Mental Health Saunders
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach?
Helping the client to examine dysfunctional thoughts and beliefs
The nurse is creating a plan of care for the client who is upset following the loss of a job and is verbalizing concerns regarding the ability to meet financial obligations. Which problem is the basis of the client's concerns?
Inability to meet role expectations
The nurse should monitor a client with a history of opioid abuse for which signs and symptoms associated with opioid withdrawal?
Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, diarrhea, and mydriasis
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction should be included in the discharge instructions?
Information regarding shelters
The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate?
Interrupt the client and offer to take her for a walk.
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply.
Looking at old photographs of family Participating in a senior citizens program Visiting the spouse's grave once a month Decorating a wall with the spouse's pictures and awards received
The nurse is assigned to a client who is pacing, agitated, and using aggressive gestures and rapid speech. The nurse should determine that which action is the priority of care at this time?
Providing a safe place for the client to pace that is away from the other clients
Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action?
Remain with the client until the anxiety decreases.
A client comes into the emergency department in a severe state of anxiety after a car crash. Which is the best nursing intervention at this time
Remain with the client.
Community mental health teams recognize that in the immediate postdisaster period, the most effective means of identifying individuals experiencing difficulty coping psychologically with the disaster is to take which action?
Station mental health professionals at established assistance centers.
The nurse suspects that the client hospitalized with a diagnosis of depression could benefit from further development of coping strategies. Which client statement supports this suspicion?
"I know that I won't become depressed again as long as I reduce my stressors."
Which client is at greatest risk for committing suicide?
A client with metastatic cancer
Which roommate choice is least appropriate for a client diagnosed with anorexia nervosa who is in a state of starvation?
A client with pneumonia
A client is unwilling to go to his church because his ex-girlfriend goes there and he feels that she will laugh at him if she sees him. Because of this hypersensitivity to a reaction from her, the client remains homebound. The home care nurse develops a plan of care that addresses which personality disorder?
Avoidant
Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship?
Establishing the parameters of the relationship
The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?
Lack of ability to cope effectively
The nurse is planning activities for a client diagnosed with bipolar disorder with aggressive social behavior. Which activity would be most appropriate for this client?
Writing
The nurse should plan which goals of the termination stage of group development? Select all that apply.
the group evaluates the experience. The group explores members' feelings about the group and the impending separation
The nurse is creating a plan of care for a client in a crisis state. When developing the plan, the nurse should consider which factor?
A client's response to a crisis is individualized and what constitutes a crisis for one client may not constitute a crisis for another client.
When planning care for a client with a history of violent behavior toward others, the nurse should include which interventions? Select all that apply.
Admitting the client to a room near the nurses' station Arranging for a security officer to be nearby and available but out of the client's sight
The nurse determines that which client is at highest risk for suicide?
An 18-year-old who abuses both alcohol and drugs and who will not meet the requirements for graduation
The nurse creating a plan of care for the client demonstrating paranoia should include which interventions in the plan of care? Select all that apply.
Ask permission before touching the client Eliminate all unnecessary physical contact with the client. Defuse any anger or verbal attacks with a nondefensive stance. Use simple and clear language when communicating with the client.
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?
Call the nursing supervisor.
Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply
Communicate expected behaviors to the client. Assist the client in identifying ways of setting limits on personal behaviors. Follow through about the consequences of behavior in a nonpunitive manner. Have the client state the consequences for behaving in ways that are viewed as unacceptable.
The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation?
During the entire family visit, the client presented with an expressionless, blank look.
The nurse is developing a plan of care for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. What is the nurse's priority in the plan of care?
Establish a trusting nurse-client relationship.
Which goal addresses the therapeutic management needs of a client experiencing hallucinations?
Facilitate the client's awareness that the hallucination is not the reality of the world.
A client with depression verbalizes feelings of low self-esteem and self-worth typified by statements such as, "I'm such a failure. I can't do anything right." Which is the best nursing response?
Identify recent behaviors or accomplishments that demonstrate the client's skills
The nurse finds a client recently admitted with a diagnosis of anorexia nervosa engaged in a strenuous exercise routine. Which action should be the priority?
Interrupt the client, and offer to take her for a walk.
During a group session, a client threatens to "punch every one of you." Which is the appropriate initial nursing action?
Remind the client that talking about personal anger is appropriate, but acting on it is not
The nurse is developing a plan of care for a client with depression who is scheduled to have electroconvulsive therapy. Which problem is a priority for this client?
Risk for aspiration
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal
The adolescent gives away a DVD and a cherished autographed picture of a performer.
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
The adolescent gives away a DVD and a cherished autographed picture of a performer.
Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply.
The average series involves 8 to 12 treatments. Some confusion may be noted after the procedure. Memory loss may occur but will resolve with time
A client who is watching television in the dayroom shares with the nurse that he has begun seeing his mother being assaulted on the television screen. Which is the nurse's initial intervention?
Turn off the television.
Which statement indicates an understanding of the focus of milieu therapy?
"A living, learning, or working environment is the focus of milieu therapy.
During a support group session, a client says, "My husband hit me a lot, but when he threatened to start hitting our kids, I stabbed him. No jury will believe me because my husband can lie to anyone and be believed." If no one in the group responds, which statement is the therapeutic response by the nurse?
"Abuse is a horribly difficult thing to experience. Can anyone in the group relate to what she's feeling?"
Which statement by the nurse indicates a need for further teaching concerning family violence?
"Abusers are more often from low-income families."
The husband of an alcohol-dependent wife says, "If anyone had said I'd be henpecked, I'd have called them a liar, but now I realize that I'm codependent." Which statement by the nurse would be therapeutic?
"Can you tell me more about that? You see yourself as being codependent with your wife?"
A client who is recovering from benzodiazepine dependence says, "I've lost so many people. First, my brother dies of cancer; then my husband leaves me for a 20-year-old. I wish I had 1 of those pills right now." Which statement by the nurse would be therapeutic?
"Can you tell me what you think the pills can do for you?"
Which statement made by an assistive personnel (AP) indicates to the registered nurse that the AP understands the concepts related to suicide
"Discussing suicide with a client is not harmful."
A battered wife says, "My husband is a bully and a womanizer and certainly doesn't provide for his family, but he's never beat me up, so I don't think I can say he's abusive." Which response by the nurse is therapeutic?
"Do you believe that there are other forms of abuse besides the physical kind?"
A client says to the nurse, "The federal guards were sent to kill me." Which is the best response by the nurse to the client's concern?
"Do you feel afraid that people are trying to hurt you?"
A hospitalized client experiencing delusions reports to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client?
"Do you feel afraid that people are trying to hurt you?"
The nurse is performing an admission assessment on a client at high risk for suicide. Which assessment question will best elicit data related to this risk?
"Do you have a plan to commit suicide?"
The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value?
"Do you recall what it was like before you started your medication?"
Which statement made by a severely depressed client requires the nurse's immediate attention?
"Feeling better really isn't important to me anymore."
During a nursing interview, a client says, "My daughter was murdered. I can't help wondering if her husband killed her, but he's been eliminated as a suspect." Which statement is a therapeutic nursing response?
"Have you shared your concerns with the police?"
When assessing a client for a possible physical dependency on alcohol, the nurse should ask which priority question?
"How do you feel when you haven't had a drink all day?"
What statement should the nurse make to a client diagnosed with post-traumatic stress disorder who appears to be experiencing anxiety?
"I can see that you are becoming upset."
The client who is actively hallucinating is fearful that the voices will direct him to kill himself. Which therapeutic statement should the nurse make at this time?
"I don't hear them, but it must be frightening to hear voices that others can't hear."
The nurse is working with a client who is demonstrating delusional thinking. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which is the best response by the nurse?
"I don't know about a religious cult. Are you afraid that people are trying to hurt you?"
The nurse is performing an assessment on a 16-year-old female client who has been diagnosed with anorexia nervosa. Which statement, made by the client, would the nurse identify as necessitating further assessment on a priority basis?
"I exercise 3 to 4 hours every day to keep my slim figure."
A client's alcohol consumption suggests the development of a tolerance for alcohol. Which statement supports the existence of an alcohol tolerance problem?
"I have a cocktail after work, wine with dinner, and no more than 2 drinks to sleep."
A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse?
"I hear what you are saying, but I have no reason to believe your roommate steals."
Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic stress disorder?
"I keep reliving the abuse."
A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply.
"I keep reliving the robbery." "I see his face everywhere I go." "I might have died over a few dollars in my pocket."
A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client should indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply
"I keep reliving the robbery." "I see his face everywhere I go." "I might have died over a few dollars in my pocket."
The spouse of a client prescribed an antidepressant tells the home health nurse, "Now that the antidepressant is working, the suicidal risk is over and you can stop making these home visits." How does the nurse appropriately respond?
"I need to continue visiting since the client may now have the energy to act on suicidal intentions.
The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement?
"I no longer feel that I deserve the beatings my husband inflicts on me."
The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment?
"I was really depressed about not getting the promotion I was promised. Looking back on it, the pay raise wouldn't have been worth the huge increase in responsibility. It's just as well; it all worked out in the end."
The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment?
"I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."
A client admitted to the mental health unit after attacking his father for disturbing him at his computer interrupts the nurse during morning rounds and says, "I need to get out of here so I can work on my computer project to save the world!" Which nursing response will have the greatest therapeutic impact?
"I will be back to talk with you in 15 minutes after I complete nursing rounds.
When planning discharge care for a client diagnosed with bipolar disorder, the nurse determines the need for further teaching when the client makes which statement?
"I will take the medicine until I am sure I can handle my own problems."
The nurse is caring for a client with a diagnosis of agoraphobia. Which statement made by the client would support this diagnosis?
"I'd be sure to have a panic attack if I left my house."
Which statement by the client best reflects the development of an effective coping response style and effective processing of information for a hospitalized client participating in Alcoholics Anonymous (AA)?
"I'm looking forward to leaving here. I will miss all of you. So, I'm happy and I'm sad, I'm excited, and I'm scared. I know that I have to work hard to be strong and that not everyone will be as helpful as you people."
The spouse of an alcoholic client is attending a support group and says to the group members, "It's all very well for everyone to label me an enabler, but if I didn't call him in sick at work, he'd lose his job. Where would we be then?" Which statement by the nurse co-leader would be therapeutic?
"It is a difficult situation, but do you agree that enabling creates codependency?"
A client diagnosed with a borderline personality disorder says to the nurse, "Sometimes I do things to get my parents mad, and sometimes I do them because I'm bored. That's what happened the night I crashed the family car. I wasn't drunk or suicidal or anything like the police thought. It was just for kicks!" Which is the most appropriate nursing response?
"It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."
Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the client to obtain a specimen of blood, the client begins to shout, "You're all vampires. Let me out of here!" Which nursing response addresses the client's anxiety?
"It must be frightening to think that others want to hurt you."
A client whose wife recently died of cancer says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house." What is the therapeutic nursing response?
"It must be hard to accept that she has passed away."
The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?
"It provides a negative reinforcement when the stimulus is produced."
A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met Bobby. My mother beats me every day, and my dad has sexually abused me since I was 10 years old!" Which response is appropriate for the nurse to make?
"It seems that you needed Bobby's help to separate from your family.
The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There is no one left who cares about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind?
"It sounds as though you are feeling all alone right now."
A client admitted to the inpatient unit is being considered for electroconvulsive therapy (ECT). While the client is calm, the daughter anxiously tells the nurse, "My mother's brain will be shocked with electricity. How can the doctor even think about doing this to her?" Which response by the nurse will best address the daughter's concerns?
"It sounds as though you are very concerned. Let's discuss the procedure."
A nursing student is assisting with the care of a client with a chronic mental illness. The nurse informs the student that a behavior modification approach (operant conditioning) will be used in treatment for the client. Which statement by the student indicates a need for further information about the therapy?
"It uses negative reinforcement."
An older resident in a long-term care facility prepares to walk out into a rainstorm after saying, "My father is waiting to take me for a ride." Which is the appropriate response by the nurse?
"Let's have a cup of coffee, and you can tell me about your father."
Which statement, made by a client who has recently experienced an emotional crisis, is most likely to assure the nurse that the client has returned to her precrisis level of functioning?
"My boss tells me that I'm being considered for a promotion and a raise."
A clinic nurse is monitoring a client with anorexia nervosa. Which client statement should indicate to the nurse that treatment has been effective?
"My friends and I went out to lunch today."
The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement?
"My rituals are ways for me to control unpleasant thoughts or feelings."
The client says to the nurse, "I wish you would just be my friend." Which is the appropriate response by the nurse?
"Our relationship is a therapeutic and helping one."
A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which is the most appropriate nursing response?
"Tell me more about the incident that causes you to feel like the rape just occurred."
A client states that she was raped a few weeks ago but still feels "as if it just happened to me." Which response should the nurse make to the client?
"Tell me more about what happened and what causes you to feel like the rape just occurred."
The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to stop using drugs." Which response by the nurse would be therapeutic?
"Tell me what makes you feel that you are ready."
During a therapy session a client with a personality disorder says to the nurse, "You look so nice today. I love how you do your hair, and I love that perfume you're wearing." Which response by the nurse would best address this breech of boundaries?
"The focus of today's session is on your issues, so let's get started."
The nurse should interpret which comment by a client diagnosed with battered wife syndrome as being consistent with the presence of low self-esteem?
"Things would be fine at home if I just could do better. He has a lot of pressures on him at work."
A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?
"This form of therapy provides a negative reinforcement when the stimulus is produced."
A heroin-addicted client who is taking methadone hydrochloride discontinues the methadone without consulting the primary health care provider. The client says to the nurse, "I thought I didn't need the methadone after 1 year. I had a job and was even saving money. I can't believe I ruined everything." Which statement by the nurse is therapeutic?
"We need to prepare you to recognize those things that trigger you to relapse."
The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns?
"What aspects of this situation are the most difficult for you?"
The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse?
"What do you find difficult about this situation?"
A client with a potential for violence is exhibiting aggressive gestures, making belligerent comments to the other clients, and is continuously pacing in the hallway. Which comment by the nurse would be therapeutic at this time?
"What is causing you to behave so agitated?"
The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question?
"What leads you to seek help now?"
The nurse is preparing a client with schizophrenia with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
"When I have command hallucinations, I'll call a friend and ask him what I should do."
The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information?
"When I have command hallucinations, I'll call a friend for help."
The client asks the nurse, "Could you ask my psychiatrist to let me have a pass for the weekend?" Which response is appropriate and assists the client in achieving the goal of optimal personal functioning?
"When your psychiatrist arrives on the unit, I will let them know that you have a question."
A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent. My daughter is my only family, but I don't want to burden her with my problems." Which response by the nurse would effectively address the client's concern?
"Wouldn't you want to know if your daughter was having difficulties so you could help if you could?"
The client diagnosed with depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue?
"You haven't had an appetite at all?"
A client who has recently lost her spouse says, "No one cares about me anymore. All the people I loved are dead." Which response demonstrates an understanding of therapeutic communication when dealing with a grieving client?
"You must be feeling all alone at this point."
A client whose spouse of 42 years recently died shares with the nurse, "My sister came over yesterday and started talking about how I need to move on with my life. I feel badly, but I got mad and told her to mind her own business." Which response by the nurse would be therapeutic?
"You need to grieve, and expressing anger can be part of grieving."
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?
"You seem restless; tell me what is happening."
The nurse observes that a client with a potential for violence is agitated, pacing up and down the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client?
"You seem restless; tell me what is happening."
A client states to the nurse, "My life has been such a failure. Nothing I do turns out right." Which response by the nurse will best address the client's low sense of self-esteem?
"You seem very discouraged. Let's identify something that you are proud of doing.
A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?
"You seem very distressed over learning you have asthma."
A client diagnosed with depression says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response should the nurse make at this time to assess the client's state of mind?
"You sound very unhappy. Are you thinking of harming yourself?"
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?
"You sound very upset. Are you thinking of hurting yourself?
A client diagnosed with schizophrenia says to the nurse, "Will you protect me from the Grand Duchess?" and points to an older client who is sitting reading a book. Which statement is the therapeutic response by the nurse?
"You will be safe here. Your thinking will be clearer after your medication starts to work."
A client diagnosed with terminal cancer says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic?
"You're feeling angry that your family continues to hope for you to be cured?"
The nurse visits a client at home. The client states, "I haven't slept at all the last couple of nights." Which response by the nurse demonstrates therapeutic communication?
"You're having difficulty sleeping?"
The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client
"You're wearing a new blouse."
A client with a diagnosis of depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." Which response by the nurse demonstrates therapeutic communication?
"You've been feeling like a failure for a while?"
A client diagnosed with depression is scheduled to receive 3 sessions of electroconvulsive therapy. The nurse should tell the client that he or she will likely start to see improvement in approximately what time frame?
1 week after the 3rd treatment session
The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply.
A birthday of March 30 A loss of interest in hobbies A suicide attempt 6 months ago Magnetic resonance imaging shows temporal lobe atrophy
As discharge approaches, the client has been quiet and withdrawn when interacting with the nurse. Which interpretation should the nurse make about the client's behavior?
A normal behavior that can occur during the termination period
A client is admitted to the mental health unit with a diagnosis of depression. The nurse should develop a plan of care for the client that includes which intervention?
A structured program of activities in which the client can participate
On review of the client's record, the nurse notes that the admission was voluntary. Based on this information, the nurse plans care anticipating which client behavior?
A willingness to participate in the planning of the care and treatment plan
The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is most helpful to this client at this time? Select all that apply
Acknowledge the client's behavior. Assist the client to an area that is quiet. Maintain a safe distance from the client.
Which is the best therapeutic approach for the nurse to use in crisis counseling?
Active, with focus on the current situation
The nurse is assessing a client who has been admitted to the coronary care unit. The client seems to fluctuate in the ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect?
Acute confusion as a result of hospital-induced psychosis
A client is preparing to attend a Gamblers Anonymous meeting for the first time. The nurse should tell the client that which is the first step in this 12-step program?
Admitting to having a problem
Which behavior would the nurse anticipate a client diagnosed with nyctophobia to demonstrate?
Always turns on the overhead light before entering a darkened room
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my doctor's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?
An expected coping mechanism
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all my primary health care provider's fault. I have done everything I've been asked to do!" Which nursing interpretation is best for this situation?
An expected coping mechanism
A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tells the nurse, "This is all of the doctor's fault. I have done everything that he has asked me to do!" How should the nurse interpret the client's statement
An expected coping mechanism
Which is the appropriate nursing intervention to address the poor nutritional intake demonstrated by a client diagnosed with depression?
Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.
The home health nurse visits a client at home and determines that the client is dependent on drugs. During the assessment, which action should the nurse take to plan appropriate nursing care?
Ask the client about the amount of drug use and its effect.
A client admitted 72 hours ago with a diagnosis of depression presents for breakfast today appropriately dressed and well groomed, and appears to be calm and relaxed, yet more energetic than before. Which initial action should the nurse take after noting this client's behavior?
Ask the client directly about the presence of any suicide-related thoughts.
A client who has shared with the group at a previous session now suddenly gets up and announces, "I'm leaving." How can the nurse initially meet the needs of both the client and the group?
Ask the client to stay and share what he is feeling.
Which behavior demonstrated by a client diagnosed with depression indicates a need for suicide precautions?
Asks about how to get a will notarized
The nurse is performing an assessment on a client being admitted to the mental health unit. During the interview, the nurse discovers that the client suffered a severe emotional trauma 1 month earlier and is now experiencing paralysis of the right arm. Which is the initial nursing action?
Assess the client for organic causes of the paralysis
A client with a history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action?
Assess the client's vital signs
When planning activities for a child diagnosed with autism, the nurse should give priority to which consideration?
Assessing all activities for safety risks
"Tell me more about the incident that causes you to feel like the rape just occurred."
Assigning to the client a staff member who will remain with the client at all times
Which is the primary goal of crisis intervention therapy
Assist the client in returning to the level of precrisis functioning
The nurse is creating a plan of care for a client diagnosed with depression whose food intake is poor. The nurse should include which interventions in the plan of care? Select all that apply.
Assist the client in selecting foods from the food menu. Offer high-calorie fluids throughout the day and evening. Offer small high-calorie, high-protein snacks during the day and evening.
Which interventions should the nurse include in the plan of care for a depressed client involved in cognitive-behavioral therapy? Select all that apply.
Assisting the client to identify and test negative cognition Assisting the client to participate in the treatment process Assisting the client to develop alternative thinking patterns Assisting the client to rehearse new cognitive and behavioral responses
Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression?
Assure that an electrocardiogram is performed within 24 hours.
The nurse reviewing a client's diagnostic results recognizes that which is a possible positive indication for a diagnosis of schizophrenia?
Atrophy of the lateral and/or third ventricles of the brain
Which activity should the nurse include in the plan of care for a client with mania who is experiencing psychomotor agitation?
Attending a clay-molding class that is scheduled for today
The nurse is caring for a client diagnosed with paranoid personality disorder who is experiencing disturbed thought processes. In formulating a nursing plan of care, which best intervention should the nurse include?
Avoid using a whisper voice in front of the client.
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. Which action should the nurse take at this time?
Call the nursing supervisor
A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take?
Call the nursing supervisor.
In formulating a discharge teaching plan, the nurse should include which precaution for a client with bipolar disorder who is prescribed lithium carbonate therapy?
Check with the psychiatrist before using any over-the-counter medications.
The nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide when which factor is identified?
Client has an immediate plan for a suicide attempt.
The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia?
Coffee, tea, and soda consumption should be limited.
Which assessment finding would be a manifestation associated with dementia?
Confabulation
A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize which assessment finding as requiring immediate intervention?
Constant physical activity and poor oral intake
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which condition that should be the focus of this consult?
Conversion disorder
A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. The nurse plans care based on which mental health condition?
Conversion disorder
The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride?
Dementia
The nursing care plan indicates a problem of self-directed violence and the risk for suicide related to suicidal ideations with a specific plan. The nurse develops a plan of care for the client and identifies which expected client outcome?
Denies presence of suicidal ideations
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply
Dental decay Loss of tooth enamel Electrolyte imbalances
The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply.
Dental decay Loss of tooth enamel Electrolyte imbalances
The history assessment of a client diagnosed with schizophrenia confirms a routine that includes smoking 2 packs of cigarettes and drinking 10 cups of coffee daily. Considering the assessment data, the nurse recognizes which as placing the client at most risk for injury?
Diminishing the effectiveness of psychotropic medication
To create a safe environment for the client diagnosed with major depression with psychotic features, the nurse most importantly devises a plan of care that deals specifically with which problem?
Disturbed thinking
A client who is exhibiting psychotic behaviors is admitted to the psychiatric unit. In developing a plan of care, the nurse should identify which as the priority client problem?
Disturbed thought processes
The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed?
Disulfiram
The nurse caring for a client diagnosed with severe depression is planning activities for the client. Which activity would be most appropriate for this client?
Drawing
The nurse is reviewing the medical record of a hospitalized client who received electroconvulsive therapy (ECT) 3 years ago for the treatment of depression. Which assessment data would support that the therapy resulted in retrograde amnesia in the client?
During the admission interview, the client can't remember why the ECT treatment was originally prescribed.
During a home visit, the nurse suspects that a young daughter of the client is bulimic. The nurse bases this suspicion on which primary characteristics of bulimia?
Eating a lot of food in a short period of time and misuse of laxatives
Which assessments should the nurse closely monitor when caring for a hospitalized client diagnosed with bulimia nervosa? Select all that apply
Electrolyte levels Intake and output Elimination patterns
A client recently admitted to the hospital in the manic phase of bipolar disorder is unkempt, taking antipsychotic medications, and complaining of abdominal fullness and discomfort. Which intervention addresses the priority sign/symptom?
Encourage frequent fluid intake and a high-fiber diet.
A depressed client who appeared sullen, distraught, and hopeless a few days ago now suddenly appears calm, relaxed, and more energetic. Which is the nurse's best initial action with regard to the client's altered demeanor?
Engage the client in one-to-one supervision, share with the client the observations that have been assessed, and ask whether the client is thinking about suicide.
What is the priority nursing action when admitting a client who has just attempted suicide?
Ensure constant observation of the client at all times.
A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?
Escort the client to his or her room, with the assistance of other staff.
A client in a manic state presents to the dayroom only partially dressed and is making sexual remarks and gestures toward the staff and other clients. Which is the initial nursing action?
Escort the client to his room to get appropriately dressed
A manic client begins to make sexual advances toward visitors in the dayroom. When the nurse firmly states that this is inappropriate and will not be allowed, the client becomes verbally abusive and threatens physical violence to the nurse. Based on the analysis of this situation, which intervention should the nurse implement?
Escort the client to their room, with the assistance of other staff
The nurse is creating a plan of care for a newly admitted client at high risk for suicide. With the focus of the plan being to promote a safe and therapeutic environment, which intervention should the nurse include?
Establish a therapeutic relationship.
A client with anorexia nervosa is a member of a predischarge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client believes that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior?
Evidence of the client's disturbed body image
During a group therapy session a client begins yelling, "I can't listen to this. You people are no different from the ones I have to deal with at home." What is the nurse's immediate action?
Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated.
The nurse reviews the assessment data of a client admitted to the hospital with a diagnosis of anxiety. The nurse should assign priority to which assessment finding?
Fist clenched, pounding table, fearful
The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs?
Flashbacks
A client asks the nurse about the meaning of behavioral therapy. Which description describes the purpose of behavioral therapy?
Fosters positive behavioral change
A home care nurse suspects that a client's spouse is experiencing caregiver strain. Which nursing action will assist in supporting the nurse's suspicion?
Gathering subjective and objective assessment from the caregiver and the client
The nurse is preparing a client with depression for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply.
Have the client void. Obtain an informed consent. Remove dentures and contact lenses. Withhold food and fluids for 6 hours.
When a client is admitted to an inpatient mental health unit with the diagnosis of anorexia nervosa, a cognitive behavioral approach is used as part of the treatment plan. The nurse plans care based on which purpose of this approach
Helping the client to examine dysfunctional thoughts and beliefs
The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
Hypertension, changes in level of consciousness, hallucinations
The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium?
Hypertension, changes in level of consciousness, hallucinations
A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right." How should the nurse plan to respond to the client's statement?
Identify recent behaviors or accomplishments that demonstrate the client's skills.
When planning the discharge of a client with chronic anxiety, the nurse directs the goals at promoting a safe environment at home. Which is the most appropriate maintenance goal?
Identifying anxiety-producing situations
When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal?
Identifying anxiety-producing situations
During the admission assessment process, the nurse observes that a client diagnosed with paranoid schizophrenia has multiple dental caries and mouth ulcers. The client denies oral pain or difficulty eating and does not present any concern over the nurse's finding. The nurse recognizes the client's response as most likely the result of which client factor?
Impaired pain perception
The nurse explains to a group of clients that methamphetamine abuse results in which vascular system dysfunction?
Impaired wound healing
The nurse notes that a client attending a group therapy session is cooperative, sharing with peers, and making appropriate suggestions during group discussions. How should the nurse interpret this behavior?
Improvement
The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention?
Including the client's support system in the teaching
The nurse is planning to instruct a mental health client and the family about the importance of medication compliance. The nurse should plan for which interventions that are associated with increased compliance? Select all that apply.
Including the family in the medication planning process Working with the psychiatrist to find the right medication at the right dose Providing the client with the injectable, long-acting form of the medication if available Working with the psychiatrist to find the medication that provides the least side effects for the client
Which client behavior indicates to the nurse that the status of a client diagnosed with intensive care unit psychosis is improving?
Increased number of hours slept at 1 time and is increasingly alert
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." Based on the client's behavior and statement, which intervention should the nurse include in the plan?
Increasing the level of suicide precautions
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan?
Increasing the level of suicide precautions
The nurse is preparing to create a care plan for a client admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse should plan to include which component as a priority in the plan of care?
Individualized goals and objectives
The emergency department nurse is caring for an adult client who is a victim of family violence. Which priority information should be included in the discharge instructions?
Information regarding shelters
The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship?
Inquiring about and examining the client's feelings for any that may block adaptive coping
The nurse is working with a client who, despite making a heroic effort, was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship?
Inquiring about and examining the client's feelings for any that may block adaptive coping
The nurse orienting a new client to a residential treatment center prepares to explain to the client that the emphasis of the center involves milieu therapy. Which is the focus of this type of therapy?
Involves group and social interaction with rules and expectations mediated by peer pressure
Soon after an assault, a client is assessed in the emergency department with behavior that is associated with severe anxiety. Which client behaviors support this level of anxiety?
Is pacing while describing the situation using a rapid speech pattern
Which characteristics would the nurse expect to note for a client with seasonal affective disorder? Select all that apply.
Is related to abnormal melatonin metabolism Improves during the spring and summer months Is a result of alterations in the available amounts of sunlight A craving for carbohydrates lessens during sunnier and spring months
The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?
Lack of ability to cope effectively
An understanding of borderline personality disorder should help the nurse determine that which problem is the priority for the client?
Low self-esteem
The client with a diagnosis of dependent personality disorder is most likely to have problems coping with which situation?
Making decisions about living arrangements after discharge
During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with post-traumatic stress disorder?
Making the client feel safe
Which are the most likely characteristics of a client who abuses alcohol? Select all that apply.
Male gender Abuses drugs as well as alcohol History of at least 1 suicide attempt
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach?
Milieu therapy
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach?
Milieu therapy
When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?
Monitor closely for harm to self or others.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically Provide reality orientation as appropriate.
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate.
The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?
Nausea, vomiting, diarrhea, muscle aches, and diaphoresis
When should the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior?
No aggressive behavior has been observed for 1 hour after the release of 2 of the extremity restraints.
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action
Nonstop physical activity and poor nutritional intake
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action?
Nonstop physical activity and poor nutritional intake
An alcohol-troubled client says, "The 12 Steps of Alcoholics Anonymous (AA) meeting really upset me. I had to go for a drink after 1 hour with those people; they're fanatics!" Which statement by the nurse would be therapeutic?
Not any 1 strategy for remaining sober is best for everyone.
The nurse has developed a plan of care for a client diagnosed with anorexia nervosa. Which client problem would the nurse select as the priority in the plan of care
Nutritional imbalance because of lack of intake
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
Observing rigid rules and regulations
The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action?
Observing rigid rules and regulations
The client tells the nurse that she cannot leave home without checking numerous times that "everything electrical has been shut off." The client's statement supports which mental health diagnosis?
Obsessive-compulsive disorder
A client is withdrawn, immobile and mute. Which appropriate action should the nurse take?
Occasionally ask open-ended questions
Several nurses are engaged in an assignment report when a client with a history of aggressive behavior approaches the nurses' station. The client becomes very loud and offensive, and demands to be seen by the psychiatrist immediately. Which intervention will address the needs of both the client and the milieu?
Offer to assist the client to an examination room until the psychiatrist is notified.
Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply.
Panic disorder Post-traumatic stress disorder Obsessive-compulsive disorder
The nurse notes documentation that a newly admitted client experiences flashbacks. What diagnosis would this notation support?
Post-traumatic stress disorder
The nurse caring for a client diagnosed with schizophrenia should include which interventions in the plan of care to assist in managing the client's concrete thinking?
Present verbal instructions regarding expectations in single, simple commands.
The nurse is planning a stress management seminar for clients in an ambulatory care setting. Which concept should the nurse plan to include in the content of the seminar?
Progressive muscle relaxation techniques are useful for easing tension from many causes.
The nurse is assigned to care for a chemically dependent client who has the potential for violent episodes. In planning care for the client, which action by the nurse should receive priority?
Projects an attitude of calmness
The nurse is developing a daily care program for a depressed client who was just admitted to the mental health unit. Which is the best approach when planning activities for this client?
Provide a structured daily program of activities, and encourage the client to participate.
The nurse caring for a client with a diagnosis of acute schizophrenia should use which approach when planning care?
Provide assistance with grooming and nutrition until the client's thinking has cleared.
The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?
Provide authority, action, and participation
The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?
Provide authority, action, and participation.
What is the appropriate nursing intervention in dealing with a suicidal client?
Provide authority, action, and participation.
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?
Provide safety for the client and other clients on the unit
The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observations, which is the nurse's immediate priority of care?
Provide safety for the client and other clients on the unit.
A client diagnosed with depression is not eating adequately and at times even refuses to eat at all. What should the nurse plan to do to meet the client's nutritional needs?
Provide small, frequent meals that include the client's food preferences.
The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. How should the nurse interpret these behaviors?
Reactions to a devastating event
The nurse in the emergency department is caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, distracted, tremulous, and bewildered at times. How should the nurse interpret these behaviors?
Reactions to a devastating event
The nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT) to treat depression. Which medical diagnosis, if noted on the client's record, would indicate a need to contact the psychiatrist scheduled to perform the ECT?
Recent myocardial infarction
A client who has a history of being sexually assaulted is found sucking her thumb while rocking in her bed and does not respond to verbal communication. The nurse should recognize that this behavior demonstrates which coping mechanism?
Regression
A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?
Remain with the client until the anxiety decreases
A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?
Remain with the client until the anxiety decreases.
The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action?
Removing the client from any immediate danger
During an admission assessment, the nurse notes that the client's diagnosis is documented as obsessive-compulsive disorder. The nurse plans care knowing that the client is most likely to experience which type of compulsive behavior?
Repetitive actions to manage anxiety
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.
Restating Active listening Maintaining neutral responses Providing acknowledgment and feedback
The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.
Restating Listening Maintaining neutral responses Providing acknowledgment and feedback
The mother of a teenage client states that her daughter, diagnosed with an anxiety disorder, "eats nothing but junk food, has never liked going to school, and hangs out with the wrong crowd." What discharge instruction will be most effective in helping the mother to manage her daughter's condition?
Restrict the amount of chocolate and caffeine products in the home.
The nurse is creating a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to improve communication. Which should the nurse include in the plan of care?
Reward the client when a desired behavior is performed
Which client's death was achieved by what is considered a soft suicide method?
Sat in a running car parked in her locked garage to die of the carbon monoxide inhalation
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement
Setting limits on the client's behavior
The nurse is conducting a group therapy session. During the session, a client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement?
Setting limits on the client's behavior
The nurse is monitoring a stress management therapy group that is in the forming stage. Which activity is characteristic of this stage of group development?
Setting the rules of conduct for members of the stress management group
A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statement describes the nurse's obligation to the client?
Share that the risk to the client's safety requires that the client's PHCP be notified.
What is the appropriate nursing intervention for a client diagnosed with post-traumatic stress disorder and paranoid tendencies who begins to pace and fidget?
Share the observation with the client so the behavior can be recognized
A client's phobia is being treated with systematic desensitization. Which modality is the focus of this therapy?
Short exposure to the phobic object
The nurse is performing an assessment on a client being admitted with a diagnosis of alcohol dependence who reports it's been 6 hours since the last drink. The information supports which assumption about the appearance of withdrawal symptoms?
Signs may appear at any time.
The nurse is creating a discharge plan for the family of a client diagnosed with a mood disorder. The nurse should plan to provide which priority information to the family?
Signs that indicate the client may be considering suicide
A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action?
Sit and talk with the client about the feelings.
The nurse is caring for a client just admitted to the mental health unit and is displaying immobile and mute behaviors and is withdrawn. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?
Sit beside the client in silence with occasional open-ended questions.
The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?
Sit beside the client in silence with simple open-ended questions.
Which client behavior demonstrates denial of a sexual abuse event?
Sitting quietly and calmly reading a magazine
The nurse in the mental health unit is performing an assessment on a client who has a history of multiple physical complaints involving several organ systems. Diagnostic studies revealed no organic pathology. The care plan developed for this client will reflect that the client is experiencing which disorder?
Somatization disorde
A newly admitted client is exhibiting signs and symptoms associated with a loss of physical functioning, although no such loss can be confirmed medically. This situation supports which mental health diagnosis?
Somatization disorder
During a mental status examination, the client states, "Glass breaks if you throw stones or shoot at it with a gun. My cousin shoots guns at the police all the time at target practice. People who live in glass houses shouldn't throw stones." How will the nurse appropriately document the client's speech?
Speech is illogical and loosely associated.
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?
Thank the client for the input, but inform the client that others now need a chance to contribute
What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session?
Thank the client for the input, but inform the client that others now need a chance to contribute.
The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect?
The client giggled while describing being physically abused as a child
When discussing an individual's tendency to substance abuse, the nurse should identify which assessment data as a primary biological factor?
The client has 2 family members who have abused.
Which assessment data would indicate that a client is most at risk for suicide?
The client has an immediate plan for a suicide attempt.
The nurse who is reviewing the record of a client admitted to the mental health unit notes that the client was admitted by voluntary status. Based on this fact, what assumption can the nurse make about the client?
The client has the right to demand and obtain release from the hospital.
Which behavior in a client with schizophrenia demonstrates the client's cognitive inability to appropriately process data from external stimuli?
The client is convinced that the curtains are actually ghosts
During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior?
The client is displaying typical behaviors.
A client is diagnosed with rape trauma syndrome. The nurse plans care based on which syndrome-associated fact?
The client regularly reexperiences the events associated with the assault.
What is an appropriate short-term outcome for a client grieving the recent loss of a spouse?
The client verbalizes stages of grief and plans to attend a community grief group.
A client comes to the clinic after losing all of his personal belongings in a hurricane. The nurse notes that the client is coping ineffectively with the situation. Which are the most realistic goals for this client? Select all that apply.
The client will develop adaptive coping patterns. The client will identify a realistic perception of stressors The client will express and share feelings regarding the present crisis. The client will identify effective coping patterns that have worked in the past.
A client with a history of anxiety appears to be in the second phase of crisis response. The nurse prepares for which client behavior?
The client will employ new coping methods that will resolve the problem.
Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia?
The client's noncompliance with medication therapy
A client arrives in the emergency department in a crisis state demonstrating signs of profound anxiety. What should the initial nursing assessment focus on?
The client's physical condition
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?
The death of a loved one
The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?
The death of a loved one
The nurse should plan which goals of the termination stage of group development? Select all that apply.
The group evaluates the experience The group explores members' feelings about the group and the impending separation.
The nurse is planning to formulate a psychotherapy group. Several clients are interested in attending the session. The nurse plans the group, based on which management principle?
The group should be limited to no more than 10 members
Which intervention demonstrates responsibility for the milieu in an inpatient psychiatric setting?
The nurse managing an aggressive client
What information regarding possible prognosis will the nurse provide to the parents of a 15-year-old newly diagnosed with schizophrenia?
Their child will be treated for an imbalance of the chemical dopamine.
An older client diagnosed with delirium becomes agitated and confused at night. Which action should be the nurse's most important strategy to minimize the client's risk for injury?
Turn off the television and radio, and use a night-light.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?
Use an indirect light source and turn off the television.
The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia?
Use of confabulation
The nurse is developing a plan of care for a client who believes the unit's food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings?
Use open-ended questions and silence
A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
Using open-ended questions and silence
Which client behavior is indicative of negative symptoms associated with schizophrenia? Select all that apply.
Verbal communication is almost nonexistent. The client needs frequent redirection because of short attention span.
Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication?
Wernicke-Korsakoff syndrome
The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia. Which client behavior supports the presence of this cognitive deficiency?
When asked to pick up the cup, the client consistently fails to identify the cup.
Which is a primary behavior of a client diagnosed with antisocial personality disorder?
Will take personal items from other clients' rooms
The nurse tells the client that a music therapy session has been scheduled as part of the treatment plan. The client tells the nurse, "I can't sing," and refuses to attend. Which nursing response is most likely to meet the client's needs?
You don't have to sing. Just listen and enjoy the music."
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." Which is the nurse's best response?
You sound very upset. Are you thinking of hurting yourself?"
A 10-year-old referred for evaluation after drawing sexually explicit scenes says to the psychiatric nurse, "I just felt like it." Which response by the nurse is focused on assessing for abuse-related symptoms?
"I am concerned about you. Are you now or have you ever been abused?
When a client is consistently 15 to 20 minutes late for weekly therapy sessions, the nurse attempts to best manage this behavior by implementing which intervention?
Asking the client if she or he is dealing with some new stressor
The nurse is planning care for a client who has a history of violent behavior and is at risk for harming others. Which intervention presents a need for follow-up because it could potentially present a danger to the client, health care providers, and others on the nursing unit?
Assigning the client to a room at the end of the hall
A client is admitted to the mental health unit after an attempted suicide by hanging. The nurse can best ensure client safety by which action?
Assigning to the client a staff member who will remain with the client at all times
A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse responds, knowing that the client's craving is a result of which factor?
Lack of naturally occurring endorphins
A supervisor reprimands the charge nurse for not adhering to the unit budget. What behavior by the charge nurse is an example of displacement?
The charge nurse blames staff for wasting supplies.
A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study?
White blood cell count
A postsurgical client with a history of heavy alcohol intake has returned to the nursing unit. Which signs/symptoms of delirium tremens should the nurse plan to continuously assess for?
Fever, hypertension, changes in level of consciousness, and hallucinations
A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa?
A client undergoing diagnostic tests
The psychiatric home care nurse visits a client diagnosed with a phobia that triggers panic attacks. When teaching the client to use paradoxical intention, which intervention will the nurse demonstrate?
Instructing the client to do what the client fears and, if possible, to exaggerate the outcome of this exposure to the point of humor
The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply.
Looking at old snapshots of family Participating in a senior citizens program Visiting the spouse's grave once a month Decorating a wall with the spouse's pictures and awards received
A woman is seen in the emergency department in a severe state of anxiety following assault and battery. Which nursing action should the nurse place highest priority on at this time?
Remaining with the client
A homeless shelter has sustained severe damage as a result of a fire, and most of the structure and people's belongings were destroyed. Ten of the individuals who are being displaced have a history of chronic mental illness. The mental health team coordinating support initially should focus their efforts on which action?
Providing the clients with shelter, clothing, and food
The nurse preparing to admit a client with a diagnosis of obsessive-compulsive disorder to the mental health unit should expect to note which behaviors in the client?
Rigidness in thought and inflexibility
Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply.
The client will keep scheduled appointments. The client's physical wounds will begin to heal properly. The client will verbalize feelings about the abusive event. The client will participate in the various aspects of the treatment plan.
