N-CLEX - Mental Health
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? 1."Well, a picture paints a thousand words." 2."You just felt like destroying your textbooks?" 3."Your parents and teachers are very concerned about your drawings." 4."I am concerned about you. Are you now or have you ever been abused?"
"I am concerned about you. Are you now or have you ever been abused?" Rationale: The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. The remaining options are insensitive, not focused on the possible sexual abuse, or too indirect to be useful.
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? 1."I hope I am going to like my new counselor." 2."I sure hope I will still be productive at work." 3."I am going to keep a close check on any stress I have in my life." 4."I will take the medicine until I am sure I can handle my own problems."
"I will take the medicine until I am sure I can handle my own problems." Rationale: The client does not demonstrate an understanding of the continued need for medication and suggests that the illness can be controlled by decreasing stress. The remaining options are common concerns of a client on discharge but do not indicate the need for further teaching.
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. 1.Dental decay 2.Moist, oily skin 3.Loss of tooth enamel 4.Electrolyte imbalances 5.Body weight well below ideal range
1.Dental decay 3.Loss of tooth enamel 4.Electrolyte imbalances Rationale: Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.
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? 1.Offer to go with the client to his room to talk. 2.Ask the client to refocus the group's discussion. 3.End the therapy session for everyone immediately. 4.Ask the client to stay and share what he is feeling.
Ask the client to stay and share what he is feeling. Rationale: If a client attempts to leave a group session, ask the client what he is feeling and try to connect the behavior with a feeling. None of the other options encourages the sharing of the client's feelings.
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? 1.Apathy 2.Impaired pain perception 3.Distrust of authority figures 4.Poor verbal communication skills
Impaired pain perception Rationale: Commonly, schizophrenia's effect on the pain center in the brain results in poor pain recognition. The client is likely not experiencing oral pain to the degree that may be felt by the individual who does not have schizophrenia. Although the remaining options may be general factors affecting this client's perceptions and personal interactions, they are not related to the pain perception threshold.
During the assessment, what is the nurse's primary goal for a confused and disoriented client diagnosed with posttraumatic stress disorder? 1.Explaining the unit rules 2.Making the client feel safe 3.Orienting the client to the unit 4.Stabilizing the client's psychiatric needs
Making the client feel safe Rationale: It is important to make a confused client feel safe. Explaining the unit rules and orienting the client to the unit are part of any admission process. Stabilizing psychiatric needs is a long-term goal.
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? 1.Assess the client's vital signs. 2.Identify the client's activity during the pain. 3.Assess for signs related to a panic disorder. 4.Determine the client's use of relaxation techniques.
Assess the client's vital signs. Rationale: Clients with panic disorders experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder. Therefore, options 2, 3, and 4 are not the priority.
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? 1."Why do you believe your roommate would steal from you?" 2."I'll see if I can arrange for you to move in with a different roommate." 3."Tell me more about your belief that your roommate would steal from you." 4."I hear what you are saying, but I have no reason to believe your roommate steals."
"I hear what you are saying, but I have no reason to believe your roommate steals." Rationale: Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Eliminate options that place the client in a defensive position by asking "why" or that in any way encourage the client's paranoid belief.
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? 1."I need you to sign a form before leaving." 2."You will get sick if you go out in the rain." 3."How old are you? Your father must no longer be living." 4."Let's have a cup of coffee, and you can tell me about your father."
"Let's have a cup of coffee, and you can tell me about your father." Rationale: The correct response acknowledges the client's comment and behavior. Allowing the client to leave after forms are signed fails to protect the client from possible harm. The remaining options do not preserve the client's dignity.
The client diagnosed with mild 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? 1."The last few weeks?" 2."You haven't had an appetite at all?" 3."Have patience, it will take time for your appetite to improve." 4."When the medication begins to work, your appetite will return."
"You haven't had an appetite at all?" Rationale: The therapeutic communication technique is restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme, which helps the nurse obtain a more specific perception of the problem from the client. The length of time is not as relevant as defining what the nutritional issue actually involves. The other options minimize the client's concerns about eating. Eliminate options that fails to focus on the nutritional issue or blocks the communication process by minimizing the client's concern.
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? 1."This form of therapy can be applied to new situations." 2."An advantage of this technique is that change is likely to last." 3."Talking to oneself is a basic component of this form of therapy." 4."This form of therapy provides a negative reinforcement when the stimulus is produced."
"This form of therapy provides a negative reinforcement when the stimulus is produced." Rationale: Negative reinforcement when the stimulus is produced is descriptive of aversion therapy. Options 1, 2, and 3 are characteristics of self-control therapy.
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? 1."I certainly care about you." 2."You must be feeling all alone at this point." 3."I don't believe that, and neither should you." 4."It isn't unusual to feel alone when you are grieving."
"You must be feeling all alone at this point." Rationale: The client is experiencing loss and is feeling hopeless. The therapeutic response by the nurse is the one that attempts to translate words into feelings. None of the remaining options encourage the client to discuss feelings but rather minimize and/or trivialize the feelings expressed.
What is the priority nursing action when admitting a client who has just attempted suicide? 1.Ensure constant observation of the client at all times. 2.Conduct a thorough mental health assessment of the client. 3.Determine whether the client has ever attempted suicide previously. 4.Remove all potentially dangerous articles from among the client's belongings.
Ensure constant observation of the client at all times. Rationale: The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one-on-one by the nurse) and never being less than an arm's length away are the best interventions. While the remaining options are appropriate, none have the priority at the time of admission.
The nurse should be prepared to manage which occurrence unique to the abuse of hallucinogenic drugs? 1.Flashbacks 2.Amotivational syndrome 3.Enhanced physical strength 4.Absence of pain perception
Flashbacks Rationale: Flashbacks, the recurrence of perceptual distortions, are unique to the use of hallucinogenic drugs. Enhanced physical strength and the inability to feel pain are indicative of phencyclidine use, whereas marijuana abuse can result in amotivational syndrome.
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 prioritynursing problem for this client? 1.Anxiety 2.Unrealistic outlook 3.Lack of ability to cope effectively 4.Disturbances in thoughts and ideas
Lack of ability to cope effectively Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.
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? 1.Restrict the daughter's socializing time with her friends. 2.Keep her daughter out of school until her anxiety is well managed. 3.Restrict the amount of chocolate and caffeine products in the home. 4.Consider taking time off from work to help her daughter learn to manage the anxiety.
Restrict the amount of chocolate and caffeine products in the home. Rationale: It is recommended that clients with anxiety disorder abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. Restricting interaction with friends and keeping the daughter out of school are unreasonable and unhealthy approaches. It may not always be realistic to expect a family member to take time off from work.
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially? 1.Move the client next to the nurses' station. 2.Use an indirect light source and turn off the television. 3.Keep the television and a soft light on during the night. 4.Play soft music during the night, and maintain a well-lit room.
Use an indirect light source and turn off the television. Rationale: Provision of a consistent daily routine and a low stimulating environment is important when a client is disoriented. Noise, including radio and television, may add to the confusion and disorientation. Moving the client next to the nurses' station may become necessary but is not the initial action.
Which is a primary behavior of a client diagnosed with antisocial personality disorder? 1.Frequently expresses suicidal ideations 2.Leaves the dayroom when anyone else enters 3.Will take personal items from other clients' rooms 4.Requires constant reassurance whenever required to make a decision
Will take personal items from other clients' rooms Rationale: A central defining characteristic of the antisocial personality is disregard for the rights and feelings of others. Taking the belongings of others would demonstrate this characteristic. Although the remaining options describe behaviors that may on occasion be exhibited by the client, none of these is the main characteristic of antisocial personality disorder.
Which short-term initial goals would be realistic for a client who was recently sexually abused? Select all that apply. 1.The client will keep scheduled appointments. 2.The client's physical wounds will begin to heal properly. 3.The client will verbalize feelings about the abusive event. 4.The client will resolve feelings of anxiety related to the event. 5.The client will participate in the various aspects of the treatment plan.
1.The client will keep scheduled appointments. 2.The client's physical wounds will begin to heal properly. 3.The client will verbalize feelings about the abusive event. 5.The client will participate in the various aspects of the treatment plan. Rationale: Resolving feelings triggered by the event will take time and therapy and so is considered a long-term goal. Short-term goals include the beginning stages of dealing with the rape trauma. Clients will be expected initially to keep appointments, participate in care, begin to explore feelings, and begin to heal any physical wounds that were inflicted at the time of the rape.
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 posttraumatic stress disorder? Select all that apply. 1."I'm afraid of spiders." 2."I keep reliving the robbery." 3."I see his face everywhere I go." 4."I don't want anything to eat now." 5."I might have died over a few dollars in my pocket." 6."I have to wash my hands over and over again many times."
2."I keep reliving the robbery." 3."I see his face everywhere I go." 5."I might have died over a few dollars in my pocket." Rationale: Reliving an event, experiencing emotional numbness (facing possible death), and having flashbacks of the event (seeing the same face everywhere) are all common occurrences with posttraumatic stress disorder. The statement "I'm afraid of spiders" relates more to having a phobia. The statement "I have to wash my hands over and over again many times" describes ritual compulsive behaviors to decrease anxiety for someone with obsessive-compulsive disorder. Stating "I don't want anything to eat now" is vague and could relate to numerous conditions.
Which subject should the nurse address in preparing for the orientation phase of the therapeutic relationship? 1.Facilitating behavioral change 2.Promoting self-esteem in the client 3.Promoting problem solving skills in the client 4.Establishing the parameters of the relationship
Establishing the parameters of the relationship Rationale: During the orientation phase of the therapeutic nurse-client relationship, four subjects need to be addressed. These subjects include the parameters of the relationship, the formal or informal contract, confidentiality, and termination of the relationship. Promoting problem solving skills and self-esteem and facilitating behavioral change are subjects of the working phase of the nurse-client relationship.
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? 1.Suggesting a reduction of medication 2.Allowing increased "in-room" activities 3.Increasing the level of suicide precautions 4.Allowing the client off-unit privileges as needed
Increasing the level of suicide precautions Rationale: A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.
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? 1.Information regarding shelters 2.Instructions regarding calling the police 3.Instructions regarding self-defense classes 4.Explaining the importance of leaving the violent situation
Information regarding shelters Rationale: Tertiary prevention of family violence includes assisting the victim after the abuse has already occurred. The nurse should provide the client with information regarding where to obtain help, including a specific plan for removing the self from the abuser and information regarding escape, hotlines, and the location of shelters. An abused person is usually reluctant to call the police. Teaching the victim to fight back is not the appropriate action for the victim when dealing with a violent person. Explaining the importance of leaving the violent situation is important, but a specific plan is necessary.
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? 1.Milieu therapy 2.Interpersonal therapy 3.Behavior modification 4.Support group therapy
Milieu therapy Rationale: All treatment team members are viewed as significant and valuable to the client's successful treatment outcomes in milieu therapy. Interpersonal therapy is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life. Behavior modification is based on rewards and punishment. Support groups are based on the premise that individuals who have experienced and are insightful concerning a problem are able to help others who have a similar problem.
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? 1.Adhering to the mandatory abuse-reporting laws 2.Notifying the caseworker of the family situation 3.Removing the client from any immediate danger 4.Obtaining treatment for the abusing family member
Removing the client from any immediate danger Rationale: Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusing situation. Options 1, 2, and 4 may be appropriate interventions, but are not the priority.
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? 1.An unreasonable fear of something 2.Repetitive actions to manage anxiety 3.Misinterpretation of common events 4.Recurring thoughts that are intrusive
Repetitive actions to manage anxiety Rationale: A compulsion is a repetitive act. The client with a phobia is likely to experience unreasonable fears. Illusions are characterized by misinterpretation of events. An obsession is a repetitive thought.
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? 1.Sad and tearful 2.Suspicious and hostile 3.Frightened and delusional 4.Rigidness in thought and inflexibility
Rigidness in thought and inflexibility Rationale: Rigid and inflexible behaviors are characteristic of the client with obsessive-compulsive disorder (OCD). Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion because this behavior is what decreases the anxiety. None of the other options are associated with OCD.
The nurse is developing a plan of care for a client who is scheduled to have electroconvulsive therapy. Which problem is a priority for this client? 1.Fear 2.Anxiety 3.Risk for aspiration 4.Distorted body image
Risk for aspiration Rationale: Priority is focused on physical problems. Aspiration is safeguarded against by keeping the client on nothing by mouth status for 6 to 8 hours before electroconvulsive therapy, removing dentures, and administering preprocedure medications as prescribed. Body image is not associated with this procedure. Although the remaining options could be appropriate problems, they are not the priority.
What is an appropriate short-term outcome for a client grieving the recent loss of a spouse? 1.The client reports three additional coping strategies. 2.The client verbalizes stages of grief and plans to attend a community grief group. 3.The client verbalizes connections between significant losses and low self-esteem. 4.The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide.
The client verbalizes stages of grief and plans to attend a community grief group. Rationale: The question is focused on grieving. The only option that deals with grief is option 2. The information in the remaining options is not related to grief.
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? 1.Members should be of the same gender. 2.The group will decide the focus of the sessions. 3.The group should be limited to no more than 10 members. 4.The focus of the group will determine when the group will meet.
The group should be limited to no more than 10 members. Rationale: The ideal number of clients in a psychotherapy group ranges from 7 to 10. Having more than 10 members is not recommended because the group will subdivide, which is counterproductive. Too large a group also can create more opportunities for acting out as opposed to working through issues. None of the other options is necessarily true.
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? 1.A crisis state indicates that the client has a mental illness. 2.A crisis state indicates that the client has an emotional illness. 3.Presenting symptoms in a crisis situation are similar for all clients experiencing a crisis. 4.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.
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. Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one client may not constitute a crisis for another client because each is a unique individual. Being in the crisis state does not mean that the client has a mental or emotional illness.
The nurse is preparing a client for electroconvulsive therapy, which is scheduled for the next morning. Which interventions would be included in the preprocedural plan? Select all that apply. 1.Have the client void. 2.Obtain an informed consent. 3.Administer tap water enemas. 4.Avoid discussing the procedure. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours.
1.Have the client void. 2.Obtain an informed consent. 5.Remove dentures and contact lenses. 6.Withhold food and fluids for 6 hours. Rationale: Enemas are not a component of the pretreatment care for a client scheduled for electroconvulsive therapy (ECT). The nurse should teach the client and family what to expect with ECT and allow the client to discuss his or her feelings regarding the procedure. The remaining options are a part of the pretreatment plan.
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? 1.Normal behavior 2.Evidence of the client's disturbed body image 3.Regression as the client is moving toward the community 4.Indicative of the client's ambivalence about hospital discharge
Evidence of the client's disturbed body image Rationale: Disturbed body image is a concern with clients with anorexia nervosa. Although the client may struggle with ambivalence and show regressed behavior, the client's coping pattern relates to the basic issue of disturbed body image. The nurse should address this need in the support group.
Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of posttraumatic stress disorder? 1."I'm always crying." 2."I'm afraid to go outside." 3."I keep reliving the abuse." 4."I keep washing my hands over and over."
"I keep reliving the abuse." Rationale: In posttraumatic stress disorder, the client relives the traumatic experience. Only the correct option includes the defining characteristic symptom of posttraumatic stress disorder. Fear of going outside is characteristic of a phobia, while always crying may indicate depression. Excessive handwashing is a characteristic of obsessive-compulsive disorder.
The nurse is discussing discharge and outpatient follow-up plans with a client hospitalized for acute depression. Which statement demonstrates the client's use of a defense mechanism and would indicate the need for follow-up treatment? 1."I don't think I can do this on my own. I still need help coping with things. I know I need to keep working with staff, even now that I'm going home." 2."This has been the hardest thing I've ever had to deal with. I've made progress in learning how to communicate, especially with my family. It's hard to tell them when I need help." 3."I really tried to listen to what people said in the group sessions. Sometimes it was hard, but I think we really helped each other. I think I've learned it's all right to get disappointed sometimes." 4."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."
"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." Rationale: Rationalization is substituting acceptable reasons for actual reasons for behavior. In the correct option the client is rationalizing and is minimizing the response to loss. The remaining options indicate that the client is reviewing and evaluating certain valued perceptions of the treatment process before discharge.
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 appropriate nursing response? 1."Next time, pick less dangerous and expensive ways to explode." 2."What can you do to stop your behavior when it gets to that point the next time?" 3."It's a good thing that you don't abuse substances, or you might be dead because of your recklessness." 4."It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop."
"It is scary when you feel out of control with such feelings of emptiness and anger that you can't stop." Rationale: Reflection, a technique that prompts the client by repeating the major theme in the client's process, is a therapeutic communication technique. In option 1 the nurse inappropriately uses a sardonic response, which is nontherapeutic because it gives advice. Asking the client what he or she can do next time is premature in the therapy. The nurse should not agree or make statements that could be interpreted as threatening.
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? 1.Coarse hand tremor, agitation, hallucinations, and hypotension 2.Hypotension, ataxia, muscular rigidity, and tactile hallucinations 3.Hypotension, stupor, agitation, headache, and auditory hallucinations 4.Fever, hypertension, changes in level of consciousness, and hallucinations
Fever, hypertension, changes in level of consciousness, and hallucinations Rationale: The symptoms associated with delirium tremens (DTs) typically are anxiety, insomnia, anorexia, hypertension, disorientation, visual or tactile hallucinations, changes in level of consciousness, agitation, fever, and delusions. Therefore, the remaining options are incorrect.
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? 1.Obtaining feedback from the client about the coping abilities of the caregiver 2.Gathering subjective and objective assessment from the caregiver and the client 3.Making a referral to the home care agency social worker to complete the assessment 4.Interviewing family members regarding their concerns for the health and well-being of the caregiver
Gathering subjective and objective assessment from the caregiver and the client Rationale: Caregiver strain can occur when a client is significantly dependent on someone else for personal and health care needs. To assess for caregiver strain, the nurse should gather subjective and objective data from the caregiver and the client. The nurse should not expect the client or family members to assess the coping abilities of the caregiver. Although a social worker may be helpful, the nurse needs to perform the assessment of the situation before making the referral.
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 bestchoice as a roommate for the client with anorexia nervosa? 1.A client with pneumonia 2.A client undergoing diagnostic tests 3.A client who thrives on managing others 4.A client who could benefit from the client's assistance at mealtime
A client undergoing diagnostic tests Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger.
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. 1.Assist the client in selecting foods from the food menu. 2.Offer high-calorie fluids throughout the day and evening. 3.Allow the client to eat alone in the room if the client requests to do so. 4.Offer small high-calorie, high-protein snacks during the day and evening. 5.Select the foods for the client to be sure that the client eats a balanced diet.
1.Assist the client in selecting foods from the food menu. 2.Offer high-calorie fluids throughout the day and evening. 4.Offer small high-calorie, high-protein snacks during the day and evening. Rationale: In caring for a client with depression whose nutritional intake is poor, the nurse should remain with the client during the meal. The nurse also should assist the client in selecting foods from the menu because the client is more likely to eat the foods that he or she likes. Offering small high-calorie, high-protein snacks and high-calorie fluids throughout the day and evening are appropriate interventions for the client to maintain nutrition.
Which is the appropriate nursing intervention to address the poor nutritional intake demonstrated by a client diagnosed with depression? 1.Weigh the client three times per week before breakfast. 2.Explain to the client the importance of a good nutritional intake. 3.Report the nutritional concern to the psychiatrist, and obtain a nutritional consultation as soon as possible. 4.Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served.
Arrange for the client to receive several small meals daily, and plan to be present while the meals are being served. Rationale: Offering small meals at several different times during the day may be less overwhelming for the client. Being available during the meals can add to the social atmosphere of eating. Weighing the client does not address how to increase nutritional intake. The client is experiencing poor concentration and is not likely able to benefit from a nutrition lecture. The option of reporting to the psychiatrist and consulting with the nutritionist is to some degree correct but does not present a method to increase food intake.
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? 1.Call the nursing supervisor. 2.Call security to block the exits to the nursing unit. 3.Restrain the client, and call the health care provider. 4.Tell the client that readmission is not possible after leaving against medical advice.
Call the nursing supervisor Rationale: The nurse should call the nursing supervisor. When clients leave against medical advice (AMA), most health care facilities have documents relating to the client's responsibilities, which the client is asked to sign before leaving. The nurse should request that the client speak to the health care provider before leaving, but if the client refuses, the nurse cannot hold the client against his or her will. Any client has a right to health care and cannot be told otherwise. The nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital.
The nurse is caring for an older client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." Which nursing response allows for continued communication about the client's state of mind? 1."That doesn't sound like the real you talking!" 2."I'm sure you have someone if you think hard enough." 3."It sounds as though you are feeling all alone right now." 4."I don't believe that, and I really don't think you do either."
"It sounds as though you are feeling all alone right now." Rationale: The client is experiencing loss because of the recent death of her husband and is expressing feelings of hopelessness. The therapeutic response by the nurse is the one that attempts to translate words into feelings. Communication would be discouraged by statements that deny the client's feelings or that do not address the client's concerns.
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 go straight." Which response by the nurse would be therapeutic? 1."You have said this many times before!" 2."Tell me what makes you feel that you are ready." 3."I need to see changes in you to believe that you are ready to go straight." 4."I'm so glad to hear you talking this way. I will let your health care provider know."
"Tell me what makes you feel that you are ready." Rationale: Clients with a long history of drug abuse need to demonstrate motivation to change the behavior, not just verbalization of the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. The correct option is the only one that will provide this direction to the client.
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? 1."What is causing you to behave so agitated?" 2."Why are you intent on upsetting the other clients?" 3."Please stop so I don't have to put you in seclusion." 4."You are going to be restrained if you do not change your behavior."
"What is causing you to behave so agitated?" Rationale: The appropriate response is to ask the client what is causing the anger. This helps make the client aware of the behavior and may assist the nurse in planning appropriate interventions. Asking why is confrontational and could further escalate the client's behavior. The remaining options constitute threats to the client, which are inappropriate.
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? 1."Why don't you want to attend? What is the real reason?" 2."You don't have to sing. Just listen and enjoy the music." 3."You must go. You have no choice if you want to get better." 4."Your health care provider has prescribed this therapy for you."
"You don't have to sing. Just listen and enjoy the music." Rationale: The correct option encourages the client to socialize and indicates that it is not necessary to sing. Avoid the use of the word why since it can be insulting to the client. Don't make or imply a demand. Focus on addressing the client's concern. The correct option is the only one that addresses the client's concern.
A client diagnosed with acute 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? 1."You sound very unhappy. Are you thinking of harming yourself?" 2."Have you talked to anyone specifically about what is bothering you?" 3."Those feelings will go away when your medication really takes effect." 4."I know what you mean; everyone gets that way when they are depressed."
"You sound very unhappy. Are you thinking of harming yourself?" Rationale: Clients who are depressed may be at higher risk for suicide. When clients make statements such as the one in the question, it is critical for the nurse specifically to assess suicidal ideation and plan. The best method is to ask the client directly about whether a specific plan has been formed. The incorrect options either do not address the client's concern or place the client's feelings on hold.
The nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client? 1."You look lovely today." 2."You're wearing a new blouse." 3."Don't worry; everyone gets depressed once in a while." 4."You will feel better when your medication starts to work."
"You're wearing a new blouse." Rationale: A client who is depressed sees the negative side of everything. Telling the client that she looks lovely today can be interpreted as "I didn't look lovely last time we met." Neutral comments such as that identified in the correct option will avoid negative interpretations. The client should not be told not to worry, that everyone gets depressed once in a while, or that he or she will feel better because such statements are inappropriate and minimize the client's feelings.
Which is the primary goal of crisis intervention therapy? 1.Introduce new, effective coping methods to the client. 2.Assess the client to identify the causative stressors. 3.Establish a sustainable therapeutic nurse-client relationship. 4.Assist the client in returning to the level of precrisis functioning.
Assist the client in returning to the level of precrisis functioning. Rationale: The primary goal of crisis intervention therapy is returning the client to a level of functioning that is equal to or better than that experienced precrisis. This goal is reached through strategies that include the introduction of new coping methods directed toward the stressors that contributed to the crisis. The establishment of a therapeutic nurse-client relationship is a general goal for all nursing relationships.
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? 1.Avoidant 2.Borderline 3.Schizotypal 4.Obsessive-compulsive
Avoidant Rationale: The avoidant personality disorder is characterized by social withdrawal and extreme sensitivity to potential rejection. The person retreats to social isolation. Borderline personality disorder is characterized by unstable mood and self-image and impulsive and unpredictable behavior. Schizotypal personality disorder is characterized by the display of abnormal thoughts, perceptions, speech, and behaviors. Obsessive-compulsive personality disorder is characterized by perfectionism, the need to control others, and a devotion to work.
