Mental Health/Psych HESI Review Questions (50 Q study with rationale)
A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A."I'll leave your tray here. I am available if you need anything else." B."You're not being poisoned. Why do you think someone is trying to poison you?" C."No one on this unit has ever died from poisoning. You're safe here." D."I will talk to your health care provider about the possibility of changing your diet."
ANS: A (A) is the best choice because the nurse does not argue with the client or demand that that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. (B and C) are challenging the client's delusions, and (B) asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. (D) has not addressed the actual problem—that is, the client's delusions.
The nurse is caring for a client who is taking the mood stabilizer divalproex sodium (Depakote). Which laboratory finding is most important to include in this client's record? A.Liver function test results B.Creatinine clearance C.Complete blood count D.Chemistry panel
ANS: A Depakote is metabolized by the liver and can cause hepatotoxicity, so laboratory findings of liver function tests (A) should be included in the client's record. (B) should be in the client record of those who are receiving lithium because it is excreted by the kidneys. (C and D) are routine laboratory tests and are not specifically related to administration of Depakote.
A client who has been hospitalized for 2 weeks for paranoia complains continuously to the staff that someone is trying to steal their clothing. What is the correct action for the nurse to take based on the client's complaints? A. Enroll the client in an exercise class to promote positive activities. B.Place a lock on the client's closet to allay the client's concerns. C.Promote extinction of the ideation by ignoring the client. D.Explain to the client that these suspicions are certainly false.
ANS: A Diverting the client's attention from paranoid ideation (A) and encouraging the client to engage in positive activities can be helpful in assisting to develop a positive self-image. (B) actually supports paranoid ideation. (C) may lower self-esteem. The nurse should not argue with the client about the delusions (D).
The nurse reviews the laboratory findings for a client's urine drug screen that is positive for cocaine. Which client behavior should be expected during cocaine withdrawal? A.Psychomotor impairment B.Agitation and hyperactivity C.Detachment from reality and drowsiness D.Distorted perceptions and hallucinations
ANS: A During cocaine withdrawal, the nurse should expect (A) and a pattern of withdrawal symptoms similar to those of one who uses amphetamines. (B, C, and D) are signs and symptoms of a person who is high on cocaine rather than one who is experiencing withdrawal from cocaine.
A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam (Valium). When developing the nursing care plan for this client, which intervention would be most important for the nurse to include? A.Assist client to focus on personal strengths. B.Set limits on self-defacing comments. C.Remind the client of daily activities in the milieu. D.Assist the client to identify why he or she was self-destructive.
ANS: A Encouraging the client to focus on his or her strengths (A) helps the client become aware of positive qualities, assists in improving self-image, and aids in coping with past and present situations. Although nursing actions should assist the client in decreasing self-defacing comments (B) and informing the client of (C), these interventions are not priorities at this time. (D) is not as important as assisting the client to overcome the depression, which resulted in the overdose, and asking "why" is not therapeutic.
The nurse is assessing a young client admitted to the psychiatric unit for acute depression related to a recent divorce. Which statement is most indicative of a client suffering from depression? A."I'm not very pretty or likeable." B."I've lost 20 pounds in the past month." C."I like to keep things to myself." D."I think everyone is out to get me."
ANS: A Feelings of hopelessness (A) are characteristic of one who is depressed. Although (B) might be indicative of depression, further assessment would be required to rule out an organic cause before attributing the statement to depression. (C and D) are indicative of a paranoid personality.
A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad. No one can help me." Which response would be best for the nurse to make? A."How can I help you? Tell me more about your problems." B."Things probably aren't as bad as they seem right now." C."Let's talk about what is right with your life." D."I hear your misery, but things will get better soon."
ANS: A Offering self shows empathy and caring (A) and gives the client the opportunity to talk while the nurse listens. (B) dismisses the client's perception that things are really bad and potentially stops further communication with the client. (C) avoids the client's problems and promotes denial. "I hear your misery" (D) is an example of reflective dialogue and would be the best choice if it were not for the rest of the sentence, "but things will get better soon," which offers false reassurance.
A schizophrenic client who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching? A."I am going to have lots of fun at the beach and plenty of time in the sun." B."While I am on vacation, I will not eat or drink anything that contains alcohol." C."I will notify the health care provider if I have a sore throat or flulike symptoms." D."I will continue to take my benztropine mesylate (Cogentin) every day."
ANS: A Photosensitivity is a side effect of Prolixin, so the client should be instructed to avoid the sun (A). (B, C, and D) indicate accurate knowledge. Alcohol acts synergistically with Prolixin (B). A sore throat and flulike symptoms (C) are signs of agranulocytosis, which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin (D), are often prescribed prophylactically with Prolixin.
A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A.Maintain a balanced diet and adequate exercise. B.Be sure that the diet is adequate in salt intake. C.Monitor for any changes in sleep pattern. D.Report any unusual facial movements.
ANS: A Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise (A). (B) is important with lithium, a mood stabilizer. (C and D) are less common than weight gain.
A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. These behaviors are often associated with which condition? A. Dissociative disorder B. Obsessive-compulsive disorder C. Panic disorder D. Posttraumatic stress syndrome
ANS: A Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness (A). (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) that are unwilled and cannot be ignored and provoke impulsive acts (compulsions), such as constant and repeated hand washing. (C) is an acute attack of anxiety characterized by personality disorganization. (D) is reexperiencing a psychologically terrifying or distressing event that is outside the usual range of human experience such as war or rape.
The nurse develops a plan of care for a client with symptoms of paranoia and psychosis. The priority nursing diagnosis is Impaired social interactions related to inability to trust. Which intervention is most important for the nurse to implement? A.Greet the client by first name during each social interaction. B.Determine if the client is experiencing auditory hallucinations. C.Introduce the client to peers on the unit as soon as possible. D.Assign the client to a group about developing social skills.
ANS: A The most important nursing intervention is to greet the client by name (A) and provide short frequent contact to establish trust. The presence of auditory hallucinations can affect social interactions (B), but is not a priority intervention. (C and D) are effective interventions after individual rapport has been established with the client.
The nurse notes multiple burns on the arms and chest of a 2-year-old Vietnamese child who is being treated for dehydration. When questioned, the child's father states that he treated the child's vomiting with the cultural practice termed coining, which resulted in burned areas. Which expected outcome statement has the highest priority? A.The child will be protected from further harm. B.The family's cultural values will be respected. C.The parents will express regret at harming their child. D.The parents will demonstrate an ability to care for burn wounds.
ANS: A The nurse's highest priority is to ensure that no further harm befalls the child (A). (B, C, and D) are also important objectives but are secondary to (A).
When planning care for the client undergoing electroconvulsive therapy (ECT), which equipment should the nurse make available? (Select all that apply.) A.Oxygen B.Suction equipment C.Continuous passive range-of-motion (CPM) machine D.Crash cart E.Chest tube drainage system
ANS: A, B, D Because aspiration is a potential complication, emergency equipment such as oxygen, suction, and a crash cart should be available (A, B, and D). The client is only unconscious for a short period; therefore, there is no need for a CPM machine (C). ECT does not put the client at risk for a pneumothorax; therefore, a chest tube drainage system is not needed (E).
Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.) A.Importance of adherence to medication regimen B.Current treatment measures for substance abuse C.Signs and symptoms of an exacerbation D.Prevention of criminal activity E.Behavior modification for aggression F.Chronic grief associated with long-term illness
ANS: A, C, F Medication adherence is an important component of successful rehabilitation (A). Clients and their families also need to know the signs and symptoms of an exacerbation or relapse of the disease (C), which is frequently associated with poor medication compliance. Acknowledging the chronic sorrow associated with severe and persistent mental illness (F) helps individuals negotiate the grieving process. (B, D, and E) are not universal problems associated with schizophrenia.
A 33-year-old client is admitted to a psychiatric facility with a medical diagnosis of major depression. When the nurse is assigning the client to a room, which roommate is best for this client? A.A 35-year-old client who recently attempted suicide. B.A manic client who has started lithium carbonate treatment. C.A client who is bipolar and is pacing the floor while telling jokes to everyone. D.A paranoid client who believes that the staff is trying to poison the food.
ANS: B (B) appears to be the most stable client described since treatment was begun with lithium carbonate (treatment of choice for manic depression). Being around another depressed individual might enhance this client's own depression and possibly support suicidal ideation (A). Clients in the manic stage of bipolar disease (C) enhance the level of anxiety of those around them, which would not be therapeutic for the client at this time. Paranoid ideation (D), which is characterized by suspiciousness, would also increase anxiety in this client.
A 25-year-old client has suffered extensive burns and is crying during dressing change treatment. The client tells the nurse, "Please let me die. Why are you all torturing me like this? I just want to die." Which response by the nurse is best? A."We aren't torturing you. These treatments are necessary to prevent a terrible infection." B."I know these treatments must seem like torture to you, but we want to help you recover." C."You have so much to live for, and all of your family members want you to live." D."Would you like me to call the chaplain so that you can discuss your feelings privately?"
ANS: B (B) offers an empathetic response without sounding patronizing. (A) is not empathetic and is actually somewhat argumentative. The client is not asking for information as much as pleading for understanding. (C) appears as scolding and places blame on the client for wanting to die and possibly hurting the client's family members as a result. (D) might be appropriate if the nurse simply asks the client if a chaplain's visit is desired, but the nurse is dismissing the client's needs by not addressing them at the moment.
Physical examination of a 6-year-old boy reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse would be most appropriate? A."I need to tell the health care provider about your child's tendency to be accident-prone." B."Tell me more about these accidents that your child has been having." C."I need to report these injuries to the authorities because they do not seem accidental." D."Boys this age always seem to require more supervision and can be quite accident-prone."
ANS: B (B) seeks more information using an open-ended, nonthreatening statement. (A) might be appropriate, but is not the best answer because the nurse is being somewhat sarcastic and is also avoiding the situation by referring it to the health care provider for resolution. Although it is true that suspected cases of child abuse must be reported, (C) is almost an attack and is jumping ahead before conclusive data are obtained. (D) is a cliché and dismisses the seriousness of the situation.
A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take? A. Notify the health care provider immediately and force fluids. B. Prior to giving the next dose, notify the health care provider of these symptoms. C. Record the symptoms and continue with medication as prescribed. D. Hold the medication and refuse to administer additional doses.
ANS: B Although these are expected symptoms, the health care provider should be notified prior to the next administration of the drug (B). Early side effects of lithium carbonate (occurring with serum lithium levels below 2 mEq/L) generally follow a progressive pattern, beginning with diarrhea, vomiting, drowsiness, and muscular weakness (C). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. (A) will lower the lithium level. (D) is not warranted.
At the first meeting of a group at a daycare center for older adults, the nurse asks one of the members what kinds of things the client would like to do with the group. The older adult shrugs and says, "You tell me. You're the leader." What would be the best response for the nurse to make? A."Yes, I am the leader today. Would you like to be the leader tomorrow?" B."Yes, I will be leading this group. What would you like to accomplish?" C."Yes, I have been assigned to lead this group. I will be here for the next 6 weeks." D. "Yes, I am the leader. You seem angry about not being the leader yourself."
ANS: B Anxiety over participation in a group and testing of the leader characteristically occur in the initial phase of group dynamics. (B) provides information and refocuses the group to defining its function. (A) is manipulative bargaining. (C) does not focus the group on its purpose or task. (D) is interpreting the client's feelings and is almost challenging.
A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask? A."Are you taking prescribed antidepressants?" B."How much alcohol do you consume daily?" C."What seems to precipitate the anxious feelings?" D."How many hours do you sleep per day?"
ANS: B First, and most importantly, the client's use of alcohol should be determined (B) because further treatment is dependent on the client's sobriety, and asking how much alcohol is being consumed is a better question than asking if the client is drinking, which is a "yes-no" answer that does not promote dialogue. (A, C, and D) provide worthwhile assessment data, but first the nurse should determine if the client is still drinking because all efforts to treat symptoms associated with depression are diminished if the client is still consuming alcohol.
A client on the psychiatric unit seeks out a particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client? A.Sublimation B.Identification C.Introjection D.Repression
ANS: B Identification (B) is an attempt to be like someone or emulate the personality traits of another. (A) is substituting an unacceptable feeling for one that is more socially acceptable. (C) is incorporating the values or qualities of an admired person or group into one's own ego structure. (D) is the involuntary exclusion of painful thoughts or memories from one's awareness.
Which ego defense mechanism is exhibited by a client with a phobia related to refusal to leave home? A.Denial B.Symbolization C.Fantasy D.Intellectualization
ANS: B Symbolization (B) allows external objects to carry the internal emotional feeling through some act such as refusing to leave a safe harbor. (A) is the unconscious failure to acknowledge an event, thought, or feeling. (C) is pretending, usually of a more desirable situation. (D) is using reason to avoid emotional conflicts.
An adult client who lives in a residential facility is mentally retarded and has a history of bipolar disorder. During the past week, the client has refused to wear clothes and frequently exposes their body to other residents. Which intervention should the nurse implement? A. Establish a one-to-one relationship to discuss the behavior. B. Redirect the client to physically demanding activities. C. Encourage the client to verbalize thoughts when acting out. D. Restrict social interactions with other residents in the facility.
ANS: B The client is exhibiting manic behavior related to bipolar disorder, and the nurse should redirect the client to activities that are physically demanding (B) so that energy can be expended in a socially acceptable manner. Psychotic clients are not capable of (A). When exhibiting acting-out behavior, the client is distracted and (C) is difficult. (D) is likely to increase manic behaviors, such as mood swings and acting-out behaviors.
The nurse admits a client with depression to the mental health unit. The client reports difficulty concentrating, has lost 10 pounds in 2 weeks, and is sleeping 12 hours a day. Which outcome is most important for the client to meet by discharge? A.Tries to interact with a few peers and staff B.Reports feeling better and less depressed C.Sits attentively with peers in group therapy D.Easily awakens for morning medications
ANS: B The client is experiencing symptoms of depression, and the outcome by discharge for this client would be that the client reports feeling better and less depressed (B). The client may interact with peers and staff (A) and sit attentively in groups (C) without any improvement in depression. Difficulty awakening is usually caused by the medication regimen for depression, so awakening (D) is not an indication of improvement.
Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first? A.Remind the client to wear the nicotine (NicoDerm) patch. B.Determine if the client still needs constant observation. C.Encourage the client to attend the smoking cessation group. D.Explain that clients on constant observation cannot smoke.
ANS: B The nurse should continually reassess the need for constant observation (B) so that the client can have unit privileges such as outdoor breaks. (A and C) do not meet the client's need and desire to smoke. (D) will cause more agitation.
While in group therapy, a client who is diagnosed with posttraumatic stress disorder (PTSD) is processing an experience from the war in Iraq when another client tips over a chair. What action should the nurse take when the client with PTSD falls to the floor in a fetal position? A.Confront the client who tipped over the chair about the inconsiderate behavior. B.Dismiss the other clients from the group therapy session for a 10-minute break. C.Reinforce reality to the client on the floor and remove him to a quiet space. D.Call a security code and medicate both clients with an antianxiety drug.
ANS: C The client who is diagnosed with PTSD is reexperiencing the traumatic experience and needs reality reassurance (confirmation that there is no danger at this time) and reduced stimuli (C). (A, B, and D) do not consider the needs of these two clients at this time.
On admission, a depressed client tells the nurse, "I can't eat because my tongue is rubber." Which is the best action for the nurse to implement? A.Provide packaged foods for the client to eat. B.Begin the client on total parenteral nutritional (TPN) therapy. C.Provide a well-balanced liquid diet for the client. D.No action is necessary because the client will eat when hungry.
ANS: C The nurse should strive to provide a safe environment (adequate nutrition is part of a safe environment) and should not argue with the client's delusions. (C) is the least invasive while providing nutrition that does not argue with the client's delusion. (A) is given to those with paranoid delusions. (B) is invasive and would be used as a last resort. (C) should be tried first. This client's delusion could be life threatening and should not be ignored (D).
A 25-year-old client has been particularly restless and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make? A."No one is after you. You're safe here." B."You'll feel better after you have rested." C."I know you must feel lonely and frightened." D."Come with me to your room, and I will sit with you."
ANS: D (D) is the best response because it offers support without judgment or demands. (A) is challenging the client's delusion. (B) is offering false reassurance. (C) is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.
A client is admitted with a diagnosis of depression. Which of the following characteristics is most indicative of depression? A.Grandiose ideation B.Self-destructive thoughts C.Suspiciousness of others D.Negative self-image
ANS: D A negative self-image (D) is a specific indicator for depression. (A) occurs with paranoia or paranoid ideation (C). (B) may be seen in depressed clients, but not always.
The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? A.Each resident's length of stay at this nursing home B.A brief description of each resident's family life C.The age and medication regimen of each group member D.The usual activity patterns of each group member
ANS: D An older person's level of activity (D) is a determining factor in adjustment to aging as described by the activity theory of aging. All the information described in (A, B, and C) might be useful to the nurse but is not as helpful during the initiation of the socialization group. The most useful initial information would be an assessment of each individual's adjustment to the aging process.
Which behavior indicates to the nurse that a client with paranoid ideas is improving? A.Arrives on time for all activities B.Talks more openly about plans to protect his possessions C.Aggressively uses the punching bag in the gym D.Discusses his feelings of anxiety with the nurse
ANS: D Anxious feelings increase paranoid ideation. If the client is able to discuss these feelings (D), then the client is improving because of fewer paranoid ideas. (A) would indicate that a client with depression or one who is passive-aggressive is improving. (B) indicates feelings of paranoia. (C) indicates the release of anger, and "anger turned inward" is sometimes used as a definition for depression.
A 27-year-old client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. The client is demanding and active. Which intervention should the nurse include in this client's plan of care? A.Schedule the client to attend various group activities. B.Reinforce the client's ability to make decisions. C.Encourage the client to identify feelings of anger. D.Provide a structured environment with little stimuli.
ANS: D Clients in the manic phase of a bipolar disorder require decreased stimuli and a structured environment (D). Noncompetitive activities that can be carried out alone should be planned for these clients. (A) is contraindicated because stimuli should be reduced as much as possible. Impulsive decision making is characteristic of clients with bipolar disorder. To prevent future complications, the nurse should monitor these clients' decisions and assist them in the decision making process (B). (C) is more often associated with depression than with bipolar disorder.
On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorder? A.Dissociative disorders B.Personality disorders C.Anxiety disorders D.Psychotic disorders
ANS: D Delusions are false beliefs characteristic of psychosis (D). Delusions are generally not characteristic of (A, B, and C).
A client mumbles out loud whether anyone is talking to her or not and the client also mumbles in group when others are talking. The nurse determines that the client is experiencing hallucinations. Which intervention should the nurse implement? A.Respond to the client's feelings rather than the illogical thoughts B.Identify beliefs and thoughts about what the client is experiencing. C.Provide the client with hope that the voices will eventually go away. D.Ask the client how she has previously managed the voices.
ANS: D The nurse should promote symptom management and determine how the client previously managed the voices (D). (A and B) are interventions that are useful with clients who are experiencing delusions. (C) is important, but the most important intervention is to promote symptom management.
A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse that someone is trying to poison her. The client's delusions are most likely related to which factor? A.Authority issues in childhood B.Anger about being hospitalized C.Low self-esteem D.Phobia of food
ANS: C Delusional clients have difficulty with trust and have low self-esteem (C). Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. (A, B, and D) are not specifically related to the development of delusions.
A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate? A.Place the client on seizure precautions and monitor frequently. B.Take the client's vital signs and notify the health care provider immediately. C.Describe the symptoms to the charge nurse and document them in the client's record. D.No action is required at this time because these are known side effects of her medications.
ANS: B This is an emergency situation, and the client requires immediate management in a critical care setting (B). These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. (A) is not indicated in this situation. (C) does not consider the seriousness of the situation. (D) is an incorrect statement.
What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam (Serax)? (Select all that apply.) A.Take the medication in the morning for best results. B.Do not combine this medication with alcohol. C.This medication is typically used for short-term treatment. D.Stop the drug immediately if sleepiness occurs. E.Avoid driving or operating equipment while taking this drug.
ANS: B, C, E Harm can occur if oxazepam is taken with alcohol or other central nervous system (CNS) depressants (B). Oxazepam is a benzodiazepine used for the short-term treatment of anxiety (C). Sleepiness is an expected side effect; therefore, driving or operating equipment should be avoided (E). The drug should be taken in the evening because of sedation effects (A) and should be tapered, not immediately stopped, because of withdrawal effects (D).
A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows that he is not. Which response is best for the nurse to make? A."Did you really believe you were Jesus Christ?" B."I think you're getting well." C."Others have had similar thoughts when under stress." D."Why did you think you were Jesus Christ?"
ANS: C (C) offers support by assuring the client that others have experienced similar situations. (A) is belittling. (B) is making an inappropriate judgment. You may have narrowed your choices to (C and D). However, you should eliminate (D) because it is a "why" question, and the client does not know why.
An individual with a known history of alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The nurse includes in the client's plan of care, "Observe for signs of delirium tremens." Which early signs indicate that the client is beginning to have delirium tremens? A.Abdominal cramping and watery eyes B.Depression and fatigue C.Restlessness and confusion D.Hostility and anger
ANS: C A client experiencing alcohol withdrawal often has delirium tremens (DTs), which are characterized by progressive disorientation. Initially, the client will appear restless and confused (C) and develop tachycardia, tachypnea, and diaphoresis. Hallucinations, paranoia, and seizures can also occur later in the development of DTs. (A) is indicative of withdrawal from opiates such as heroin or morphine. (B) is often seen in cocaine withdrawal. (D) is most characteristic of the paranoid client.
An 8-year-old child is seen in the clinic with a green vaginal discharge. Which action is most important for the nurse to implement? A.Assess the child's blood pressure. B.Counsel the child to wear cotton underwear. C.Report as suspected child abuse. D.Determine if the child takes bubble baths.
ANS: C A green vaginal discharge is indicative of gonorrhea, a sexually transmitted disease. Because the child is 8 years old, the nurse should suspect child abuse and report the incident to the proper authorities (C). (A) is usually not related to infection. (B and D) are helpful in preventing bladder infections, but a green vaginal discharge is not a symptom of a bladder infection.
A middle-aged client tells the clinic nurse, "I'm again starting to feel overwhelmed and anxious with all my responsibilities. I don't know what to do." Which is the best response for the nurse to make? A."Describe in more detail your feelings about being overwhelmed." B."Why don't you give up some of your commitments?" C."What has worked for you in the past?" D."I know, but it is important to take time for yourself."
ANS: C A nurse can help the client solve problems by identifying past coping mechanisms that could be transferred into current situations that the client finds to be overwhelming (C). The client has already expressed some degree of hopelessness (overwhelmed and anxious), so (A) is redundant. (B) is advice giving and may not be possible for the person, and this response does not encourage the client to employ known methods of coping. (D) is also considered advice giving, with an implied value judgment.
Over a period of several weeks, one participant of a socialization group at a community daycare center for older adults monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation? A.Talk to the client outside the group about his behavior. B.Ask the client to give others a chance to talk. C.Allow the group to handle the problem. D.Ask the client to join another group.
ANS: C After several weeks, the group is in the working phase, and the group members should be allowed to determine the direction of the group. The nurse should ignore the comments and allow the group to handle the situation (C). A good leader should not have separate meetings with group members (A), because such behavior is manipulative on the part of the leader. (B) is dictatorial and is not in keeping with good leadership skills. (D) is avoiding the problem. Remember, identify which phase the group is in (initial, working, or termination) as an aid to determining expected communication style.
A client believes that his health care provider is an FBI agent and that his apartment is a site for slave trading. The client believes that the FBI has cameras in the apartment, so it is not safe to return there. Based on these symptoms, which class of medication is most likely to find to be prescribed for this client? A.Antianxiety medication B.Mood stabilizer C.Antipsychotic D.Sedative-hypnotic
ANS: C An antipsychotic (C) will be most likely prescribed because the client's thoughts are delusional. The client needs an antipsychotic medication to promote rational thoughts. (A) may lessen anxiety associated with the delusions, but is not the treatment of choice for altered thoughts. (B) will manage mood swings, and (D) will be prescribed for sleep.
A client who recently retired is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of guilt." What is true about the goal statement referring to the client's depression? A.Implementation of the goal should be deferred until further data can be gathered. B.The depression will dissipate once the client becomes accustomed to retirement. C.Depressed clients may be unaware of guilt feelings and should be encouraged to increase self-awareness. D.Nursing goals should be approved by the treatment team before they are initiated.
ANS: C Depression is associated with feelings of guilt, and clients are often not aware of these feelings (C). Awareness is the first step in dealing with guilt (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings. Although a goal may be changed based on an evaluation of interventions to meet the goal, a goal should never be ignored (A). (B) dismisses the client's symptoms as age-related. Setting goals for the nursing care plan is a function of the nurse (D), although the nurse can collaborate with the treatment team.
A client on the psychiatric unit, diagnosed with bipolar disorder, becomes loud and shouts at one of the nurses, "You fat tub of lard, get something done around here!" What is the best initial action for the nurse to take? A.Have the staff escort the client to his room. B.Tell the client that his behavior will be documented in his record. C.Redirect the client by offering an activity such as playing card games. D.Review the medication record for an antipsychotic drug.
ANS: C Distracting the client, or redirecting him toward a constructive activity (C), prevents further escalation of the inappropriate behavior. (A) could result in escalating the abuse and might unnecessarily involve another staff member in the abusive situation. (B) may be more threatening to the client. (D) may be indicated if the behavior escalates, but at this time the best initial action is (C).
A client who was admitted 2 days earlier to a drug rehabilitation unit tells the nurse, "I'm going to do what you people tell me to do so I can get out of here and get a job." What is the most accurate interpretation of this client's statement? A.The treatment program is effective and the client is highly motivated. B.Defense mechanisms are being used to decrease anxiety. C.Manipulation is being used to achieve the client's personal goals. D.The client has insight into his behaviors, so privileges should be given.
ANS: C Drug abusers tend to be manipulative, so (C) is the best interpretation of the client's statement at this time in the client's treatment. He has been in treatment only 2 days, which is not enough time to benefit from the program, so (A and D) are highly unlikely. Although defense mechanisms (B) are frequently used to decrease anxiety, this statement is more likely because of (C).
During a home visit, a client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. The nurse records several statements made by the client. Based on which statement should the nurse determine that the client needs hospitalization? A."Sometimes I take an extra one of my pills when I hear the voices." B."The voices are louder when I forget to take my medication. " C."No matter what I do, I cannot make the voices go away. " D."I just try to tell the voices to stop when they bother me. "
ANS: C Hospitalization is needed if the client continues to hear voices telling the client to do things that can cause self-harm (C). (A or B) do not require hospitalization unless symptoms become severe. The client should continue symptom management strategies (D) to prevent hospitalization.
A nurse working in the emergency department of a children's hospital admits a child whose injuries could have been the result of abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse? A.Obtain objective data such as radiographs before reporting suspicions. B.Confirm suspicions of abuse with the health care provider. C.Report any case of suspected child abuse. D.Document injuries to confirm suspected abuse.
ANS: C It is the nurse's legal responsibility to report all suspected cases of child abuse (C), and notifying the nurse manager or charge nurse starts the legal reporting process. (A, B, and D) delay the first step in reporting the abuse.
A child is brought to the emergency department with a broken arm. Because of other injuries, the nurse suspects that the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, "I won't leave my son! Don't you touch him! You'll hurt my child!" What is the best interpretation of the mother's statements? A.She is regressing to an earlier behavior pattern. B.She is sublimating her anger. C.She is projecting her feelings onto the nurse. D.She is suppressing her fear.
ANS: C Projection is attributing one's own thoughts, impulses, or behaviors onto another; it is the mother who is probably harming the child, and she is attributing her actions to the nurse (C). The mother may be immature, but (A) is not the best description of her behavior. (B) is substituting a socially acceptable feeling for an unacceptable one. These are not socially acceptable feelings. The mother may be suppressing her fear (D) by displaying anger, but such an interpretation cannot be concluded from the data presented.
A client in the critical care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveals no significant changes, and the nurse formulates the diagnosis of Confusion related to ICU psychosis. Which intervention is best to implement based on this client's behavior? A.Move all medical equipment away from the client's bedside. B.Allay fears by teaching the client about the causes of the disease. C.Cluster care to allow for brief rest periods during the day. D.Encourage visitation by the client's family members, including the client's young children.
ANS: C The best intervention is to organize care so that the client can experience rest periods (C). The critical care unit contains many lifesaving treatment modalities that offer clients an array of auditory, visual, and even painful stimuli. These stressors can result in isolation and confusion. (A) is not practical because the client may need assistance from medical equipment to survive. The client is too ill to receive teaching (B). Although (D) may be supportive, young children are routinely prohibited from critical care units because of increased risk of infectious disease transmission.
