal

C. Opiate withdrawal Clonidine is used as adjunctive therapy in opiate withdrawal. Option A: Benzodiazepines and neuroleptic agents are typically used to treat PCP intoxication. Option B: Benzodiazepines, such as chlordiazepoxide (Librium), and neuroleptic agents, such as haloperidol, are used to treat alcohol withdrawal. Option D: Antidepressants and medications with dopaminergic activity in the brain, such as fluoxetine (Prozac), are used to treat cocaine withdrawal.

A client with panic disorder experiences an acute attack while the nurse is completing an admission assessment. List the following interventions according to their level of priority. A. Remain with the client. B. Encourage physical activity. C. Encourage low, deep breathing. D. Reduce external stimuli. E. Teach coping measures.

A, D, C, B, then E. The nurse should remain with the client to provide support and promote safety. Reducing external stimuli, including dimming lights and avoiding crowded areas, will help decrease anxiety. Encouraging the client to use slow, deep breathing will help promote the body's relaxation response, thereby interrupting stimulation from the autonomic nervous system. Encouraging physical activity will help him to release energy resulting from the heightened anxiety state; this should be done only after the client has brought his breathing under control. Teaching coping measures will help the client learn to handle anxiety; however, this can only be accomplished when the client's panic has dissipated and he is better able to focus.

Alfred was newly diagnosed with anxiety disorder. The physician prescribed buspirone (BuSpar). The nurse is aware that the teaching instructions for newly prescribed buspirone should include which of the following? A. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days. B. A warning about the incidence of neuroleptic malignant syndrome (NMS). C. A reminder of the need to schedule blood work in 1 week to check blood levels of the drug. D. A warning that immediate sedation can occur with a resultant drop in pulse.

A. A warning about the drugs delayed therapeutic effect, which is from 14 to 30 days. The client should be informed that the drug's therapeutic effect might not be reached for 14 to 30 days. The client must be instructed to continue taking the drug as directed. Option B: NMS hasn't been reported with this drug, but tachycardia is frequently reported. Option C: Blood level checks aren't necessary.

Genevieve only attends social events when a family member is also present. She exhibits behavior typical of which anxiety disorder? A. Agoraphobia B. Generalized anxiety disorder C. Obsessive-compulsive disorder D. Post-traumatic stress disorder

A. Agoraphobia Agoraphobia is a disorder characterized by avoidance of situations in which escape may not be possible or help may be unavailable.

A 60-year-old female client who lives alone tells the nurse at the community health center "I really don't need anyone to talk to". The TV is my best friend. The nurse recognizes that the client is using the defense mechanism known as? A. Displacement B. Projection C. Sublimation D. Denial

D. Denial Option D: The client statement is an example of the use of denial, a defense that blocks problem by unconscious refusing to admit they exist.

Which of the following foods would the nurse Trish eliminate from the diet of a client in alcohol withdrawal? A. Milk B. Orange Juice C. Soda D. Regular Coffee

D. Regular Coffee Option D: Regular coffee contains caffeine which acts as psychomotor stimulants and leads to feelings of anxiety and agitation. Serving coffee top the client may add to tremors or wakefulness

Which is the desired outcome in conducting desensitization: A. The client verbalize his fears about the situation B. The client will voluntarily attend group therapy in the social hall. C. The client will socialize with others willingly D. The client will be able to overcome his disabling fear.

D. The client will be able to overcome his disabling fear. The client will overcome his disabling fear by gradual exposure to the feared object. Options A, B, and C are not the desired outcome of desensitization.

The parents of Suzanne, a child with attention deficit hyperactivity disorder, tell the nurse they have tried everything to calm their child and nothing has worked. Which action by the nurse is most appropriate initially? A. Actively listen to the parents' concern before planning interventions. B. Encourage the parents to discuss these issues with the mental health team. C. Provide literature regarding the disorder and its management. D. Tell the parents they are overacting to the problem.

A. Actively listens to the parents' concern before planning interventions. The nurse would encourage parents to fully discuss and describe their perception of the problem in order to assess the family system before determining appropriate interventions.

A group of community nurses sees and plans care for various clients with different types of problems. Which of the following clients would they consider the most vulnerable to post-traumatic stress disorder? A. An eight (8)-year-old boy with asthma who has recently failed a grade in school B. A 20-year-old college student with DM who experienced date rape C. A 40-year-old widower who has recently lost his wife to cancer D. A wife of an individual with a severe substance abuse problem

B. A 20-year-old college student with DM who experienced date rape Post-traumatic stress disorder is caused by the experience of severe, specific trauma. Rape is a severely traumatic event. Although the situations in options A, C, and D are certainly stressful, they are not at the level of severe trauma.

31. Linda is pacing the floor and appears extremely anxious. The duty nurse approaches in an attempt to alleviate Linda's anxiety. The most therapeutic question by the nurse would be? A. Would you like to watch TV? B. Would you like me to talk with you? C. Are you feeling upset now? D. Ignore the client

B. Would you like me to talk with you? Option B: The nurse presence may provide the client with support & feeling of control.

Which medication is commonly used in treatment programs for heroin abusers to produce a non-euphoric state and to replace heroin use? A. Diazepam B. Carbamazepine C. Clonidine D. Methadone

D. Methadone Methadone maintenance programs are used to provide a heroin-depleted individual with a medically controlled dose of methadone to produce a noneuphoric state that will prevent withdrawal symptoms. This method of treatment is advocated to help heroin abusers avoid criminal activities associated with obtaining heroin; it also prevents diseases associated with I.V. use of heroin.

The nurse is caring for a client who she believes has been abusing opiates. Assessment findings in a client abusing opiates such as morphine include: A. dilated pupils and slurred speech. B. rapid speech and agitation. C. dilated pupils and agitation. D. euphoria and constricted pupils

D. euphoria and constricted pupils. Option D: Assessment findings in a client abusing opiates include agitation, slurred speech, euphoria, and constricted pupils.

The nurse is working with a client who abuses alcohol. Which of the following facts should the nurse communicate to the client? A. Abstinence is the basis for successful treatment. B. Attendance at Alcoholics Anonymous meetings every day will cure alcoholism. C. For treatment to be successful, family members must participate. D. An occasional social drink is an acceptable behavior for the alcoholic

A. Abstinence is the basis for successful treatment. The foundation of any treatment for alcoholism is abstinence. Option B: Attendance at Alcoholics Anonymous is helpful to some individuals to maintain strict abstinence. Option C: Participation in treatment by the family is beneficial to both the client and the family but isn't essential. Option D: Abstinence requires refraining from social drinking.

A client with obsessive-compulsive disorder is hospitalized on an inpatient unit. Which nursing response is most therapeutic? A. Accepting the client's obsessive-compulsive behaviors B. Challenging the client's obsessive-compulsive behaviors C. Preventing the client's obsessive-compulsive behaviors D. Rejecting the client's obsessive-compulsive behaviors

A. Accepting the client's obsessive-compulsive behaviors A client with obsessive-compulsive behavior uses this behavior to decrease anxiety. Accepting this behavior as the client's attempt to feel secure is therapeutic. When a specific treatment plan is developed, other nursing responses may also be acceptable. Options B, C, and D: The remaining answer choices will increase the client's anxiety and therefore are inappropriate.

Nurse Lynnette notices that a female client with obsessive-compulsive disorder washes her hands for long periods each day. How should the nurse respond to this compulsive behavior? A. By designating times during which the client can focus on the behavior. B. By urging the client to reduce the frequency of the behavior as rapidly as possible. C. By calling attention to or attempting to prevent the behavior. D. By discouraging the client from verbalizing anxieties.

A. By designating times during which the client can focus on the behavior. The nurse should designate times during which the client can focus on the compulsive behavior or obsessive thoughts. Option B: The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly. Option C: She shouldn't call attention to or try to prevent the behavior. Trying to prevent the behavior may cause pain and terror to the client. Option D: The nurse should encourage the client to verbalize anxieties to help distract attention from the compulsive behavior.

A client with a phobic disorder is treated by systematic desensitization. The nurse understands that this approach will do which of the following? A. Help the client execute actions that are feared B. Help the client develop insight into irrational fears C. Help the client substitutes one fear for another D. Help the client decrease anxiety

A. Help the client execute actions that are feared Systematic desensitization is a behavioral therapy technique that helps clients with irrational fears and avoidance behavior to face the thing they fear, without experiencing anxiety. Options B and C: There is no attempt to promote insight with this procedure, and the client will not be taught to substitute one fear for another. Option D: Although the client's anxiety may decrease with successful confrontation of irrational fears, the purpose of the procedure is specifically related to performing activities that typically are avoided as part of the phobic response

When nurse Hazel considers a client's placement on the continuum of anxiety, a key in determining the degree of anxiety being experienced is the client's: A. Perceptual field B. Delusional system C. Memory state D. Creativity level

A. Perceptual field Perceptual field is a key indicator of anxiety level because the perceptual fields narrow as anxiety increases.

Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of: A. Projection B. Identification C. Repression D. Regression

A. Projection Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.

Tony with agoraphobia has been symptom-free for 4 months. Classic signs and symptoms of phobia include: A. Severe anxiety and fear B. Withdrawal and failure to distinguish reality from fantasy C. Depression and weight loss D. Insomnia and inability to concentrate

A. Severe anxiety and fear Phobias cause severe anxiety (such as panic attack) that is out of proportion to the threat of the feared object or situation. Physical signs and symptoms of phobias include profuse sweating, poor motor control, tachycardia and elevated B.P.

When performing a physical examination on a female anxious client, nurse Nelli would expect to find which of the following effects produced by the parasympathetic system? A. Muscle tension B. Hyperactive bowel sounds C. Decreased urine output D. Constipation

B. Hyperactive bowel sounds The parasympathetic nervous system would produce incomplete G.I. motility resulting in hyperactive bowel sounds, possibly leading to diarrhea.

Nurse Jessie is assessing a client suffering from stress and anxiety. A common physiological response to stress and anxiety is: A. Urticaria B. Vertigo C. Sedation D. Diarrhea

D. Diarrhea Diarrhea is a common physiological response to stress and anxiety.

Nurse Fred is assessing a client who has just been admitted to the ER department. Which signs would suggest an overdose of an antianxiety agent? A. Suspiciousness, dilated pupils and incomplete BP B. Agitation, hyperactivity and grandiose ideation C. Combativeness, sweating, and confusion D. Emotional lability, euphoria, and impaired memory

D. Emotional lability, euphoria, and impaired memory Signs of anxiety agent overdose include emotional lability, euphoria, and impaired memory.

After seeking help at an outpatient mental health clinic, Ruby who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, Ruby returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for Ruby? A. Recommending a high-protein, low-fat diet. B. Giving sleep medication, as prescribed, to restore a normal sleep-wake cycle. C. Allowing the client time to heal. D. Exploring the meaning of the traumatic event with the client.

D. Exploring the meaning of the traumatic event with the client. The client with PTSD needs encouragement to examine and understand the meaning of the traumatic event and consequent losses. Otherwise, symptoms may worsen and the client may become depressed or engage in self-destructive behavior such as substance abuse. Option A: A special diet isn't indicated unless the client also has an eating disorder or a nutritional problem. Option B: The physician may prescribe antianxiety agents or antidepressants cautiously to avoid dependence; sleep medication is rarely appropriate. Option C: The client must explore the meaning of the event and won't heal without this, no matter how much time passes. Behavioral techniques, such as relaxation therapy, may help decrease the client's anxiety and induce sleep.

Nurse Christine is teaching an adolescent health class about the dangers of inhalant abuse; the nurse warns about the possibility of: A. Contracting an infectious disease, such as hepatitis or AIDS B. Recurrent flashback events C. Psychological dependence after initial use D. Sudden death from cardiac or respiratory depression

D. sudden death from cardiac or respiratory depression Inhalants are CNS depressants; if taken in an excess amount, they can cause cardiac and respiratory depressions. It is impossible to control the inhalant dosage; therefore, death can occur.

Initial interventions for Marco with acute anxiety include all except which of the following? A. Touching the client in an attempt to comfort him B. Approaching the client in calm, confident manner C. Encouraging the client to verbalize feelings and concerns D. Providing the client with a safe, quiet and private place

A. Touching the client in an attempt to comfort him The emergency nurse must establish rapport and trust with the anxious client before using therapeutic touch. Touching an anxious client may actually increase anxiety.

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see: A. tension and irritability. B. slow pulse. C. hypotension. D. constipation.

A. tension and irritability. An amphetamine is a nervous system stimulant that is subject to abuse because of its ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Options B and C: These are incorrect because amphetamines stimulate norepinephrine, which increases the heart rate and blood flow. Option D: Diarrhea is a common adverse effect, so option D is incorrect.

A 16-year-old boy is admitted to the facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include: A. violence on television. B. passive parents. C. an internal locus of control. D. a single-parent family

A. violence on television. Violence on television has been correlated with an increase in aggressive behavior. Option B: Passive parents contribute to acting-out behaviors but not specifically to violence. Option C: An internal locus of control leads to a positive sense of self-esteem and isn't related to violence or aggression. Option D: There is no direct correlation between single-parent families and violence.

The school nurse assesses Brook, a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all that apply. A. Constant fidgeting and squirming B. Excessive fatigue and somatic complaints C. Difficulty paying attention to details D. Easily distracted E. Running away F. Talking constantly, even when inappropriate

A, C, D, and F These behaviors are all characteristic of ADHD and indicate that the child is inattentive, hyperactive, and impulsive.

A 15-year-old boy was hospitalized in a psychiatric unit because he initiates frequent fights with peers. Which implementation is most appropriate? A. Anticipate and neutralize potentially explosive situations. B. Ignore minor infractions of rules against fighting. C. Isolate the adolescent from contact with peers. D. Talk to the adolescent each time fighting occurs.

A. Anticipate and neutralize potentially explosive situations. The nurse is responsible for maintaining a safe environment; therefore, it would be appropriate to observe for signs that an explosive situation is developing and intervening to neutralize the situation, thereby preventing a fight.

Which medications have been found to help reduce or eliminate panic attacks? A. Antidepressants B. Anticholinergics C. Antipsychotics D. Mood stabilizers

A. Antidepressants

The newly hired nurse is assessing a client who abuses barbiturates and benzodiazepine. The nurse would observe for evidence of which withdrawal symptoms? A. Anxiety, tremors, and tachycardia B. Respiratory depression, stupor, and bradycardia C. Muscle aches, cramps, and lacrimation D. Paranoia, depression, and agitation

A. Anxiety, tremors, and tachycardia Barbiturates and benzodiazepine are CNS depressants; therefore, withdrawal symptoms are related to CNS stimulation caused by the rebounding of neurotransmitters (norepinephrine). Symptoms include increased anxiety, tremors, and vital sign changes (such as tachycardia and hypertension).

The nurse describes a client as anxious. Which of the following statement about anxiety is true? A. Anxiety is usually pathological B. Anxiety is directly observable C. Anxiety is usually harmful D. Anxiety is a response to a threat

D. Anxiety is a response to a threat Anxiety is a response to a threat arising from internal or external stimuli.

During an initial assessment of a client admitted to a substance abuse unit for detoxification and treatment, the nurse asks questions to determine patterns of use of substances. Which of the following questions are most appropriate at this time? Select all that apply. A. How long have you used substances? B. How often do you use substances? C. How do you get substances into your body? D. Do you feel bad or guilty about your use of substances? E. How much of each substance do you use? F. Have you ever felt you should cut down substance use? G. What substances do you use?

A, B, C, E, G These questions will elicit information about the client's pattern of use of substances. Options D and F are questions related to CAGE, a tool for screening suspected substance abusers.

The nurse is aware that the outcome criteria would be appropriate for a child diagnosed with oppositional defiant disorder? A. Accept responsibility for own behaviors B. Be able to verbalize own needs and assert rights. C. Set firm and consistent limits with the client D. Allow the child to establish his own limits and boundaries

A. Accept responsibility for own behaviors Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, disobedient, and blame others for their actions. Accountability for their actions would demonstrate progress for the oppositional child. Option B is incorrect as the oppositional child usually, focuses on his own needs. Options C and D aren't outcome criteria but interventions.

The community nurse practicing primary prevention of alcohol abuse would target which groups for educational efforts? A. Adolescents in their late teens and young adults in their early twenties B. Elderly men who live in retirement communities C. Women working in careers outside the home D. Women working in the home

A. Adolescents in their late teens and young adults in their early twenties High-risk groups for alcohol abuse include individuals between ages 18 and 25 and the unemployed.

A male client is being treated for alcoholism. After a family meeting, the client's spouse asks the nurse about ways to help the family deal with the effects of alcoholism. Nurse Lily should suggest that the family join which organization? A. Al-Anon B. Make Today Count C. Emotions Anonymous D. Alcoholics Anonymous

A. Al-Anon Al-Anon is an organization that assists family members to share common experiences and increase their understanding of alcoholism. Option B: Make Today Count is a support group for people with life-threatening or chronic illnesses. Option C: Emotions Anonymous is a support group for people experiencing depression, anxiety, or similar conditions. Option D: Alcoholics Anonymous is an organization that helps alcoholics recover by using a twelve-step program.

Alexi who has separation anxiety disorder has not attended school for three (3) weeks, and she cries and exhibits clinging behaviors when her mother encourages attendance. The priority nursing action by the home-care psychiatric nurse would be to: A. Assist the child in returning to school immediately with family support. B. Arrange for a home-school teacher to visit for two (2) weeks C. Encourage family discussion of various problem areas. D. Use play therapy to help the child express her feelings.

A. Assist the child to return to school immediately with family support. When a child refuses to attend school as part of separation anxiety disorder, it is important to avoid reinforcing this behavior. The nurse's priority would be to assist the child in returning to school immediately with support from the family.

The client admitted for alcohol detoxification develops increased tremors, irritability, hypertension, and fever. The nurse should be alert for impending: A. Delirium tremens B. Korsakoff's syndrome C. Esophageal varices D. Wernicke's syndrome

A. Delirium tremens Delirium Tremens is the most extreme central nervous system irritability due to withdrawal from alcohol. Option B: This refers to an amnestic syndrome associated with chronic alcoholism due to a deficiency in Vit. B. Option C: This is a complication of liver cirrhosis which may be secondary to alcoholism. Option D: This is a complication of alcoholism characterized by irregularities of eye movements and lack of coordination.

Nurse John is aware that a serious effect of inhaling cocaine is? A. Deterioration of nasal septum B. Acute fluid and electrolyte imbalances C. Extrapyramidal tract symptoms D. Esophageal varices

A. Deterioration of nasal septum Cocaine is a chemical that when inhaled, causes destruction of the mucous membranes of the nose.

When developing a plan of care for a female client with acute stress disorder who lost her sister in a car accident. Which of the following would the nurse expect to initiate? A. Facilitating progressive review of the accident and its consequences B. Postponing discussion of the accident until the client brings it up C. Telling the client to avoid details of the accident D. Helping the client to evaluate her sister's behavior

A. Facilitating progressive review of the accident and its consequences The nurse would facilitate progressive review of the accident and its consequence to help the client integrate feelings & memories and to begin the grieving process.

Nurse Bella is aware that assessment finding is most consistent with early alcohol withdrawal? A. Heart rate of 120 to 140 beats/minute B. Heart rate of 50 to 60 beats/minute C. Blood pressure of 100/70 mmHg D. Blood pressure of 140/80 mmHg

A. Heart rate of 120 to 140 beats/minute Tachycardia, a heart rate of 120 to 140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.

Nurse Tiffany reinforces the behavioral contract for a child having difficulty controlling aggressive behaviors on the psychiatric unit. Which of the following is the best rationale for this method of treatment? A. It will assist the child to develop more adaptive coping methods. B. It will avoid having the nurse be responsible for setting the rules. C. It will maintain the nurse's role in controlling the child's behavior. D. It will prevent the child from manipulating the nurse.

A. It will assist the child to develop more adaptive coping methods. Behavioral therapy is employed for the purpose of developing adaptive behavior that will improve coping. The nurse works to enhance the child's self-functioning and responsibility for his own behavior using appropriate means to develop better coping

The care for the client experiencing alcohol withdrawal places priority on which of the following: A. Monitoring his vital signs every hour B. Providing a quiet, dim room C. Encouraging adequate fluids and nutritious foods D. Administering Librium as ordered

A. Monitoring his vital signs every hour Pulse and blood pressure are usually elevated during withdrawal; Elevation may indicate impending delirium tremens. Option B: Client needs quiet, well lighted, consistent and secure environment. Excessive stimulation can aggravate anxiety and cause illusions and hallucinations. Option C: Adequate nutrition with supplements of Vit. B should be ensured. Option D: Sedatives are used to relieve anxiety.

An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism? A. Regression B. Projection C. Reaction-formation D. Intellectualization

A. Regression An adult who throws temper tantrums, such as this one, is displaying regressive behavior, or behavior that is appropriate at a younger age. Option B: In projection, the client blames someone or something other than the source. Option C: In reaction formation, the client acts in opposition to his feelings. Option D: In intellectualization, the client overuses rational explanations or abstract thinking to decrease the significance of a feeling or event.

After administering naloxone (Narcan), an opioid antagonist, Nurse Ronald should monitor the female client carefully for which of the following? A. Respiratory depression B. Epilepsy C. Kidney failure D. Cerebral edema

A. Respiratory depression After administering naloxone (Narcan) the nurse should monitor the client's respiratory status carefully, because the drug is short acting & respiratory depression may recur after its effects wear off.

Situation: A nurse may encounter children with mental disorders. Her knowledge of these various disorders is vital. When planning school interventions for a child with a diagnosis of attention deficit hyperactivity disorder, a guide to remember is to: A. Provide as much structure as possible for the child B. Ignore the child's overactivity. C. Encourage the child to engage in any play activity to dissipate energy D. Remove the child from the classroom when disruptive behavior occurs

A. provide as much structure as possible for the child Decrease stimuli for behavior control thru an environment that is free of distractions, a calm non-confrontational approach and setting limit to time allotted for activities. Option B: The child will not benefit from a lenient approach. Option C: Dissipate energy through safe activities. Option D: This indicates that the classroom environment lacks structure.

Elsa is being treated in a chemical dependency unit. She tells the nurse that she only uses drugs when under stress and therefore does not have a substance problem. Which defense mechanism is the client using? A. Compensation B. Denial C. Suppression D. Undoing

B. Denial Individuals who have substance problems often use denial. Options A, C, and D: Compensation, suppression, and undoing are incorrect and do not fit the situation described.

Francis who is addicted to cocaine withdraws from the drug. Nurse Ron should expect to observe: A. Hyperactivity B. Depression C. Suspicion D. Delirium

B. Depression There is no set of symptoms associated with cocaine withdrawal, only the depression that follows the high caused by the drug.

The psychiatric nurse uses cognitive-behavioral techniques when working with a client who experiences panic attacks. Which of the following techniques are common to this theoretical framework? (Select all that apply.) A. Administering anti-anxiety medication as prescribed B. Encouraging the client to restructure thoughts C. Helping the client to use controlled relaxation breathing D. Helping the client examine evidence of stressors E. Questioning the client about early childhood relationships F. Teaching the client about anxiety and panic

B, C, D, F These are all appropriate techniques based on the framework of cognitive-behavioral therapy.

A client admitted to the psychiatric unit for treatment of substance abuse says to the nurse, "It felt so wonderful to get high." Which of the following is the most appropriate response? A. "If you continue to talk like that, I'm going to stop speaking to you." B. "You told me you got fired from your last job for missing too many days after taking drugs all night." C. "Tell me more about how it felt to get high." D. "Don't you know it's illegal to use drugs?"

B. "You told me you got fired from your last job for missing too many days after taking drugs all night." Confronting the client with the consequences of substance abuse helps to break through denial. Option A: Making threats isn't an effective way to promote self-disclosure or establish a rapport with the client. Option C: Although the nurse should encourage the client to discuss feelings, the discussion should focus on how the client felt before, not during, an episode of substance abuse. Encouraging elaboration about his experience while getting high may reinforce the abusive behavior. Option D: The client undoubtedly is aware that drug use is illegal; a reminder to this effect is unlikely to alter behavior.

The nurse is caring for a client being treated for alcoholism. Before initiating therapy with disulfiram (Antabuse), the nurse teaches the client that he must read labels carefully on which of the following products? A. Carbonated beverages B. Aftershave lotion C. Toothpaste D. Cheese

B. Aftershave lotion Disulfiram may be given to clients with chronic alcohol abuse who wish to curb impulse drinking. Disulfiram works by blocking the oxidation of alcohol, inhibiting the conversion of acetaldehyde to acetate. As acetaldehyde builds up in the blood, the client experiences noxious and uncomfortable symptoms. Even alcohol rubbed onto the skin can produce a reaction. The client receiving disulfiram must be taught to read ingredient labels carefully to avoid products containing alcohol such as aftershave lotions. Options A, C, and D: Carbonated beverages, toothpaste, and cheese don't contain alcohol and don't need to be avoided by the client.

Another client is brought to the emergency room by friends who state that he took something an hour ago. He is actively hallucinating, agitated, with an irritated nasal septum. A. Heroin B. Cocaine C. LSD D. Marijuana

B. Cocaine The manifestations indicate intoxication with cocaine, a CNS stimulant. Option A: Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. Option C: Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs. Option D: Intoxication with Marijuana, a cannabinoid is manifested by Option A: Intoxication with heroine is manifested by euphoria then impairment in judgment, attention and the presence of papillary constriction. Option C: Intoxication with hallucinogen like LSD is manifested by grandiosity, hallucinations, synesthesia and increase in vital signs. Option D: Intoxication with Marijuana, a cannabinoid is manifested by the sensation of slowed time, conjunctival redness, social withdrawal, impaired judgment, and hallucinations.

Kris periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, Kris may experience: A. Heightened concentration B. Decreased perceptual field C. Decreased cardiac rate D. Decreased respiratory rate

B. Decreased perceptual field Panic is the most severe level of anxiety. During panic attack, the client experiences a decrease in the perceptual field, becoming more focused on self, less aware of surroundings and unable to process information from the environment. The decreased perceptual field contributes to impaired attention and in ability to concentrate.

Joy who has just experienced her second spontaneous abortion expresses anger towards her physician, the hospital and the "rotten nursing care". When assessing the situation, the nurse recognizes that the client may be using the coping mechanism of: A. Projection B. Displacement C. Denial D. Reaction formation

B. Displacement The client's anger over the abortion is shifted to the staff and the hospital because she is unable to deal with the abortion at this time.

Nurse Martha is teaching her students about anxiety medications; she explains that benzodiazepines affect which brain chemical? A. Acetylcholine B. Gamma-aminobutyric acid (GABA) C. Norepinephrine D. Serotonin

B. Gamma-aminobutyric acid (GABA) Antianxiety medications stimulate the neurotransmitter GABA, which is a chemical associated with relaxation. The other options are not affected by benzodiazepines.

Nurse Gloria questions the parents of a child with oppositional defiant disorder about the roles of each parent in setting rules of behavior. The purpose for this type of questioning is to assess which element of the family system? A. Anxiety levels B. Generational boundaries C. Knowledge of growth and development D. Quality of communication

B. Generational boundaries An important element in assessing the family system is determining if the parents establish and maintain appropriate generational boundaries, establishing clear rules and expectations as part of the parental role.

The nurse provides a referral to Alcoholics Anonymous to a client who describes a 20-year history of alcohol abuse. The primary function of this group is to: A. Encourage the use of a 12-step program. B. Help members maintain sobriety. C. Provide fellowship among members. D. Teach positive coping mechanisms.

B. Help members maintain sobriety. The primary purpose of Alcoholics Anonymous is to help members achieve and maintain sobriety. Options A, C, and D: Although each of the remaining answer choices may be an outcome of attendance at Alcoholics Anonymous, the primary purpose is directed toward sobriety of members.

When planning care for a female client using ritualistic behavior, Nurse Gina must recognize that the ritual: A. Helps the client focus on the inability to deal with reality B. Helps the client control the anxiety C. Is under the client's conscious control D. Is used by the client primarily for secondary gains

B. Helps the client control the anxiety Option B: The rituals used by a client with obsessive-compulsive disorder help control the anxiety level by maintaining a set pattern of action.

Jordanne is a client with a fear of air travel. She is being treated in a mental institution for phobic disorder. The treatment method involves systematic desensitization. The nurse would consider the treatment successful if: A. Jordanne plans a trip requiring air travel. B. Jordanne takes a short trip in an airplane. C. Jordanne recognizes the unrealistic nature of the fear of riding on airplanes. D. Jordanne verbalizes a decreased fear about air travel.

B. Jordanne takes a short trip in an airplane. Systematic desensitization is a behavioral technique in which the client with a specific phobia is gradually able to work through hierarchal fears until the most fearful situation is encountered. In this case, the most fearful is riding an airplane.

Mario is admitted to the emergency room with drug-included anxiety related to over ingestion of prescribed antipsychotic medication. The most important piece of information the nurse in charge should obtain initially is the: A. Length of time on the med. B. Name of the ingested medication & the amount ingested C. Reason for the suicide attempt D. Name of the nearest relative & their phone number

B. Name of the ingested medication & the amount ingested Option B: In an emergency, lives saving facts are obtained first. The name and the amount of medication ingested are of utmost important in treating this potentially life threatening situation.

A client is admitted with needle tracks on his arm, stuporous and with pin point pupil will likely be managed with: A. Naltrexone (Revia) B. Narcan (Naloxone) C. Disulfiram (Antabuse) D. Methadone (Dolophine)

B. Narcan (Naloxone) Narcan is a narcotic antagonist used to manage the CNS depression due to overdose with heroin. Option A: This is an opiate receptor blocker used to relieve the craving for heroin. Option C: Disulfiram is used as a deterrent in the use of alcohol. Option D: Methadone is used as a substitute in the withdrawal from heroin

An 11-year-old child diagnosed with conduct disorder is admitted to the psychiatric unit for treatment. Which of the following behaviors would the nurse assess? A. Restlessness, short attention span, hyperactivity B. Physical aggressiveness, low-stress tolerance disregard for the rights of others C. Deterioration in social functioning, excessive anxiety, and worry, bizarre behavior D. Sadness, poor appetite and sleeplessness, loss of interest in activities

B. Physical aggressiveness, low-stress tolerance disregard for the rights of others Physical aggressiveness, low-stress tolerance, and a disregard for the rights of others are common behaviors in clients with conduct disorders.

Mandy, a nurse who works at Nurseslabs Rehabilitation Center is assessing a client for recent stressful life events. She recognizes that stressful life events are both: A. Desirable and growth-promoting. B. Positive and negative. C. Undesirable and harmful. D. Predictable and controllable.

B. Positive and negative. The concept of stressful life event is based on the research of Holmes and Rahe, who found that both positive and negative changes result in stress. Options A and C: Stressful life events are not always desirable and growth promoting, nor are they always undesirable and harmful. Option D: Some stressful life events can be predictable and controllable; however, many life events are entirely unpredictable.

A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals is a priority? A. The client will commit to a drug-free lifestyle. B. The client will work with the nurse to remain safe. C. The client will drink plenty of fluids daily. D. The client will make a personal inventory of strengths

B. The client will work with the nurse to remain safe. The priority goal in alcohol withdrawal is maintaining the client's safety. Options A, C, and D: Committing to a drug-free lifestyle, drinking plenty of fluids, and identifying personal strengths are important goals, but ensuring the client's safety is the nurse's top priority.

Marco approached Nurse Trisha asking for advice on how to deal with his alcohol addiction. Nurse Trisha should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Alcoholics Anonymous (A.A.) C. Total abstinence D. Aversion Therapy

C. Total abstinence Option C: Total abstinence is the only effective treatment for alcoholism.

Situation: The nurse assigned to the detoxification unit attends to various patients with substance-related disorders. A 45 years old male revealed that he experienced a marked increase in his intake of alcohol to achieve the desired effect This indicates: A. Withdrawal B. Tolerance C. Intoxication D. Psychological dependence

B. Tolerance Tolerance refers to the increase in the amount of the substance to achieve the same effects. Option A: Withdrawal refers to the physical signs and symptoms that occur when the addictive substance is reduced or withheld. Option B: Intoxication refers to the behavioral changes that occur upon recent ingestion of substance. Option D: Psychological dependence refers to the intake of the substance to prevent the onset of withdrawal symptoms.

A male client has approached the nurse asking for advice on how to deal with his alcohol addiction. Nurse Sally should tell the client that the only effective treatment for alcoholism is: A. Psychotherapy B. Total abstinence C. Alcoholics Anonymous (AA) D. Aversion therapy

B. Total abstinence Total abstinence is the only effective treatment for alcoholism. Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain. Options A, C, and D: Psychotherapy, attendance at AA meetings, and aversion therapy are all adjunctive therapies that can support the client in his efforts to abstain.

A 5-year-old boy is diagnosed to have autistic disorder. Which of the following manifestations may be noted in a client with autistic disorder? A. Argumentativeness, disobedience, angry outburst B. Intolerance to change, disturbed relatedness, stereotypes C. Distractibility, impulsiveness, and overactivity D. Aggression, truancy, stealing, lying

B. intolerance to change, disturbed relatedness, stereotypes These are manifestations of autistic disorder. Option A: These manifestations are noted in Oppositional Defiant Disorder, a disruptive disorder among children. Option C: These are manifestations of Attention Deficit Disorder. Option D: These are the manifestations of Conduct Disorder

The nurse is assessing a client on admission to the chemical dependency unit for alcohol detoxification. When the nurse asks about alcohol use, this client is most likely to: A. accurately describe the amount consumed. B. underestimate the amount consumed. C. overestimate the amount consumed. D. deny any consumption of alcohol.

B. underestimate the amount consumed. Most people who abuse substances underestimate their consumption in an attempt to conform to social norms or protect themselves. Options A, C, and D: Few accurately describe or overestimate consumption; some may deny it. Therefore, on admission, quantitative and qualitative toxicology screens are done to validate information obtained from the client.

The nurse in the substance abuse unit is trying to encourage a client to attend Alcoholics Anonymous meetings. When the client asks the nurse what he must do to become a member, the nurse should respond: A. "You must first stop drinking." B. "Your physician must refer you to this program." C. "Admit you're powerless over alcohol and that you need help." D. "You must bring along a friend who will support you."

C. "Admit you're powerless over alcohol and that you need help." The first of the "Twelve Steps of Alcoholics Anonymous" is admitting that an individual is powerless over alcohol and that life has become unmanageable. Option A: Although Alcoholics Anonymous promotes total abstinence, a client will still be accepted if he drinks. Option B: A physician referral isn't necessary to join. Option D: New members are assigned a support person who may be called upon when the client has the urge to drink.

After completing chemical detoxification and a 12-step program to treat cocaine addiction, a client is being prepared for discharge. Which remark by the client indicates a realistic view of the future? A. "I'm never going to use cocaine again." B. "I know what I have to do. I have to limit my cocaine use." C. "I'm going to take 1 day at a time. I'm not making any promises." D. "I will substitute cocaine for something else"

C. "I'm going to take 1 day at a time. I'm not making any promises." Twelve-step programs focus on recovery 1 day at a time. Option A: Such programs discourage people from claiming that they will never again use a substance because relapse is common. Option B: The belief that one may use a limited amount of an abused substance indicates denial. Option D: Substituting one abused substance for another predisposes the client to cross-addiction.

A male client is being admitted to the substance abuse unit for alcohol detoxification. As part of the intake interview, the nurse asks him when he had his last alcoholic drink. He says that he had his last drink six (6) hours before admission. Based on this response, nurse Lorena should expect early withdrawal symptoms to: A. Begin after seven (7) days B. Not occur at all because the time period for their occurrence has passed C. Begin anytime within the next one (1) to two (2) days D. Begin within two (2) to seven (7) days

C. Begin anytime within the next one (1) to two (2) days Acute withdrawal symptoms from alcohol may begin 6 hours after the client has stopped drinking and peak 1 to 2 days later. Delirium tremens may occur 2 to 4 days — even up to 7 days — after the last drink.

Situation: A 35-year-old male has an intense fear of riding an elevator. He claims " As if I will die inside." This has affected his studies The client is suffering from: A. Agoraphobia B. Social phobia C. Claustrophobia D. Xenophobia

C. Claustrophobia Claustrophobia is fear of closed space. Option A: Agoraphobia is fear of open space or being a situation where escape is difficult. Option B: Social phobia is fear of performing in the presence of others in a way that will be humiliating or embarrassing. Option D: Xenophobia is fear of strangers.

A nurse is developing a care plan for a female client with post-traumatic stress disorder. Which of the following would she do initially? A. Instruct the client to use distraction techniques to cope with flashbacks. B. Encourage the client to put the past in proper perspective. C. Encourage the client to verbalize thoughts and feelings about the trauma. D. Avoid discussing the traumatic event with the client.

C. Encourage the client to verbalize thoughts and feelings about the trauma. Planning care for a client with post-traumatic stress disorder would involve helping the client to verbalize thoughts and feelings about the trauma. This will help the client work through the strong emotions connected with the trauma and, therefore foster the belief that she is able to cope. Options A and D: Avoiding discussion and using distraction techniques would be inappropriate. Option B may be possible later after the client is able to verbalize strong emotions.

A 39-year-old mother with obsessive-compulsive disorder has become immobilized by her elaborate hand washing and walking rituals. Nurse Trish recognizes that the basis of O.C. disorder is often: A. Problems with being too conscientious B. Problems with anger and remorse C. Feelings of guilt and inadequacy D. Feeling of unworthiness and hopelessness

C. Feelings of guilt and inadequacy Option C: Ritualistic behavior seen in this disorder is aimed at controlling guilt and inadequacy by maintaining an absolute set pattern of behavior.

Nurse Wilma is teaching a client about disulfiram (Antabuse), which the client is taking to deter his use of alcohol. She explains that using alcohol when taking this medication can result in: A. Abdominal cramps and diarrhea. B. Drowsiness and decreased respiration. C. Flushing, vomiting, and dizziness. D. Increased pulse and blood pressure.

C. Flushing, vomiting, and dizziness. Disulfiram (Antabuse) prevents complete alcohol metabolism in the body. Therefore when alcohol is consumed, the client has a hypersensitivity reaction. Flushing, vomiting, and dizziness are associated with the incomplete breakdown of alcohol metabolites.

Cely is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mmHg and pulse is 92 bpm. Which of the medications would the nurse expect to administer? A. Naloxone (Narcan) B. Benztropine (Cogentin) C. Lorazepam (Ativan) D. Haloperidol (Haldol)

C. Lorazepam (Ativan) Option C: The nurse would most likely administer benzodiazepine, such as lorazepan (ativan) to the client who is experiencing symptom: The client's experiences symptoms of withdrawal because of the rebound phenomenon when the sedation of the CNS from alcohol begins to decrease.

Nurse Julie recommends that the family of a client with substance-related disorder attend a support group, such as Al-Anon and Alateen. The purpose of these groups is to help family members understand the problem and to: A. Change the problem behaviors of the abuser. B. Learn how to assist the abuser in getting help. C. Maintain focus on changing their own behaviors. D. Prevent substance problems in vulnerable family members.

C. Maintain focus on changing their own behaviors. Family support groups, such as Al-Anon and Alateen, emphasize the importance of changing one's own behavior rather than trying to change the behavior of the individual with a substance abuse problem.

Which behavioral assessment in a child is most consistent with a diagnosis of conduct disorder? A. Arguing with adults B. Gross impairment in communication C. Physical aggression toward others D. Refusal to separate from caretaker

C. Physical aggression toward others Physical aggression toward others is a significant criterion consistent with the diagnoses of conduct disorder.

A female client begins to experience alcoholic hallucinosis. Nurse Joy is aware that the best nursing intervention at this time? A. Keeping the client restrained in bed B. Checking the client's blood pressure every 15 minutes and offering juices C. Providing a quiet environment and administering medication as needed and prescribed D. Restraining the client and measuring blood pressure every 30 minutes

C. Providing a quiet environment and administering medication as needed and prescribed Manifestations of alcoholic hallucinosis are best treated by providing a quiet environment for reducing stimulation and administering prescribed central nervous system depressants in dosages that control symptoms without causing over-sedation. Option A: Although bed rest is indicated, restraints are unnecessary unless the client poses a danger to himself or others. Also, restraints may increase agitation and make the client feel trapped and helpless when hallucinating. Option B: Offering juice is appropriate, but measuring blood pressure every 15 minutes would interrupt the client's rest. Option D: To avoid overstimulating the client, the nurse should check blood pressure every 2 hours.

A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using? A. Displacement B. Projection C. Rationalization D. Sublimation

C. Rationalization Rationalization is the defense mechanism that involves offering excuses for maladaptive behavior. The client is defending his substance abuse by providing reasons related to life stressors. This is a common defense mechanism used by clients with substance abuse problems.

Nurse Rob has observed a co-worker arriving to work drunk at least three times in the past month. Which action by Nurse Rob would best ensure client safety and obtain necessary assistance for the co-worker? A. Ignore the co worker's behavior, and frequently assess the clients assigned to the co-worker. B. Make general statements about safety issues at the next staff meeting. C. Report the coworker's behavior to the appropriate supervisor. D. Warn the co-worker that this practice is unsafe.

C. Report the coworker's behavior to the appropriate supervisor. The nurse is obligated by ethical considerations of client safety, as well as by nurse practice acts in many states, to report substance abuse in health care workers. Most healthcare facilities have an employee assistance program to help workers with substance abuse problems. Option A: Ignoring the co worker's behavior would be a form of enabling behavior (codependency) on the staff nurse's part. Option B: Making general statements about safety in a staff meeting avoids dealing with the problem. Option D: Warning the co-worker is inadequate; it does not ensure client safety or helps him receive necessary aid.

A client is experiencing anxiety attack. The most appropriate nursing intervention should include? A. Turning on the television B. Leaving the client alone C. Staying with the client and speaking in short sentences D. Ask the client to play with other clients

C. Staying with the client and speaking in short sentences Option C: Appropriate nursing interventions for an anxiety attack include using short sentences, staying with the client, decreasing stimuli, remaining calm and medicating as needed.

Nurse John is aware that the therapy that has the highest success rate for people with phobias would be: A. Psychotherapy aimed at rearranging maladaptive thought process B. Psychoanalytical exploration of repressed conflicts of an earlier development phase C. Systematic desensitization using relaxation technique D. Insight therapy to determine the origin of the anxiety and fear

C. Systematic desensitization using relaxation technique The most successful therapy for people with phobias involves behavior modification techniques using desensitization.

When planning the discharge of a client with chronic anxiety, Nurse Chris evaluates achievement of the discharge maintenance goals. Which goal would be most appropriately having been included in the plan of care requiring evaluation? A. The client eliminates all anxiety from daily situations B. The client ignores feelings of anxiety C. The client identifies anxiety-producing situations D. The client maintains contact with a crisis counselor

C. The client identifies anxiety-producing situations Option C: Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus.

The nurse is providing care for a client undergoing opiate withdrawal. Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with: A. barbiturates. B. amphetamines. C. methadone. D. benzodiazepines.

C. methadone. Methadone is used to detoxify opiate users because it binds with opioid receptors at many sites in the central nervous system but doesn't have the same deleterious effects as other opiates, such as cocaine, heroin, and morphine. Options A, B, and D: Barbiturates, amphetamines, and benzodiazepines are highly addictive and would require detoxification treatment.

The nurse observes a client pacing in the hall. Which statement by the nurse may help the client recognize his anxiety? A. "I guess you're worried about something, aren't you? b. "Can I get you some medication to help calm you?" c. "Have you been pacing for a long time?" d. "I notice that you're pacing. How are you feeling?"

D. "I notice that you're pacing. How are you feeling?" By acknowledging the observed behavior and asking the client to express his feelings the nurse can best assist the client to become aware of his anxiety.

Initial intervention for a client with a specific phobia should be to: A. Encourage to verbalize his fears as much as he wants. B. Assist him to find meaning to his feelings in relation to his past. C. Establish trust through a consistent approach. D. Accept her fears without criticizing.

D. Accept her fears without criticizing. The client cannot control her fears although the client knows it's silly and can joke about it. Option A: Allow expression of the client's fears but he should focus on other productive activities as well. Options B and C: These are not the initial interventions.

A man is admitted to the nursing care unit with a diagnosis of cirrhosis. He has a long history of alcohol dependence. During the late evening following his admission, he becomes increasingly disoriented and agitated. Which of the following would the client be least likely to experience? A. Diaphoresis and tremors. B. Increased blood pressure and heart rate. C. Illusions. D. Delusions of grandeur.

D. Delusions of grandeur Delusions of grandeur are symptomatic of manic clients, not clients withdrawing from alcohol. The symptoms and history of alcohol abuse suggest this client is in alcohol withdrawal. Option A: Diaphoresis and tremors occur in the first phase of alcohol withdrawal. Option B: The blood pressure and heart rate increase in the first phase of alcohol withdrawal. Option C: Illusions are common in persons withdrawing from alcohol. Illusions occur most often in dim artificial lighting where the environment is not perceived accurately.

A client is admitted for detoxification after a cocaine overdose. The client tells the nurse that he frequently uses cocaine but he can control his use if he chooses. Which coping mechanism is he using? A. Withdrawal B. Logical thinking C. Repression D. Denial

D. Denial Denial is an unconscious defense mechanism in which emotional conflict and anxiety are avoided by refusing to acknowledge feelings, desires, impulses, or external facts that are consciously intolerable. Option A: Withdrawal is a common response to stress, characterized by apathy. Option B: Logical thinking IS the ability to think rationally and make responsible decisions, which would lead the client to admitting the problem and seeking help. Option C: Repression is suppressing past events from the consciousness because of guilty association.

A client voluntarily admits himself to the substance abuse unit. He confesses that he drinks 1 qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness

D. Diaphoresis, tremors, and nervousness Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Option A: Although diarrhea may be an early sign of alcohol withdrawal, tachycardia — not bradycardia — is associated with alcohol withdrawal. Option B: Dehydration and an elevated temperature may be expected, but a temperature above 101° F indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal. Option C: If withdrawal symptoms remain untreated, seizures may arise later.

A male adult client voluntarily admits himself to the substance abuse unit. He confesses that he drinks one (1) qt or more of vodka each day and uses cocaine occasionally. Later that afternoon, he begins to show signs of alcohol withdrawal. What are some early signs of this condition? A. Vomiting, diarrhea, and bradycardia B. Dehydration, temperature above 101° F (38.3° C), and pruritus C. Hypertension, diaphoresis, and seizures D. Diaphoresis, tremors, and nervousness

D. Diaphoresis, tremors, and nervousness Alcohol withdrawal syndrome includes alcohol withdrawal, alcoholic hallucinosis, and alcohol withdrawal delirium (formerly delirium tremens). Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.

Nurse Daya, a school nurse, is meeting with the school and health treatment team about a child who has been receiving methylphenidate (Ritalin) for two (2) months. The meeting is to evaluate the results of the child's medication use. Which behavior change noted by the teacher will help determine the medication's effectiveness. A. Decrease repetitive behaviors B. Decreased signs of anxiety C. Increased depressed mood D. Increased ability to concentrate on tasks

D. Increased ability to concentrate on tasks

A client with a history of polysubstance abuse is admitted to the facility. She complains of nausea and vomiting 24 hours after admission. The nurse assesses the client and notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through which of the following withdrawals? A. Alcohol withdrawal B. Cannabis withdrawal C. Cocaine withdrawal D. Opioid withdrawal

D. Opioid withdrawal The symptoms listed are specific to opioid withdrawal. Option A: Alcohol withdrawal would show elevated vital signs. Option B: There is no real withdrawal from cannabis. Option C: Symptoms of cocaine withdrawal include depression, anxiety, and agitation.

Nurse Penny is aware that the symptoms that distinguish post-traumatic stress disorder from other anxiety disorder would be: A. Avoidance of situation & certain activities that resemble the stress B. Depression and a blunted affect when discussing the traumatic situation C. Lack of interest in family & others D. Re-experiencing the trauma in dreams or flashback

D. Re-experiencing the trauma in dreams or flashback Option D: Experiencing the actual trauma in dreams or flashback is the major symptom that distinguishes post-traumatic stress disorder from other anxiety disorder.

The therapeutic approach in the care of an autistic child includes the following EXCEPT: A. Engage in diversionary activities when acting -out B. Provide an atmosphere of acceptance C. Provide safety measures D. Rearrange the environment to activate the child

D. Rearrange the environment to activate the child The child with autistic disorder does not want change. Maintaining a consistent environment is therapeutic. Option A: Angry outburst can be re-channelled through safe activities. Option B: Acceptance enhances a trusting relationship. Option C: Ensure safety from self-destructive behaviors like head banging and hair pulling.

A female client is brought by ambulance to the hospital emergency room after taking an overdose of barbiturates is comatose. Nurse Trish would be especially alert for which of the following? A. Epilepsy B. Myocardial Infarction C. Renal failure D. Respiratory failure

D. Respiratory failure Barbiturates are CNS depressants; the nurse would be especially alert for the possibility of respiratory failure. Respiratory failure is the most likely cause of death from barbiturate overdose.

The child with conduct disorder will likely demonstrate: A. Easy distractibility to external stimuli. B. Ritualistic behaviors C. Preference for inanimate objects. D. Serious violations of age related norms.

D. Serious violations of age-related norms. This is a disruptive disorder among children characterized by more serious violations of social standards such as aggression, vandalism, stealing, lying and truancy. Option A: This is characteristic of attention deficit disorder. Options B and C: These are noted among children with autistic disorder.

Which of the following assessment would provide the best information about the client's physiologic response and the effectiveness of the medication prescribed specifically for alcohol withdrawal? A. Sleeping pattern B. Mental alertness C. Nutritional status D. Vital signs

D. Vital signs Monitoring of vital signs provides the best information about the client's overall physiologic status during alcohol withdrawal & the physiologic response to the medication used.

A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal? A. naloxone (Narcan) B. haloperidol (Haldol) C. magnesium sulfate D. chlordiazepoxide (Librium)

D. chlordiazepoxide (Librium) Chlordiazepoxide (Librium) and other tranquilizers help reduce the symptoms of alcohol withdrawal. Naloxone (Narcan) is administered for narcotic overdose. Haloperidol (Haldol) may be given to treat clients with psychosis, severe agitation, or delirium. Magnesium sulfate and other anticonvulsant medications are only administered to treat seizures if they occur during withdrawal.

A 38-year-old client is admitted for alcohol withdrawal. The most common early sign or symptom that this client is likely to experience is: A. impending coma. B. manipulating behavior. C. suppression. D. perceptual disorders.

D. perceptual disorders. Perceptual disorders, especially frightening visual hallucinations, are very common with alcohol withdrawal Option A: Coma isn't an immediate consequence. Option B: Manipulative behaviors are part of the alcoholic client's personality but aren't signs of alcohol withdrawal. Option C: Suppression is a conscious effort to conceal unacceptable thoughts, feelings, impulses, or acts and serves as a coping mechanism for most alcoholics.

To establish an open and trusting relationship with a female client who has been hospitalized with severe anxiety, the nurse in charge should? A. Encourage the staff to have frequent interaction with the client B. Share an activity with the client C. Give client feedback on behavior D. Respect client's need for personal space

Respect client's need for personal space Option D: Moving to a client's personal space increases the feeling of threat, which increases anxiety.