Mental Health Final Study Guide
All of the following are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client? A) Observe for signs of fear or agitation B) Maintain reality through frequent contact C) Encourage to participate in the treatment milieu D) Assess community support systems
Ans: A Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The nurse must observe for signs of building agitation or escalating behavior such as increased intensity of pacing, loud talking or yelling, and hitting or kicking objects. The nurse must then institute interventions to protect the client, nurse, and others in the environment.
The police find a woman wandering around a parking lot, singing very loudly. They bring her to the hospital; she has no knowledge of what she has been doing for the past 12 hours and is dressed in unfamiliar clothing. This is an example of A) dissociation. B) manipulation. C) psychosis. D) regression.
Ans: A The client experienced a temporary alteration in conscious awareness. This situation is not an example of manipulation. The woman is not experiencing psychosis. Regression occurs when there is a retreat to an earlier stage of development and comfort.
During the mental status assessment, the client expresses the belief that the CIA is stalking the client and plans to kidnap the client. Which would be the best response by the nurse? A. "What kinds of things have been happening? B. "You can tell me about that after I finish asking these questions." C. "That makes no sense at all." D) "Why would the CIA be interested in you?"
Ans: A
Which of the following interventions would assist the client with the appropriate expression of anger? A) Encourage catharsis B) Encourage verbalization C) Improve self-esteem D) Isolate the client from others
Ans: B Verbally expressing angry feelings is a safe and appropriate way to deal with anger. Isolation and catharsis can increase angry and hostile feelings. The other choices are not appropriate responses in this situation.
The physician has prescribed Haldol 10 mg for a severely psychotic client. The client refuses the medication. Which nursing intervention is an appropriate response? A) Accept the client's decision B) Obtain a discharge order for noncompliance C) Tell the client that he is too sick to refuse D) Restrain the client and give the medication IM
Ans: A Clients have the right to refuse medication even when they are psychotic. The client cannot be discharged just because he refuses to take his medications. In this situation, it is not appropriate for the nurse to tell the client that he is too sick to refuse. Restraints are not an appropriate means of getting the client to take the medication.
An adolescent on the unit is argumentative with staff and peers. The nurse tells the adolescent, "Arguing is not allowed. One more word and you will have to stay in your room the rest of the day." The nurse's directive is A) inappropriate; room restriction is not treatment in the least restrictive environment. B) inappropriate; the adolescent should be offered a sedative before room restriction. C) appropriate; room restriction is an effective behavior modification technique. D) appropriate; the adolescent should not have conflicts with others.
Ans: A Clients have the right to treatment in the least restrictive environment appropriate to meet their needs. It means that a client does not have to be hospitalized if he or she can be treated in an outpatient setting or in a group home. It also means that the client must be free of restraint or seclusion unless it is necessary. Verbal and behavioral techniques should be instituted before physical measures such as sedation, restraint, or seclusion.
Which of the following is true about the use of touch with a client with dissociative identity disorder? A) It is best not to touch the client without his or her permission. B) Make sure the client knows the touch is friendly and supportive. C) Touch the client only if you are in his or her direct line of vision. D) Touching will convey a sense of security to the client.
Ans: A Clients interpret touch differently, so it is important to assess each client's comfort with being touched; these clients often have a history of abuse, so permission should be given before touch is used.
Which of the following is most essential when planning care for a client who is experiencing a crisis? A)Explore previous coping strategies B)Explore underlying personality dynamics C)Focus on emotional deficits D)Offer a referral to a self-help group
Ans: A Crisis intervention focuses on using the person's strengths, such as previous coping skills, and providing support to deal with the current situation. Exploring underlying personality dynamics and focusing on emotional deficits would not help the client in the crisis situation. When the client is in a crisis situation, offering a self-help group would not be appropriate.
Which of the following interventions by the nurse will increase the client's sense of security? A) Allowing the client to perform the rituals B) Distracting the client from rituals with other activities C) Encouraging the client to talk about the purpose of the rituals D) Stopping the client from performing the rituals
Ans: A Feedback: The client performs rituals to decrease anxiety and will feel most secure when performing the rituals. The other choices would not promote a sense of security of the client.
A concerned family member tells the nurse, "I am concerned about my brother. He has been acting very different lately." Knowing the family has a history of bipolar disorder, the nurse inquires further about this. Which behavior during the past week might indicate that the brother has bipolar disorder? A) Taking unnecessary risks B) Sleeping more C) Intense focus D) Showing low self-esteem
Ans: A Feedback: The diagnosis of a manic episode or mania requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: exaggerated self-esteem; sleeplessness; pressured speech; flight of ideas; reduced ability to filter extraneous stimuli; distractibility; increased activities with increased energy; and multiple, grandiose, high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments.
A client who is manic states, "What time is it? I have to see the doctor. Is breakfast here yet? I've got to see the doctor first. Can I get my cereal out of the kitchen?" Which would be the most appropriate response by the nurse? A) "Please slow down. I'm not sure what you need first." B) "You will have to be quiet and have breakfast after the doctor comes." C) "Are you hungry?" D) "Your thoughts seem to be racing this morning."
Ans: A Feedback: The speech of manic clients may be pressured: rapid, circumstantial, rhyming, noisy, or intrusive with flights of ideas. The nurse must keep channels of communication open with clients, regardless of speech patterns. The nurse can say, "Please speak more slowly. I'm having trouble following you." This puts the responsibility for the communication difficulty on the nurse rather than on the client.
A child with attention deficit hyperactivity disorder is taking methylphenidate (Ritalin) in divided doses. If the child takes the first dose at 8 AM, which behavior might the school nurse expect to see at noon? A) Increased impulsivity or hyperactive behavior B) Lack of appetite for lunch C) Sleepiness or drowsiness D) Social isolation from peers
Ans: A Feedback: Ritalin has a short half-life, so doses are needed about every 4 hours during the day to maintain symptom control. Giving stimulants during daytime hours usually effectively combats insomnia
What is an important role of the nurse with regard to residents opposing plans to establish a group home or residential facility in their neighborhood? A) To provide information to correct misinformation related to stereotypes of persons with mental illnesses B) To persuade neighborhood residents that mentally ill people need safe, affordable, and desirable housing C) To provide for the safety and security of the neighborhood D) To ensure the security of persons in the group home
Ans: A Frequently, residents oppose plans to establish a group home or residential facility in their neighborhood. They argue that having a group home will decrease their property values, and they may believe that people with mental illness are violent, will act bizarrely in public, or will be a menace to their children. These people have strongly ingrained stereotypes and a great deal of misinformation. Local residents must be given the facts, and nurses are in a position to advocate for clients by educating members of the community. The neighborhood residents who object to the establishment of a group home or residential setting may not be motivated to understand the needs of mentally ill people. It is not the responsibility for the nurse to provide for the safety and security of the neighborhood or protect the safety and security of persons in the group home.
A young woman telephones the emergency department and loudly tells the nurse, "I've been raped! Please help me!" Which of the following is the priority for the nurse to determine? A) If the client was in a safe place, her condition, and if transportation is available B) If the client knew her assailant, knew her location, and had notified the police C) If the client has insurance, if she could get to the hospital by herself, and if pregnancy is a possibility D) If the client had bathed, douched, or changed clothed
Ans: A If the client is injured, she may need immediate medical attention; if she is in a safe place, she can talk to the nurse on the phone. All other questions can wait until the client's safety is ensured.
Which of the following statements by the nurse would be most appropriate to a colleague who very quietly and numbly tells the nurse that she had arrived at the scene of an automobile-pedestrian accident and unsuccessfully performed CPR on a victim 3 days ago? The nurse and her colleague are sitting in the break room and no one else is present. A) "Tell me what you saw." B) "That is horrible!" C) "Why did you perform CPR?" D) "I know how you feel; the same thing happened to me several years ago and I never recovered."
Ans: A One of the most effective ways of avoiding pathologic responses to trauma is effectively dealing with the trauma soon after it occurs. Describing what the colleague saw may be very helpful to him or her. "That is horrible," is a judgment and is not likely to be helpful. "Why did you perform CPR," might make the colleague feel defensive. "I know how you feel; the same thing happened to me several years ago and I never recovered," is nonsupportive and robs the colleague of any hope that he or she will recover.
A nurse is providing care to a woman who has just delivered a stillborn baby. Which would be the most appropriate nursing response to address the woman's grief? A) "Would you like to hold your child?" B) "Can I do anything for you?" C) "If something was wrong, it's better this way" D) "Your son is in heaven with God now."
Ans: A The opportunity to hold the baby may help the woman deal with the first stage of grieving: denial; it also allows her to express emotions over the loss. Asking the client, "Can I do anything for you," is a closed-ended question and will likely be replied to with a yes or no answer. Stating,"If something was wrong, it's better this way,"is not sensitive to the woman's loss. Stating "Your child is in heaven with God now," would be inappropriate because it may not be consistent with the woman's beliefs.
The nurse asks the client, "What is similar about a cow and a horse?" and "What do a bus and an airplane have in common?" These questions would best assess which of the following areas? A) Intellectual function B) Insight C) Judgment D) Memory
Ans: A These questions would elicit information about the client's intellectual function. Insight is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Judgment refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. Questions about memory would require that the client identify knowledge of past events
The nurse is using limit setting with a child diagnosed with conduct disorder. Which statement reflects the most effective way for the nurse to set limits with the child? A) "That is not allowed here. You will lose a privilege. You need to stop." B) "Stop what you are doing. Go to your room." C) "I would appreciate if you would not do that." D) "Why do you do these things?"
Ans: A Feedback: The nurse must set limits on unacceptable behavior at the beginning of treatment. Limit setting involves three steps: (1) informing clients of the rule or limit; (2)explaining the consequences if clients exceed the limit; and (3) stating expected behavior.
The client spoke of a current event in the national news and described it as it relates to the client. Then the client spoke of a historical event and described it as it relates to the client. Which of the following questions might the nurse ask to determine if the client is experiencing ideas of reference? A) Where were you when this happened? B) Why do you think that? C) Are you sure? D) That is unbelievable!
Ans: A Ideas of reference are the client's inaccurate interpretation that general evens are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. Where were you when this happened would relate to the place and might give the nurse more information to validate the client's previous comments. Why do you think that may be interpreted as the nurse challenging the client. Are you sure is a closed-ended question and does not encourage the client to elaborate. That is unbelievable is a statement rather than a question and could be interpreted as the nurse's opinion of the information provided by the client.
A college freshman is admitted to the hospital with a diagnosis of schizophrenia. Friends reported that she had been in her room for 2 days in a trance-like state, not eating nor speaking to anyone. Which of the following is the highest priority for this client? A) Assessing fluid intake and output B) Completing an assessment of mental status C) Obtaining more data about her college experiences D) Providing for adequate rest
Ans: A Physiologic homeostasis is a priority for this client. Completing an assessment of mental status, obtaining data about college experiences, and providing adequate rest are not the highest priority.
Which of the following are reasons that the nurse must understand why and how anxiety behaviors work? Select all that apply. A) To provide better care for the client B) To help understand the role anxiety plays in performing nursing responsibilities C) To help the nurse to mask his or her own feelings of anxiety D) So the nurse can identify that his or her own needs are more important than the clients E) To help nurses to function at a high level
Ans: A B E Nurses must understand why and how anxiety behaviors work, not just for client care but to help understand the role anxiety plays in performing nursing responsibilities. Nurses are expected to function at a high level and to avoid allowing their own feelings and needs to hinder the care of their clients, but as emotional beings, nurses are just as vulnerable to stress and anxiety as others, and they have needs of their own.
The therapeutic communication interaction is most comfortable when the nurse and client are: A) 3-6 ft apart B) 0-18 inches apart C) 2-3 feet apart D) 4-12 ft apart
Ans: A) 3-6 ft apart
How can a nurse avoid the possibility of finding the client's behavior unacceptable or distasteful? A)By being aware of the client's behavior and background before beginning the relationship; and exploring the possibility of a conflict of a colleague. B)By using silence instead of verbal responses for all instance of the client describing their behavior C)By using facial expressions of annoyance if the client expresses behavior that the nurse disapproves of D)By turning away from the client when the nurse does not want the client to see his or her facial expression
Ans: A) By being aware of the client's behavior and background before beginning the relationship; and exploring the possibility of a conflict of a colleague.
Which of the following questions would best help the nurse to evaluate the effectiveness of antipsychotic medications for a client who has schizophrenia? Select all that apply. A) Have the symptoms you were experiencing disappeared? B) If the symptoms have not disappeared, are you able to carry out your daily life despite the persistence of some psychotic symptoms? C) Are you committed to taking the medication as prescribed? D) Are you satisfied with your quality of life? E) Do you have access to community agencies that will help you to live successfully in this community?
Ans: A, B, C, D The client's perception of the success of treatment plays a part in evaluation. "Do you have access to community agencies that will help you to live successfully in this community?" is an appropriate question to ask to evaluate the plan of care but does not directly relate to antipsychotic medications
Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses? Select all that apply. A) Alzheimer's dementia B) Schizophrenia C) Anorexia nervosa D) Acute alcohol intoxication E) Generalized anxiety disorder
Ans: A, B, D Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. Clients with paranoid delusions may believe others are out to get them; believing they are protecting themselves, they retaliate with hostility or aggression. Some clients have auditory hallucinations that command them to hurt others. Aggressive behavior also is seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders
Which of the following are criteria that must be adhered to when instituting the short- term use of restraint or seclusion? Select all that apply. A) The client is aggressive. B) The client is being punished. C) The client is imminently dangerous to himself or herself or to others. D) The client is physically and emotionally self-controlled. E) All other means of calming the client have been unsuccessful.
Ans: A, C, E Short-term use of restraint or seclusion is permitted only when the client is imminently aggressive and dangerous to himself or herself or to others, and all other means of calming the client have been unsuccessful. The nurse must frequently contact the client and reassure the client that restraint is a restorative, not a punitive, procedure. If the client is physically and emotionally self-controlled, there is no reason for the client to be restrained or secluded
The nurse has been working with a client with an eating disorder for 1 week. During the morning treatment team meeting, the treatment plan is updated. Which would be appropriate interventions at this time in the nurse-client relationship? Select all that apply. A) Exploring perceptions of reality B) Establishing boundaries C)Promoting a positive self-concept D)Working through resistance E) Identifying problems
Ans: A, C, D Specific tasks of the working phase include maintaining the relationship, gathering more data, exploring perceptions of reality, developing positive coping mechanisms, promoting a positive self-concept, encouraging verbalization of feelings, facilitating behavior change, working through resistance, evaluating progress and redefining goals as appropriate, providing opportunities for the client to practice new behaviors, and promoting independence. Establishing boundaries and dealing with testing behaviors are completed in the orientation phase, which should be completed by this point.
A client with schizophrenia has returned to the clinic because of an increase in symptoms. The client reports he stopped taking his meds because he did not like the side effects. The nurse educates the client about managing uncomfortable side effects. Which of the following is included in the teaching plan? Select all that apply. A) Suck on hard candy as desired B) Spend at least 30 minutes outside in the sun daily C) Use stool softeners as needed D) Decrease the amount of daily fluid intake E) Maintain a balanced calorie-controlled diet
Ans: A, C, E Unwanted side effects are frequently reported as the reason clients stop taking medications. interventions such as eating a proper diet and drinking enough fluids, using a stool softener to avoid constipation, sucking on hard candy to minimize dry mouth, or using sunscreen to avoid sunburn, can help control some of these uncomfortable side effects.
The nursing student understands correctly when identifying which objective is appropriate for all clients with anxiety disorders? A) The client will experience reduced anxiety and accept the fact that underlying conflicts cannot be treated. B) The client will experience reduced anxiety and develop alternative responses to anxiety-provoking situations. C) The client will experience reduced anxiety and learn to control primitive impulses. D) The client will experience reduced anxiety and strive for insight through psychoanalysis.
Ans: B A primary client outcome is improved adaptive coping skills.
Which one of the following is a result of federal legislation? A) Making it easier to commit people for mental health treatment against their will. B) Making it more difficult to commit people for mental health treatment against their will. C) State mental institutions being the primary source of care for mentally ill persons. D) Improved care for mentally ill persons.
Ans: B Commitment laws changed in the early 1970s, making it more difficult to commit people for mental health treatment against their will. Deinstitutionalization accomplished the release of individuals from long-term stays in state institutions. Deinstitutionalization also had negative effects in that some mentally ill persons are subjected to the revolving door effect, which may limit care for mentally ill persons.
A client who suffers from frequent panic attacks describes the attack as feeling disconnected from himself. The nurse notes in the client's chart that the client reports experiencing: A) hallucinations. B) depersonalization. C) derealization. D) denial.
Ans: B During a panic attack, the client may describe feelings of being disconnected from himself or herself (depersonalization) or sensing that things are not real (derealization). Denial is not admitting reality. Hallucinations involve sensing something that is not there.
Several family members arrive to visit an African American client. The nurse can best meet this client's need for socialization by providing the client and family which of the following? A)Individual visits to provide the client with a calm environment B)Group gatherings and open conversation C)Inclusion of ritualistic health practices with the family present D)A spiritual healer to remove the illness and protect the family
Ans: B During illness, families are often a support system for the sick person. Families often feel comfortable demonstrating public affection such as hugging and touching one another. Conversation among family and friends may be animated and loud. Spiritual rituals are more prevalent in Native American cultures
A woman is in treatment for an anxiety disorder. Her history reveals that she was sexually abused repeatedly by her husband. Which of the following interventions would be appropriate in relation to this piece of data? A) Avoid discussing the abuse so as not to upset her. B) Encourage her to talk about feelings related to the abuse. C) Request an anxiolytic to reduce her anxiety levels. D) Help her explore her role in perpetuating the abuse.
Ans: B Encourage the client to talk about his or her experience(s); be accepting and nonjudgmental of the client's accounts and perceptions. Retelling the experience can help the client to identify the reality of what has happened and help to identify and work through related feelings. Do not imply that the client is responsible for the abuse.
A peer reports for work looking unkempt and disheveled. Her movements are uncoordinated, and her breath smells like mouthwash. Another nurse suspects this peer is intoxicated. What should be the action of the nurse who suspects that a peer is intoxicated? A) Immediately call the supervisor to report the peer's behavior. B) Ask the peer if she feels alright and express concern. C) Give the peer some information about the hospital's employee assistance program. D) Ignore the situation until someone else validates the observations.
Ans: B Feedback: Client safety is a priority; the impaired nurse should not be caring for clients. After client safety is ensured, the nurse should call the supervisor to handle the situation. It is not the nurse's responsibility to give out information on the hospital's employee assistance program. It is not appropriate to ignore the situation.
A child with ADHD complains to his parents that he does not like the side effects of his medicine, Adderall. The parents ask the nurse for suggestions to reduce the medication's negative side effects. The nurse can best help the parents by offering which advice? A) Give the child his medicine at night. B) Have the child eat a good breakfast and snacks late in the day and at bedtime. C) Limit the number of calories the child eats each day. D) Let the child take daytime naps.
Ans: B Feedback: Giving stimulants during daytime hours usually effectively combats insomnia. Eating a good breakfast with the morning dose and substantial nutritious snacks late in the day and at bedtime helps the child to maintain an adequate dietary intake. Daytime napping for a child with ADHD is unrealistic and not developmentally necessary.
Which nursing intervention would be most likely to help the client with anorexia to establish healthy eating patterns? A) Leave the client alone to relax during meals. B) Offer liquid protein supplements if the client is unable to complete meal. C) Observe the client for 30 minutes after all meals. D) Weigh the client weekly in the same clothing at the same time of day.
Ans: B Feedback: Nursing interventions designed to establish nutritional eating patterns include sitting with the client during meals and snacks, giving a liquid protein supplement to replace any food not eaten to ensure consumption of the total number of prescribed calories, adhering to treatment program guidelines regarding restrictions, observing the client following meals and snacks for 1 to 2 hours, weighing client daily in uniform clothing, and being alert for attempts to hide or discard food or inflate weight.
A client with alcohol dependence is admitted to the hospital with pancreatitis. Which intervention should be included in the client's plan of care? A) Fluid restriction of 1000 mL per 24 hours B) Glucometer checks b.i.d. C) High-protein diet D) Protective isolation precautions
Ans: B Feedback: Pancreatitis can cause elevated serum glucose levels. The other choices are not necessarily appropriate.
Ans: A Feedback: The client performs rituals to decrease anxiety and will feel most secure when performing the rituals. The other choices would not promote a sense of security of the client.
Ans: B Feedback: The nurse encourages the client to talk about the feelings and to describe them in as much detail as the client can tolerate. Because many clients try to hide their rituals and to keep obsessions secret, discussing these thoughts, behaviors, and resulting feelings with the nurse is an important step. It is not necessary for the nurse to have the same obsession as the client.
An adult client is put in restraints after all other attempts to reduce aggression have failed. Which of the following is required now that restraints have been instituted? A) Review of the appropriateness of restraints every 8 hours B) A face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint. C) A documented nursing assessment every 4 hours D) Constant one-on-one supervision during the first hour and then video monitoring
Ans: B For adult clients, use of restraint and seclusion requires a face-to-face evaluation by a licensed independent practitioner within 1 hour of restraint or seclusion and every 8 hours thereafter, a physician's order every 4 hours, documented assessment by the nurse every 1 to 2 hours, and close supervision of the client. Staff must monitor a client in restraints continuously on a 1:1 basis for the duration of the restraint period. A client in seclusion is monitored 1:1 for the first hour and then may be monitored by audio and video equipment.
The nurse is interviewing a client with a history of physical aggression. Which of the following should the nurse avoid? A) Anticipating that a loss of control is possible and planning accordingly B) Explaining the consequences the client will face if control is lost C) Interviewing the client with another staff member present D) Responding to verbal threats by terminating the interview and obtaining assistance
Ans: B Giving the client an ultimatum is likely to foster hostile or aggressive behavior; the other measures are all appropriate for a client with a history of aggression
A client grieving the recent loss of her husband asks if she is becoming mentally ill because she is so sad. The nurse's best response would be: A)"You may have a temporary mental illness because you are experiencing so much pain." B)"You are not mentally ill. This is an expected reaction to the loss you have experienced." C)"Were you generally dissatisfied with your relationship before your husband's death?" D)"Try not to worry about that right now. You never know what the future brings."
Ans: B Mental illness includes general dissatisfaction with self, ineffective relationships, ineffective coping, and lack of personal growth. Additionally the behavior must not be culturally expected. Acute grief reactions are expected and therefore not considered mental illness. False reassurance or overanalysis does not accurately address the client's concerns.
The client says to the nurse, "I feel really close to you. You are the only true friend I have." The most therapeutic response the nurse can make is: A) "We are not friends, I am your nurse." B) "Since ours is a professional relationship, let's explore other opportunities in your life for friendship." C) "You think we are friends?" D) "I am glad we can be friends, I will always be here for you."
Ans: B The nurse's response must let the client know in clear terms that the relationship is professional while not demeaning or ridiculing the client. Choices A, C, and D would not be appropriate replies in this situation.
The nurse is conducting a history and physical exam on a client who is grieving the unwanted loss of a marriage by divorce. Which of the following physical symptoms of grief would the nurse most likely expect to detect in the history? A)Headaches B)Insomnia C)Weight loss D)GI upset
Ans: B Those grieving may complain of insomnia, headaches, impaired appetite, weight loss, lack of energy, palpitations, indigestion, and changes in the immune and endocrine systems. Sleep disturbances are among the most frequent and persistent bereavement-associated symptoms.
During the admission interview, the nurse asks the client what led to his hospitalization. The client responds, "They lied about me. They said I murdered my mother. You're the killers. You all killed my mother. She died before I was born." The best initial response by the nurse would be, A)"I just saw your mother. She's fine." B)"You're having very frightening thoughts." C)"We'll put you in a private room until you're in better control." D)"If your mother died before you were born, you wouldn't be here."
Ans: B When the nurse states, "You're having very frightening thoughts," the nurse is verbalizing the implied or voicing what the client has hinted or suggested. The other responses would not be the best initial response in this situation
A client is being discharged on lithium. The nurse encourages the client to follow which health maintenance recommendations? Select all that apply. A) Weigh self weekly at the same time of day. B) Drink a 2-L bottle of decaffeinated fluid daily. C) Do not alter dietary salt intake. D) See the doctor if you get the flu. E) Restrict involvement in intense exercise.
Ans: B, C, D Feedback: Clients should drink adequate water (approximately 2 L/day) and continue with the usual amount of dietary table salt. Having too much salt in the diet because of unusually salty foods or the ingestion of salt-containing antacids can reduce receptor availability for lithium and increase lithium excretion, so the lithium level will be too low. If there is too much water, lithium is diluted, and the lithium level will be too low to be therapeutic. Drinking too little water or losing fluid through excessive sweating, vomiting, or diarrhea increases the lithium level, which may result in toxicity. Monitoring daily weights and the balance between intake and output and checking for dependent edema can be helpful in monitoring fluid balance. The physician should be contacted if the client has diarrhea, fever, flu, or any condition that leads to dehydration.
The parents of a young adult male who has schizophrenia ask how they can recognize when their son is beginning to relapse. The nurse teaches the family to look for which of the following? Select all that apply. A) Excessive sleeping B) Fatigue C) Irritability D) Increased inhibition E) Negativity
Ans: B, C, E Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being.
In the space of 5 minutes, the client has been laughing and euphoric, then angry, and then crying for no reason that is apparent to the nurse. This behavior would be best described as A) flight of ideas. B) lack of insight. C) labile mood. D) tangential thinking
Ans: C Moods that shift rapidly, displaying a range of emotions, are termed labile. Flight of ideas is manifested by excessive amount and rate of speech composed of fragmented or unrelated ideas. Lack of insight would be manifested by the lack of the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. Tangential thinking would be manifested by wandering off the topic and never providing the information requested.
Which approach to therapy is most effective when planning for a client with negative thinking? A) Behavior modification B) Client-centered therapy C) Cognitive therapy D) Reality therapy
Ans: C Feedback: Cognitive therapy focuses on changing the client's thinking first, in the belief that then feelings and behavior can change as well. Behavior modification is a method of attempting to strengthen a desired behavior or response by reinforcement, either positive or negative. Client-centered therapy focuses on the role of the client, rather than the therapist, as the key to the healing process. Reality therapy focuses on the person's behavior and how that behavior keeps him or her from achieving life goals.
Which meal would the nurse provide to best meet the nutritional needs of a client who is manic? A) Peanut butter sandwich, chips, cola B) Fried chicken, mashed potatoes, milk C) Ham sandwich, cheese slices, milk D) Spaghetti, garlic bread, salad, tea
Ans: C Feedback: Finger foods, or things clients can eat while moving around, are the best options to improve nutrition. Such foods should be as high in calories and protein as possible.
Several medications are prescribed for a client who has anorexia. Which medication may be prescribed to help treat the client's distorted body image? A) Amitriptyline (Elavil) B) Cyproheptadine (Periactin) C) Olanzapine (Zyprexa) D) Fluoxetine (Prozac)
Ans: C Feedback: Several classes of drugs have been studied, but few have shown clinical success. Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) in high doses (up to 28 mg/day) can promote weight gain in clients with anorexia nervosa. Olanzapine (Zyprexa) has been used with success because of its antipsychotic effect (on bizarre body image distortions) and associated weight gain. Fluoxetine (Prozac) has some effectiveness in preventing relapse in clients whose weight has been partially or completely restored. However, close monitoring is needed because weight loss can be a side effect.
The nurse is providing education to a group of persons from several community agencies about hoarding by elder persons. Which of the following is important for the nurse to emphasize? A) Treatment will likely start to be effective in the short term. B) If the person had help to clean up his or her environment, the hoarding would be cured. C) It is not beneficial to tell the client that his or her thoughts and rituals interfere with his or her life or that his or her ritual actions really have no lasting effect on anxiety. D) One agency should be able to address all of the client's needs.
Ans: C Feedback: Treatment for hoarding in older adults may need to continue over a long period of time to reach successful outcomes. Most persons who are hoarders will not seek assistance to clean up their environment because they feel ashamed. If the environment were to be cleaned up and no other intervention employed, the person would continue to hoard. It is not beneficial to tell the clients that their thoughts and rituals interfere with their life or that their ritual actions really have no lasting effect on anxiety—they already know that. Multiple community agencies may be needed to deal with hoarding in the older adult.
A client with antisocial personality disorder is begging to use the phone to call his wife, even though it is against the unit rules. The client begs, "It is just this once, and she will be so hurt if I don't call her." Which would be the most appropriate response by the nurse?A)"Only to help your wife, you can call this time." B)"I will get in trouble with my supervisor if I let you call." C)"You may not use the phone to call your wife." D)"You cannot call because you need to focus on your recovery while you are here, not your wife."
Ans: C Feedback:The client may attempt to bend the rules "just this once" with numerous excuses and justifications. The nurse's refusal to be manipulated or charmed will help decrease manipulative behavior. Avoid any discussion about why requirements exist. State the requirement in a matter-of-fact manner. Avoid arguing with the client.
A client who has been physically aggressive arrives at the emergency room for a psychiatric assessment. Which would be the best approach for the nurse to use? A) Have a sense of humor to show a lack of fear. B) Provide close contact to increase the client's sense of safety. C) Use brief statements and questions to obtain information. D) Use open-ended questions, so the client can elaborate.
Ans: C Following an aggressive episode, clients may have difficulty expressing themselves; short, concise statements and questions will get needed information. Humor or open-ended questions may be frustrating or annoying for the client. It is not safe for the nurse to provide close contact under these circumstances.
A nurse documents that a patient has successfully acquired a job performing janitorial services at a local manufacturing company. The goal of which of the following levels of prevention has been achieved? A) Primary prevention B) Secondary prevention C) Tertiary prevention D) Community prevention
Ans: C Nurses work to provide mental health prevention services to reduce risks to the mental health of persons, families, and communities. Examples include primary prevention, such as stress management education; secondary prevention, such as early identification of potential mental health problems; and tertiary prevention, such as monitoring and coordinating rehabilitation services for the mentally ill.
Which of the following are cognitive-behavioral therapy techniques that may be used effectively with anxious clients? Select all that apply. A) Positive reframing B) Decatastrophizing C) Assertiveness training D) Humor E) Unlearning
Ans: C The client has severe anxiety; the priority is to lower the client's anxiety level. The first action should be to replace the dressing on the wound to decrease the client's level of anxiety and to prevent contamination of the wound before a new dressing can be applied. The other choices could be done after replacing the dressing on the wound.
A student nurse is having a first experience in an inpatient psychiatric unit and is frightened by the behaviors of the clients with schizophrenia. The student should take which of the following actions to deal with fear? A) Express fear to the psychiatrist during rounds B) Pretend to not be afraid C) Stay in an open area while talking with the clients D) Insist that the instructor accompanies the student at all times.
Ans: C he nurse also may be genuinely frightened or threatened if the client's behavior is hostile or aggressive. The nurse must acknowledge these feelings and take measures to ensure his or her safety. This may involve talking to the client in an open area rather than in a more isolated location or having an additional staff person present rather than being alone with the client. if the nurse pretends to be unafraid, the client may sense the fear anyway and feel less secure, leading to a greater potential for the client to lose personal control. It is not possible for the instructor to accompany the student at all times.
Which slogans would be used in a 12-step program? Select all that apply. A) "Pull yourself together." B) "Get control of your problem." C) "One day at a time." D) "Easy does it." E) "Let go and let God."
Ans: C, D, E Feedback: Before the illness of addiction was fully understood, most of the society and even the medical community viewed chemical dependency as a personal problem; the user was advised to "pull yourself together" and "get control of your problem." Key slogans in AA reflect the ideas in the 12 steps, such as "One day at a time" (approach sobriety one day at a time), "easy does it" (don't get frenzied about daily life and problems, and "let go and let God" (turn your life over to a higher power).
The client says to the nurse, "I know I can learn to cope with my family situation. By getting help here at the clinic, I'll be able to deal with them more effectively, and I won't be so stressed out all the time." This client is demonstrating a high level of A) Hardiness. B) Resilience. C) Sense of belonging. D) Self-efficacy.
Ans: D
.For a client taking clozapine (Clozaril), which of the following symptoms should the nurse report to the physician immediately as it may be indicative of a potentially fatal side effect? A)Inability to stand still for 1 minute B)Mild rash C)Photosensitivity reaction D)Sore throat and malaise
Ans: D Clozapine (Clozaril) produces fewer traditional side effects than do most antipsychotic drugs, but it has the potentially fatal side effect of agranulocytosis. This develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. This side effect may not be manifested immediately and can occur up to 24 weeks after the initiation of therapy. Any symptoms of infection must be investigated immediately. Agranulocytosis is characterized by fever, malaise, ulcerative sore throat, and leukopenia.Mild rash and photosensitivity reaction are not serious side effects
Which thought process would cause a client with antisocial personality disorder to want to do everything for himself? A) Belief in his own self-worth B) Inability to delay gratification C) Rewards for competitive behavior D) Sense of mistrust of others
Ans: D Feedback: Clients believe others are just like them, that is, ready to exploit and use others for their own gain. These clients are devoid of personal emotions, and actually the self is quite shallow and empty. These clients view relationships as serving their needs and pursue others only for personal gain. There is no competition because these clients believe they are only taking care of themselves because no one else will.
A client has been admitted to the inpatient unit after using inhalants recently. Which is an antidote to treat inhalant toxicity? A) Ativan B) Narcan C) Antabuse D) There is no antidote
Ans: D Feedback: There is no antidote or specific medication to treat inhalant toxicity. Ativan, Narcan, and Antabuse are not used to treat inhalant toxicity.
The nurse is talking to a client with schizoid personality disorder about finding a job. Which suggestion by the nurse would be most helpful? A) "Being a loner really limits your employment opportunities." B) "Maybe your friend could see if there is a night position available at the convenience store." C) "Perhaps working part-time at a fast-food restaurant would be something you could do." D) "There is a job posting at the hospital for a file clerk in medical records."
Ans: D Feedback: Clients with schizoid disorder often work well in jobs with minimal interpersonal demands. "Being a loner really limits your employment opportunities," is not a positive suggestion for this client. "Maybe your friend could see it there is a night position available at a convenience store," does not promote independence in finding a job, and a job at a convenience store would entail interpersonal demands. "Perhaps working part-time at a fast-food restaurant would be something you could do," would not be correct because working in a fast-food restaurant would involve the use of many interpersonal skills.
A nursing supervisor reprimands an employee for being chronically late for work. If the employee handles the reprimand using the defense mechanism of displacement, he would most likely do which of the following? A) Argue with the supervisor that he is usually on time B) Make a special effort to be on time tomorrow C) Tell fellow employees that the supervisor is picking on him D) Tell the unit housekeeper that his work is sloppy
Ans: D Feedback: Displacement involves venting feelings toward another, less threatening person. Arguing is denial. Making a special effort is compensation. Telling fellow employees that the supervisor is picking on him is projection.
Which of the following is most important to maintain therapeutic boundaries when working with aggressive clients? A) Encourage clients to express how the nurse can avoid causing emotional irritation. B) Discuss difficult patient care situations with a supervisor. C) Reflect on your actions that may have instigated the client's anger, D) Do not personalize a client's anger
Ans: D Feedback: Do not take the client's anger or aggressive behavior personally or as a measure of your effectiveness as a nurse. The client's aggressive behavior, however, does not necessarily reflect the nurse's skills and abilities. Clients should not dictate nurses' behaviors. The nurse is not responsible for angering the client. Individuals are responsible for their own emotional control. If the nurse cannot maintain boundaries, assistance should be sought form a supervisor.
A client voluntarily admitted to the inpatient psychiatric unit is currently experiencing mild delirium. The client approaches the nurse and states, "I'm going to take walk outside. I'll be back in about 10 minutes." Which is the most appropriate nursing action? A) Further assess the client's motives for wanting to walk. B) Give the client permission to go on a walk on the grounds. C) Tell the client the walk is not allowed and restrict him to the unit. D) Designate a staff member to accompany the client on the walk.
Ans: D Feedback: The nurse teaches clients to request assistance for activities such as getting out of bed or going to the bathroom. If clients cannot request assistance, they require close supervision to prevent them from attempting activities they cannot perform safely alone. The nurse responds promptly to calls from clients for assistance and checks clients at frequent intervals.
Which statement would indicate that medication teaching for the parents of a 6-year-old child with attention deficit hyperactivity disorder (ADHD) has been effective? A) "We'll teach him the proper way to take the medication, so he can manage it independently." B) "We'll be sure he takes Ritalin at the same time every day, just before bedtime." C) "We're so glad that Ritalin will eliminate the problems of ADHD." D) "We'll be sure to record his weight on a weekly basis."
Ans: D Feedback: Stimulant medications used to treat ADHD can suppress appetite, and the child may lose or fail to gain weight properly. The client is too young to manage his medications independently. Ritalin should be given in divided doses. Ritalin reduces hyperactivity, impulsivity, and mood lability and helps the child to pay attention more appropriately.
A client on the unit suddenly cries out in fear. The nurse notices that the client's head is twisted to one side, his back is arched, and his eyes have rolled back in their sockets. The client has recently begun drug therapy with haloperidol (Haldol). Based on this assessment, the first action of the nurse would be to A) get a stat. order for a serum drug level. B) hold the client's medication until the symptoms subside. C) place an urgent call to the client's physician. D) give a PRN dose of benztropine (Cogentin) IM.
Ans: D Feedback: The client is having an acute dystonic reaction; the treatment is anticholinergic medication. Dystonia is most likely to occur in the first week of treatment, in clients younger than 40 years, in males, and in those receiving high-potency drugs such as Haldol. Immediate treatment with anticholinergic drugs usually brings rapid relief.
A parent of a child with autism spectrum disorder asks the nurse if there is anything that can be done to control the child's tantrums. Which option should the nurse inform the parents that may be appropriate? A) Give the child rewards for resisting tantrums. B) Reason with the child why tantrums are not effective. C) Place the child in a time-out when tantrums occur. D) Explore the use of antipsychotic medications to control tantrums.
Ans: D Feedback: Pharmacologic treatment with antipsychotics, such as haloperidol (Haldol) or risperidone(Risperdal), may be effective for specific target symptoms such as temper tantrums, aggressiveness, self-injury, hyperactivity, and stereotyped behaviors
Which of the following statements about the crisis phase of aggression when the client becomes physically aggressive is true? A) All staff should act to take charge of the situation. B) The client must be restrained or sedated at once. C) Staff should avoid communicating with the client. D) Four to six trained staff members are needed to restrain
Ans: D Four to six trained staff members are needed to restrain, with four staff members each handling a limb and one protecting the client's head and one helps control the client's torso, if needed. When a client becomes physically aggressive, the staff must take charge of the situation for the safety of the client, staff, and other clients. Only staff with training in safe techniques for managing behavioral emergencies should participate
The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse, "What do you think about that?" Which is the best response by the nurse? A) Batterers never change, so it would be best for you to leave. B) If you don't leave, he'll think you're going to continue to endure his abuse. C) If you leave, maybe he'll see that he has to change his behavior. D) You may be in more physical danger after you leave him.
Ans: D Statistics indicate that violence increases when the victim attempts to leave or end the relationship. It is not appropriate for the nurse to offer advice such as this. It is not the victim's fault whether the victim stays or not. If you leave, maybe he'll see that he has to change his behavior, is not appropriate as it minimizes the situation
A 22-year-old client has been manipulative of staff and disruptive in the milieu. Although she is not dangerous to herself or others, she has created problems on the unit and clearly is not making progress. The nurses offer prescribed medication, but she consistently refuses any drugs. The staff realizes that legally this client can A) be coerced to accept treatment. B) be committed by her family to receive needed treatment. C) have her family sign permission for treatment. D) continue to refuse treatment.
Ans: D The client maintains the right to refuse treatment even if it is needed when she is not dangerous to herself or others. If a client able to give consent, she cannot be coerced into doing so, have her family sign permission for her, or be committed by the family to receive treatment unless she is a danger to herself or others.
The nurse is assessing an elderly female in the emergency department. There are many bruises present on her body in varying stages of healing. After documenting the bruising in the assessment, what should the nurse do next? a) Notify the physician that abuse is suspected b) Follow the facility's policy and procedures for reporting abuse c) Call the nursing supervisor immediately d) Ask the client when and how the bruises occurred
Ans: D The nurse should not assume the bruises were caused by abuse; the client's explanation is an important step in the assessment of potential abuse. A nurse must assess for abuse prior to getting the supervisor and physician involved. Reporting abuse would be initiated after a thorough assessment.