N3381 - Psychiatric Mental Health Exam 2

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Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1.Monitor vital signs. 2.Provide a safe environment. 3.Address hallucinations therapeutically. 4.Provide stimulation in the environment. 5.Provide reality orientation as appropriate. 6.Maintain NPO (nothing by mouth) status.

1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 4. Provide reality orientation as appropriate. Rationale:When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.

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. 1.The client will develop adaptive coping patterns. 2.The client will identify a realistic perception of stressors. 3.The client will cease to have negative feelings about the event. 4.The client will express and share feelings regarding the present crisis. 5.The client will identify effective coping patterns that have worked in the past.

1.The client will develop adaptive coping patterns. 2.The client will identify a realistic perception of stressors. 4.The client will express and share feelings regarding the present crisis. 5.The client will identify effective coping patterns that have worked in the past. Rationale:The feelings of negativity related to the loss caused by the hurricane are not likely to stop; lessening with time is the only reasonable possibility. The remaining options present a positive movement toward increased self-esteem and problem solving without requiring a total shift in realistic perceptions.

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. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

2. Looking at old snapshots of family 3.Participating in a senior citizens program 4.Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received Rationale:Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

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.

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? 1.Force foods and fluids. 2.Restrict social activities until food intake is increased. 3.Promptly provide snacks and meals when the client requests them. 4.Provide small, frequent meals that include the client's food preferences.

Provide small, frequent meals that include the client's food preferences. Rationale:A depressed client may eat small amounts of food because large amounts may seem overwhelming. If the client becomes overwhelmed, he or she may respond by withdrawing further. Forcing foods and fluids and restricting social activities will cause further withdrawal by the client since both will be viewed as a punishment. Providing snacks and meals when the client requests them will not ensure adequate nutritional intake.

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? 1.Refer the client to a psychiatrist. 2.Encourage the client to move and use the arm. 3.Assess the client for organic causes of the paralysis. 4.Encourage the client to talk about his or her feelings.

Assess the client for organic causes of the paralysis. Rationale:The initial nursing action would be to assess for any physiological causes of the paralysis. Although the client may be referred to a psychiatrist, this is not the initial action. It is not appropriate to encourage the client to use the arm without ruling out a physiological cause of the paralysis. Although a component of the plan of care would be to encourage the client to discuss feelings, this would not be the initial nursing action.

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.

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.

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? 1."Did you know that more people identify with just what you are saying?" 2."Which of the features that describe codependence caused you to recognize that?" 3."Can you tell me more about that? You see yourself as being codependent with your wife?" 4."Have you discussed your feelings with your wife? What does your wife think about what you've said?"

"Can you tell me more about that? You see yourself as being codependent with your wife?" Rationale:This question describes the husband of an alcohol-dependent wife who is developing awareness of his codependency. Codependency consists of an individual's becoming preoccupied with the needs and concerns of another to the exclusion of his or her own needs. The therapeutic statement seeks clarification and summarizes and focuses the client on his own concerns and discoveries. When the nurse provides a social response that is nontherapeutic, it does not focus on the client's feelings. Intellectual questioning does not facilitate expression of feelings. Asking questions that are off-focus from the client's feelings are nontherapeutic because they constitute probing. The nurse will gather this information, but by gaining the trust of the client, not by probing.

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? 1."Can you tell me what you think the pills can do for you?" 2."It sounds as if you feel that all of this has just happened to you." 3."It must have been a terrible loss for you when your brother died." 4."How did your husband's interest in a younger woman make you feel?"

"Can you tell me what you think the pills can do for you?" Rationale:In the correct option, the nurse reflects back to the client what she is verbalizing and assists her to assess coping strategies. It is nontherapeutic for the nurse to change the focus from the client's expression of feelings related to the benzodiazepine. Asking the client to self-assess her own behavior in events is premature.

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? 1."I don't believe this is true." 2."The guards are not out to kill you." 3."Do you feel afraid that people are trying to hurt you?" 4."What makes you think the guards were sent to hurt you?"

"Do you feel afraid that people are trying to hurt you?" Rationale:It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.

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? 1."What are you feeling right now?" 2."Do you have a plan to commit suicide?" 3."How many times have you attempted suicide in the past?" 4."Why were your attempts at suicide unsuccessful in the past?"

"Do you have a plan to commit suicide?" Rationale:When assessing for suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Although the other options are questions that may provide information that will be helpful in planning care for the client, these questions will not provide information regarding the risk of suicide.

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.

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? 1."I check my weight every day without fail." 2."I've been told that I am 10% below ideal body weight." 3."I exercise 3 to 4 hours every day to keep my slim figure." 4."My best friend was in the hospital with this disease a year ago."

"I exercise 3 to 4 hours every day to keep my slim figure." Rationale:Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to immediately assess this statement further to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check weight every day. Many clients with anorexia nervosa check their weight 20 times or more each day. A body weight 15% below the ideal weight or less is most significant with anorexia nervosa. Although it is unfortunate that the client's best friend had the disease, this is not considered a major threat to the client's physical well-being

Which piece of subjective data obtained during assessment of a severely anxious client would indicate the possibility of post-traumatic 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 post-traumatic stress disorder, the client relives the traumatic experience. Only the correct option includes the defining characteristic symptom of post-traumatic stress disorder. Fear of going outside is characteristic of a phobia, while always crying may indicate depression. Excessive hand washing is a characteristic of obsessive-compulsive disorder.

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. 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."

"I keep reliving the robbery." "I see his face everywhere I go." "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 post-traumatic 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.

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? 1."I no longer feel that I deserve the beatings my husband inflicts on me." 2."My attendance at the meetings has helped me to see that I provoke my husband's violence." 3."I enjoy attending the meetings because they get me out of the house and away from my husband." 4."I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."

"I no longer feel that I deserve the beatings my husband inflicts on me." Rationale:Al-Anon support groups are a protected, supportive opportunity for spouses and significant others to learn what to expect and to obtain excellent pointers about successful behavioral changes. The correct option is the healthiest response because it exemplifies an understanding that the alcoholic partner is responsible for his behavior and cannot be allowed to blame family members for loss of control. Option 2 is incorrect because the nonalcoholic partner should not feel responsible when the spouse loses control. Option 3 indicates that the group is viewed as an escape, not as a place to work on issues. Option 4 indicates that the wife remains codependent.

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.

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.

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? 1."My husband tells me that I'm back to my old cheerful self." 2."My boss tells me that I'm being considered for a promotion and a raise." 3."When I find myself getting stressed, I immediately use the relaxation techniques I've learned." 4."I have a different perspective on life now. I'm more confident of my ability to handle any problem."

"My boss tells me that I'm being considered for a promotion and a raise." Rationale:The report that the client is doing well at work indicates a level of functioning amid stress that is at least equal to that of the precrisis period. Being told by her spouse that she is again cheerful is a positive improvement but is not indicative of general functioning. Being self-aware and recognizing the need to implement coping methods appropriately when stress triggers are present is a positive indicator of improvement, as is an improved sense of empowerment and confidence in handling problems, but neither indicates the true ability to successfully handle stress efficiently or the client's return to her precrisis level of functioning.

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement? 1."Inner voices tell me to perform my rituals." 2."My behavior is a conscious attempt to punish myself." 3."I'm demonstrating control when I engage in my rituals." 4."My rituals are ways for me to control unpleasant thoughts or feelings."

"My rituals are ways for me to control unpleasant thoughts or feelings." Rationale:In obsessive-compulsive disorder (OCD), the rituals performed by the client are an unconscious response that helps to divert and control the unpleasant thought or feeling and prevent acting on it. This decreases the client's anxiety. OCD is not associated with a need for control or punishment, or with hallucinations.

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? 1."You need to try to be realistic. The rape did not just occur." 2."It will take some time to get over these feelings about your rape." 3."Tell me more about the incident that causes you to feel like the rape just occurred." 4."What do you think that you can do to alleviate some of your fears about being raped again?"

"Tell me more about the incident that causes you to feel like the rape just occurred." Rationale:The correct option allows the client to express her ideas and feelings more fully and portrays a nonhurried, nonjudgmental, supportive attitude on the part of the nurse. Clients need to be reassured that their feelings are normal and that they may express their concerns freely in a safe, caring environment. Option 1 immediately blocks communication. Option 2 places the client's feelings on hold. Option 4 places the problem solving totally on the client.

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? 1."Thank you, the perfume was a gift." 2."Your comment is really inappropriate." 3."Neither my hair nor my perfume is the focus of today's session." 4."The focus of today's session is on your issues, so let's get started."

"The focus of today's session is on your issues, so let's get started." Rationale:The therapeutic response by the nurse is the one that clarifies the content of the client's statements and directs the client to the purpose of the session. The nurse should confront the client verbally regarding the inappropriate statements and refocus the client back to the issue of the session. Avoid options that may be judgmental and may provide an opening for a verbal struggle or those that are a social response and could be misinterpreted by the client.

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 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? 1."It sounds as if everything you do is either all or nothing." 2."Talk to your counselor; maybe everything isn't ruined yet." 3."You will need to restart your recovery starting from the beginning." 4."We need to prepare you to recognize those things that trigger you to relapse."

"We need to prepare you to recognize those things that trigger you to relapse." Rationale:The therapeutic statement is the one that helps the client to reframe with more moderation. In reframing, the nurse focuses on the positive aspects of learning to overcome failure. The nurse must avoid being condescending or overly negative. The nurse uses an example of 1 support system that still exists to detour the faulty thinking. However, the nurse does not have the ability to know whether the counselor is supportive, so this is not the therapeutic statement.

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? 1."Why don't you tell your spouse about this?" 2."What do you find difficult about this situation?" 3."This is not the best time to make that decision." 4."I agree with you. You should get out of this situation."

"What do you find difficult about this situation?" Rationale:The most helpful response is one that encourages the client to solve problems. Giving advice implies that the nurse knows what is best and can foster dependency. The nurse should not agree with the client, and the nurse should not request that the client provide explanations.

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? 1. "With whom do you live?" 2."Who is available to help you?" 3."What leads you to seek help now?" 4."What do you usually do to feel better?"

"What leads you to seek help now?" Rationale:The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills.

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? 1."My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."I need to get enough sleep and eat well to help prevent feeling anxious." 4."When I have command hallucinations, I'll call a friend and ask him what I should do."

"When I have command hallucinations, I'll call a friend and ask him what I should do." Rationale:The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.

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? 1."My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."When I have command hallucinations, I'll call a friend for help." 4."I need to get enough sleep and eat well to help prevent feeling anxious."

"When I have command hallucinations, I'll call a friend for help." Rationale:The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. If the client is experiencing a hallucination, the nurse or health care counselor, not a friend, should be contacted to discuss whether the client has intentions to hurt herself or himself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. The client statements in the remaining options will aid in wellness but are not specific interventions for hallucinations, if they occur.

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? 1."Let's talk about the circumstances that caused you to lose your job." 2."There are homeless shelters available for people who are experiencing this exact situation." 3."Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" 4."Being homeless would allow us to admit you to the hospital so you will have a place to eat and sleep."

"Wouldn't you want to know if your daughter was having difficulties so you could help if you could?" Rationale:The therapeutic communication technique is clarification that attempts to put vague ideas into words. It helps the client to view the explicit correlation between the client's feelings and actions. Asking why a client lost a job is not directly related to the client's feelings and concerns. Offering to provide a homeless shelter or to commit the client to the hospital does not address the issue at hand and places the client's concerns and feelings on hold.

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 primary 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 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.

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? 1."Have you talked to your family about this?" 2."Everyone feels this way when they are depressed." 3."You will feel better once your medication begins to work." 4."You sound very upset. Are you thinking of hurting yourself?"

"You sound very upset. Are you thinking of hurting yourself?" Rationale: 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? Rationale:Clients who are depressed may be at risk for suicide. It is critical for the nurse to assess suicidal ideation and plan. The nurse should ask the client directly whether a plan for self-harm exists. Options 1, 2, and 3 do not deal directly with the client's feelings.

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? 1."Have you shared your feelings with your family?" 2."I think we should talk more about your anger with your family." 3."You're feeling angry that your family continues to hope for you to be cured?" 4."You are probably very depressed, which is understandable with such a diagnosis."

"You're feeling angry that your family continues to hope for you to be cured?" Rationale:Restating is a therapeutic communication technique in which the nurse repeats what the client says to show understanding and to review what was said. Although it is appropriate for the nurse to attempt to assess the client's ability to discuss feelings openly with family members, it does not help the client discuss the feelings causing the anger. The nurse's direct attempt to expect the client to talk more about the anger is premature. The nurse would never make a judgment regarding the reason for the client's feeling; this is nontherapeutic in the one-to-one relationship.

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.

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? 1.Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities, until the client asks to participate in milieu 4.A structured program of activities in which the client can participate

A structured program of activities in which the client can participate Rationale:A client with depression often is withdrawn while experiencing difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. The remaining options are either too "restrictive" or offer little or no structure and stimulation.

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? 1.Encouraging quiet reading and writing for the first few days 2.Identification of physical activities that will provide exercise 3.No socializing activities until the client asks to participate in milieu 4.A structured program of activities in which the client can participate

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. 1.Initiate confinement measures. 2.Acknowledge the client's behavior. 3.Assist the client to an area that is quiet. 4.Maintain a safe distance from the client. 5.Allow the client to take control of the situation.

Acknowledge the client's behavior. Assist the client to an area that is quiet. Maintain a safe distance from the client. Rationale:During the escalation period, the client's behavior is moving toward loss of control. Nursing actions include taking control, maintaining a safe distance, acknowledging behavior, moving the client to a quiet area, and medicating the client if appropriate. To initiate confinement measures during this period is inappropriate. Initiation of confinement measures, if needed, is most appropriate during the crisis period.

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? 1.Admitting to having a problem 2.Substituting other activities for gambling 3.Stating that the gambling will be stopped 4.Discontinuing relationships with people who gamble

Admitting to having a problem Rationale:The first step in the 12-step program is to admit that a problem exists. Substituting other activities for gambling may be a strategy but it is not the first step. The remaining options are not realistic strategies for the initial step in a 12-step program.

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? 1. An expected coping mechanism 2. An ineffective defense mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client

An expected coping mechanism Rationale:The nurse needs to be aware of the effective and ineffective coping mechanisms that can occur in a client when loss is anticipated. The expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, God or other spiritual being, or caregivers. Notifying the hospital lawyer is inappropriate. Guilt may or may not be a component of the client's feelings, and the data in the question do not indicate that guilt is present.

Which is the appropriate nursing intervention to address the poor nutritional intake demonstrated by a client diagnosed with depression? 1.Weigh the client 3 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.

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. 1.Ask permission before touching the client. 2.Provide a warm, social approach to the client. 3.Eliminate all unnecessary physical contact with the client. 4.Defuse any anger or verbal attacks with a nondefensive stance. 5.Use simple and clear language when communicating with the client.

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. Rationale:When caring for a client with paranoia, the nurse should ask permission if touch is necessary because touch may be interpreted as a sexual or physical assault. The nurse must eliminate any physical contact and not touch the client unless necessary and with the client's permission. The anger that a paranoid client expresses often is displaced, and when a staff member becomes defensive, both client and staff anger may escalate. Simple and clear language should be used in speaking to the client to prevent misinterpretation and to clarify the nurse's intent and action. The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance.

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? 1.Ask the client why he started taking illegal drugs. 2.Ask the client about the amount of drug use and its effect. 3.Ask the client how long he thought that he could take drugs without someone finding out. 4.Not ask any questions for fear that the client is in denial and will throw the nurse out of the home.

Ask the client about the amount of drug use and its effect. Rationale:Whenever the nurse carries out an assessment for a client who is dependent on drugs, it is best for the nurse to attempt to elicit information by being nonjudgmental and direct. Option 1 is incorrect because it is judgmental and off-focus, and reflects the nurse's bias. Option 3 is incorrect because it is judgmental, insensitive, and aggressive, which is nontherapeutic. Option 4 is incorrect because it indicates passivity on the nurse's part and uses rationalization to avoid the therapeutic nursing intervention.

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? 1.Facing the client when providing care 2.Assigning the client to a room at the end of the hall 3.Ensuring that a security officer is available at all times if needed 4.Keeping the door to the client's room open when providing care to the client

Assigning the client to a room at the end of the hall Rationale:The client should be placed in a room near the nurses' station and not at the end of a long, relatively unprotected corridor. The nurse should not become isolated with a potentially violent client. The nurse should never turn away from the client, and the door to the client's room should be kept open. A security officer should be within immediate call in case violent behavior appears imminent.

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? 1.Requesting that a peer remain with the client at all times 2.Removing the client's clothing and placing the client in a hospital gown 3.Assigning to the client a staff member who will remain with the client at all times 4.Admitting the client to a seclusion room where all potentially dangerous articles are removed

Assigning to the client a staff member who will remain with the client at all times Rationale:Hanging is a serious suicide attempt. The plan of care must reflect action that ensures the client's safety. Constant observation status (one-to-one) with a staff member is the best choice. Placing the client in a hospital gown and requesting that a peer remain with the client would not ensure a safe environment. Seclusion should not be the initial intervention, and the least restrictive measure should be used.

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.

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. 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.

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? 1.Increase socialization of the client with peers. 2.Avoid using a whisper voice in front of the client. 3.Begin to educate the client about social supports in the community. 4.Have the client sign a release of information to appropriate parties for assessment purposes.

Avoid using a whisper voice in front of the client. Rationale:Disturbed thought processes related to paranoid personality disorder are the client's problem, and the plan of care must address this problem. The client is distrustful and suspicious of others. The members of the health care team need to establish a rapport and trust with the client. Laughing or whispering in front of the client would be counterproductive. The remaining options ask the client to trust on a multitude of levels. These options are actions that are too intrusive for a client with this disorder.

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.

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? 1.Call the nursing supervisor. 2.Call security to block all exit areas. 3.Restrain the client until the primary health care provider (PHCP) can be reached. 4.Tell the client that the client cannot return to this hospital again if the client leaves now.

Call the nursing supervisor. Rationale:Most health care facilities have documents that the client is asked to sign relating to the client's responsibilities when the client leaves against medical advice. The client should be asked to wait to speak to the PHCP before leaving and to sign the "against medical advice" document before leaving. If the client refuses to do so, the nurse cannot hold the client against the client's will. Therefore, in this situation, the nurse should call the nursing supervisor. The nurse can be charged with false imprisonment if a client is made to believe wrongfully that he or she cannot leave the hospital. Restraining the client and calling security to block exits constitutes false imprisonment. All clients have a right to health care and cannot be told otherwise.

The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? 1.Coffee, tea, and soda consumption should be limited. 2.If the client is compliant, the relapse of symptoms will never occur. 3.Psychotropic medications may cause mild cardiovascular symptoms. 4.Most schizophrenic clients are able to taper off their medications eventually.

Coffee, tea, and soda consumption should be limited. Rationale The nurse should include which information in the medication teaching plan for a client diagnosed with schizophrenia? Rationale:Caffeine can inhibit the action of psychotropic medications commonly prescribed for schizophrenia. Most clients will require continuous medication therapy to manage their symptoms. Although medication compliance is a strong factor in minimizing the reoccurrence of relapses, relapse could occur. Cardiovascular symptoms are not typical side effects of psychotropic medications.

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? 1.Dementia 2.Schizophrenia 3.Seizure disorder 4.Obsessive-compulsive disorder

Dementia Rationale:Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication.

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? 1.Displays less anxiety and agitation 2.Denies presence of suicidal ideations 3.Develops adequate problem-solving skills 4.Establishes a relationship with staff and peers

Denies presence of suicidal ideations Rationale:A suicidal client may have numerous problems that encompass inadequate coping skills, anxiety, and strained interpersonal relationships. However, this question specifies that the problems that need to be dealt with are self-directed violence and risk for suicide related to suicidal ideations with a specific plan. The expected outcome is that the client no longer has suicidal ideations. The remaining options are not related directly to the data stated in the question.

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? 1.Developing lung cancer and/or other respiratory disorders 2.Withdrawal symptoms triggering a stress-induced relapse 3.Diminishing the effectiveness of psychotropic medication 4.Developing gastrointestinal disorders, including bleeding ulcers

Diminishing the effectiveness of psychotropic medication Rationale:Both caffeine and nicotine can inhibit the action of psychotropic medications, which are commonly prescribed for schizophrenia. Although each of the remaining options presents a risk for injury, ineffective medication therapy presents the greatest risk for injury that currently affects this client.

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? 1.Clonidine 2.Disulfiram 3.Pyridoxine hydrochloride 4.Chlordiazepoxide hydrochloride

Disulfiram Rationale:Disulfiram is a medication used for alcoholism, and it aids in the maintenance of sobriety. Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of vitamin B6 deficiency. Chlordiazepoxide hydrochloride is an antianxiety medication (a benzodiazepine) that is used in the management of acute alcohol withdrawal symptoms.

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? 1.Continue to assess the client's behaviors and document clearly in the chart. 2.Report to the psychiatrist that the client is adapting to the unit and is feeling safe. 3.Notify the health team of these observations and alert them to the suspicion that the client is contemplating suicide. 4.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.

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. Rationale: The sudden change in the depressed client's mood and affect may indicate that the client has come to a decision about suicide. The only way to be sure is to ask the client directly. Eliminate options that present strategies that would be used with any client. Avoid options that make unfounded assumptions such as a meaning of the behavior. Notifying others of your concern may be necessary at some point but does nothing to address the problem directly.

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? 1.Place the client in seclusion for 30 minutes. 2.Tell the client that the behavior is inappropriate. 3.Escort the client to his or her room, with the assistance of other staff. 4.Tell the client that his or her telephone privileges are revoked for 24 hours.

Escort the client to his or her room, with the assistance of other staff. Rationale:The client is at risk for injury to self and others and should be escorted out of the dayroom. Seclusion is premature in this situation. Telling the client that the behavior is inappropriate has already been attempted by the nurse. Denying privileges may increase the agitation that already exists in this client.

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? 1.Monitor for repetitive behavior. 2.Demand active participation in care. 3.Educate the client about self-care needs. 4.Establish a trusting nurse-client relationship.

Establish a trusting nurse-client relationship. Rationale:The priority is to establish a trusting relationship with the client. Demanding anything from the client should never occur. The remaining options are appropriate components of the plan of care but are not the priority. A trusting nurse-client relationship needs to be established first.

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? 1.Inform the yelling client to leave the group immediately. 2.Call security personnel to the session to ensure everyone's safety. 3.Ask the other clients to describe how the aggressive yelling made them feel. 4.Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated.

Firmly reinforce limits on behavior, stating that aggressive yelling will not be tolerated. Rationale:The client is displacing anger. The nurse sets limits on behavior, reinforces group rules, and ensures physical safety and a sense of control. Requiring the client to leave the group would be an immediate action if the client presents with escalating behavior. The question presents no data indicating such behavior. Calling security and exploring the responses of other clients are premature actions at this point. Exploration may occur later in the group process.

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. 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.

Have the client void. Obtain an informed consent. Remove dentures and contact lenses. 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.

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? 1.Manipulation 2.Improvement 3.Attention seeking 4.Desire to be accepted

Improvement Rationale:The behaviors identified in the question indicate improvement in the client's condition. The question presents no information indicating that the client is being manipulative. Acting out is attention-seeking behavior. All clients have a desire to be accepted.

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? 1.Reassure the client that things will get better. 2.Tell the client that this is not true and that we all have a purpose in life. 3.Identify recent behaviors or accomplishments that demonstrate the client's skills. 4.Remain with the client and sit in silence; this will encourage the client to verbalize feelings.

Identify recent behaviors or accomplishments that demonstrate the client's skills. Rationale 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? Rationale:Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging, but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

Identify recent behaviors or accomplishments that demonstrate the client's skills. Rationale:Feelings of low self-esteem and worthlessness are common symptoms of a depressed client. An effective plan of care to enhance the client's personal self-esteem is to provide experiences for the client that are challenging but that will not be met with failure. Reminders of the client's past accomplishments or personal successes are ways to interrupt the client's negative self-talk and distorted cognitive view of self. Options 1 and 2 give advice and devalue the client's feelings. Silence may be interpreted as agreement.

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? 1.Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations

Identifying anxiety-producing situations Rationale:Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing situations, and this option does not encourage the development of internal strengths. Suppressing feelings will not resolve anxiety. Elimination of all anxiety from life is impossible.

When planning the discharge of a client with chronic anxiety, which is the most appropriate maintenance goal? 1.Suppressing feelings of anxiety 2.Identifying anxiety-producing situations 3.Continuing contact with a crisis counselor 4.Eliminating all anxiety from daily situations

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. 1.Including the family in the medication planning process 2.Arranging medication administration to occur once per day 3.Working with the psychiatrist to find the right medication at the right dose 4.Providing the client with the injectable, long-acting form of the medication if available 5.Working with the psychiatrist to find the medication that provides the least side effects for the client

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 Rationale:Including the family in the medication planning process; providing clients with the injectable, long-acting form of the medication; and finding the right medication at the right dose that provides the fewest side effects for the client are measures that will promote compliance. Not all medications can be given on a once-per-day dosing regimen because of their short half-life.

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? 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 herself or himself. Suicide precautions are necessary to keep the client safe. The remaining options are therefore incorrect interpretations.

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.Instructions 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.

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? 1.Exploring the client's ability to function 2.Exploring the client's potential for self-harm 3.Inquiring about the client's perception or appraisal of why the rescue was unsuccessful 4.Inquiring about and examining the client's feelings for any that may block adaptive coping

Inquiring about and examining the client's feelings for any that may block adaptive coping Rationale:The client must first deal with feelings and negative responses before the client can work through the meaning of the crisis. The correct option pertains directly to the client's feelings and is client-focused. The remaining options do not directly focus on or address the client's feelings.

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? 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.

When should the nurse determine that it will be safe to remove the restraints from a client who demonstrated violent behavior? 1.Administered medication has taken effect. 2.The client verbalizes the reasons for the violent behavior. 3.The client apologizes and tells the nurse that it will never happen again. 4.No aggressive behavior has been observed for 1 hour after the release of 2 of the extremity restraints.

No aggressive behavior has been observed for 1 hour after the release of 2 of the extremity restraints. Rationale:The best indicator that the behavior is controlled is the fact that the client exhibits no signs of aggression after partial release of restraints. The remaining options do not ensure that the client has controlled the behavior.

The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1.Incessant talking and sexual innuendoes 2.Grandiose delusions and poor concentration 3.Outlandish behaviors and inappropriate dress 4.Nonstop physical activity and poor nutritional intake

Nonstop physical activity and poor nutritional intake Rationale:Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.

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? 1.Disrupted appearance because of weight 2.Inability to feed self because of weakness 3.Pain because of an inflamed gastric mucosa 4.Nutritional imbalance because of lack of intake

Nutritional imbalance because of lack of intake Rationale:The priority client problem for the client with anorexia nervosa is lack of intake and nutritional imbalance since it is the basis of the condition. Although the problems identified in the other options may be considerations in the plan of care for the client with anorexia nervosa, nutritional imbalance is the priority.

The nurse monitors a client diagnosed with anorexia nervosa understanding that the client manages anxiety by which action? 1.Engaging in self-mutilating acts 2.Observing rigid rules and regulations 3.Always reverting to the independent role 4.Constantly striving to avoid making decisions

Observing rigid rules and regulations Rationale:Clients with anorexia nervosa have the desire to please others. Rules and rituals help them manage their anxiety. Their need to be correct or perfect interferes with rational decision-making processes. These clients generally don't engage in self-mutilation.

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1.Engaging in immoral acts 2.Always reinforcing self-approval 3.Observing rigid rules and regulations 4.Having the need always to make the right decision

Observing rigid rules and regulations Rationale:Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients to manage their anxiety.

Clients with which diagnoses are commonly prescribed interventions to manage anxiety? Select all that apply. 1.Dementia 2.Panic disorder 3.Multiple personality disorder 4.Post-traumatic stress disorder 5.Obsessive-compulsive disorder

Panic disorder Post-traumatic stress disorder Obsessive-compulsive disorder Rationale:Multiple personality disorder is considered to be a dissociative disorder rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Dementia may or may not be associated with anxiety.

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? 1. Signs of depression 2. Reactions to a devastating event 3. Evidence that the client is a high suicide risk 4. Indicative of the need for hospital admission

Reactions to a devastating event Rationale:During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. The symptoms noted indicate an expected reaction. Options 1, 3, and 4 are incorrect interpretations.

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? 1.Type 2 diabetes mellitus 2.Peripheral vascular disease 3.Recent myocardial infarction 4.Newly diagnosed hyperthyroidism

Recent myocardial infarction Rationale:Several conditions present risks in the client scheduled for ECT. These include recent myocardial infarction, stroke (brain attack), and cerebrovascular malformation or an intracranial lesion. The conditions in the remaining options do not present specific risks associated with ECT.

Immediately after an assault, the client is extremely agitated, trembling, and hyperventilating. What is the appropriate initial nursing action? 1.Begin to teach relaxation techniques. 2.Encourage the client to discuss the assault. 3.Remain with the client until the anxiety decreases. 4.Place the client in a quiet room alone to decrease stimulation.

Remain with the client until the anxiety decreases. Rationale:This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is critical for the nurse to remain with the client. The client in a severe state of anxiety would not be able to learn relaxation techniques. Processing the experience at this point will further increase the client's level of anxiety.

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.

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 interactions 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.

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.

A client calls the nurse and reports feeling anxious. What is the appropriate initial nursing action? 1.Sit and talk with the client about the feelings. 2.Ask the assistive personnel to check on the client. 3.Administer the prescribed as-needed antianxiety medication. 4.Call the client's primary health care provider to report the client's anxiety.

Sit and talk with the client about the feelings. Rationale:The appropriate initial nursing action is to sit and talk with the client expressing anxiety. An assistive personnel is not prepared to deal with the client's anxiety. Antianxiety medication may be necessary, but this would not be the initial appropriate nursing action. While it may become necessary, calling the health care provider is premature initially.

What is the most appropriate nursing action to help manage a manic client who is monopolizing a group therapy session? 1.Ask the client to leave the group for this session only. 2.Refer the client to another group that includes other manic clients. 3.Tell the client to stop monopolizing in a firm but compassionate manner. 4.Thank the client for the input, but inform the client that others now need a chance to contribute.

Thank the client for the input, but inform the client that others now need a chance to contribute. Rationale:If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others. Although telling the client to stop monopolizing in a firm but compassionate manner may be a direct response, the correct option is more specific and provides direction for the client. The remaining options are inappropriate since they are not directed toward helping the client in a therapeutic manner.

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? 1.Ask direct questions to encourage talking. 2.Leave the client alone so as to minimize external stimuli. 3.Sit beside the client in silence with simple open-ended questions. 4.Take the client into the dayroom with other clients to provide stimulation.

Sit beside the client in silence with simple open-ended questions. Rationale:Clients who are withdrawn may be immobile and mute and may require consistent, repeated approaches. Communication with withdrawn clients requires much patience from the nurse. Interventions include the establishment of interpersonal contact. The nurse facilitates communication with the client by sitting in silence, asking simple open-ended questions rather than direct questions, and pausing to provide opportunities for the client to respond. Although overstimulation is not appropriate, there is no therapeutic value in ignoring the client. The client's safety is not the responsibility of other clients.

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? 1. Depression 2. Somatization disorder 3. Post-traumatic stress disorder 4. Obsessive-compulsive disorder

Somatization disorder Rationale: Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. None of the other options are associated with loss of physical function.

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? 1.Depression 2.Somatization disorder 3.Post-traumatic stress disorder 4.Obsessive-compulsive disorder

Somatization disorder Rationale:Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. None of the other options are associated with loss of physical function.

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? 1.Depression 2.Schizophrenia 3.Somatization disorder 4.Obsessive-compulsive disorder

Somatization disorder Rationale:Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.

Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal? 1.The adolescent gives away a DVD and a cherished autographed picture of a performer. 2.The adolescent runs out of the therapy group, swearing at the group leader, and to her room. 3.The adolescent becomes angry while speaking on the telephone and slams down the receiver. 4.The adolescent gets angry with her roommate when the roommate borrows the client's clothes without asking.

The adolescent gives away a DVD and a cherished autographed picture of a performer. Rationale:A depressed suicidal client often gives away that which is of value as a way of saying goodbye and wanting to be remembered. Options 2, 3, and 4 deal with anger and acting-out behaviors that are often typical of an adolescent.

Which information provided by the nurse accurately describes electroconvulsive therapy? Select all that apply. 1.The average series involves 8 to 12 treatments. 2.Some confusion may be noted after the procedure. 3.Memory loss may occur but will resolve with time. 4.This treatment is a permanent cure to the condition. 5.This treatment is tried before the use of medications.

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. Rationale:Electroconvulsive therapy (ECT) as a form of treatment is considered when medication therapy has failed, the client is at high risk for suicide, or depression is judged to be overwhelmingly severe. Treatments are administered 3 times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effect is amnesia for events occurring near the period of treatment. Memory deficits may occur and tend to resolve with time. This treatment is not a permanent cure to the client's condition.

Which assessment data would indicate that a client is most at risk for suicide? 1.The client demonstrates impulsiveness. 2.The client is disorganized in actions and thoughts. 3.The client has an immediate plan for a suicide attempt. 4.The client has a history of unsuccessful suicide attempts.

The client has an immediate plan for a suicide attempt. Rationale:Having a plan, particularly if the method is immediate and available, places the client at very high risk. Clients also at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse; those with a personal or family history of suicide attempts, depression, or alcoholism; or those with a history of psychotic episodes. Although impulsiveness, disorganization in actions and thoughts, and previous suicide attempts are related to suicide risk, these are not data that makes the client most at risk from the options provided.

What is an appropriate short-term outcome for a client grieving the recent loss of a spouse? 1.The client reports 3 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 2 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 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? 1.Witnessing a murder 2.The death of a loved one 3.A fire that destroyed the client's home 4.A recent rape episode experienced by the client

The death of a loved one Rationale:A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis refers to a crisis of disaster, is not a part of everyday life, and is unplanned and accidental. Adventitious crises may result from a natural disaster (e.g., floods, fires, tornadoes, earthquakes), a national disaster (e.g., war, riots, airplane crashes), or a crime of violence (e.g., rape, assault, murder in the workplace or school, bombings, or spousal or child abuse).

The nurse should plan which goals of the termination stage of group development? Select all that apply. 1. The group evaluates the experience. 2. The real work of the group is accomplished. 3. Group interaction involves superficial conversation. 4. Group members become acquainted with one another. 5. Some structuring of group norms, roles, and responsibilities takes place. 6.The group explores members' feelings about the group and the impending separation.

The group evaluates the experience. The group explores members' feelings about the group and the impending separation. Rationale:The stages of group development include the initial stage, the working stage, and the termination stage. During the initial stage, the group members become acquainted with one another, and some structuring of group norms, roles, and responsibilities takes place. During the initial stage, group interaction involves superficial conversation. During the working stage, the real work of the group is accomplished. During the termination stage, the group evaluates the experience and explores members' feelings about the group and the impending separation.

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.

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? 1.Using open-ended questions and silence 2.Sharing personal preference regarding food choices 3.Documenting reasons why the client does not want to eat 4.Offering opinions about the necessity of adequate nutrition

Using open-ended questions and silence Rationale:Open-ended questions and silence are strategies used to encourage clients to discuss their problems. Sharing personal food preferences is not a client-centered intervention. The remaining options are not helpful to the client because they do not encourage the client to express feelings. The nurse should not offer opinions and should encourage the client to identify the reasons for the behavior.

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? 1.Platelet count 2.Cholesterol level 3.Blood urea nitrogen 4.White blood cell count

White blood cell count Rationale:Clozapine is an antipsychotic medication. Clients taking clozapine can experience hematological adverse effects, including agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to this medication.

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.

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? 1.Chess 2.Writing 3.Ping pong 4.Basketball

Writing Rationale:Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing (journaling), walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. The remaining options have a competitive element to them and should be avoided because they can stimulate aggression and increase psychomotor activity.

N3381 - Psychiatric Mental Health Exam 2

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