NUR 325 - Exam 4 PrepU
Borderline personality disorder
A 30-year-old client who has not paid rent in 4 months is being evicted from an apartment. The client is brought to the hospital after the client uses a kitchen knife to cut the client's wrist in response to the stress of the eviction. The client's behavior is consistent with what?
mania
A 30-year-old woman has been brought to the emergency department after causing a disturbance. She is wearing a pair of tight, pink yoga pants, high heels, a sports bra, and a bright-colored hat. The woman's care providers would recognize that the woman's dress may suggest what?
A loss of interest or inability to derive pleasure for previously enjoyed activities
A 46-year-old client comes to the community mental health center because the client thinks they might be suffering from depression. When assessing this client, which symptom would the nurse identify as being necessary for the diagnosis of major depressive disorder to be made?
Imbalanced nutrition: less than body requirements related to chronic alcohol intake
A 47-year-old client has been admitted to the hospital after being found unconscious in a park. Upon regaining consciousness, the client admits to heavy alcohol use over many years. Assessment reveals a low body mass index, low electrolyte levels, and impaired skin integrity. Vital signs are within normal ranges. What nursing diagnosis should be prioritized in the care of this client?
Dependent
A 70-year-old client comes to the clinic with the client's daughter for group therapy. The client wants the daughter to do everything with the client, is afraid to be left alone, and is having difficulty making any individual decisions. Interventions for this client would center around the diagnosis of which personality disorder?
Chlordiazepoxide
A client admitted for acute alcohol intoxication begins to experience mild sweating, tachycardia, fever, and nausea and vomiting. Of the following, the drug treatment of choice would be what?
"My role here is to help you recover. Let's talk about what else you can be doing after discharge."
A client asks the nurse to go to lunch with the client one day next week after the client is discharged. Which statement is the most therapeutic response?
relapse
A client begins to exhibit hallucinations and delusions along with disorganized speech after forgetting to take antipsychotic medication. The nurse suspects that the client is at which point in the clinical course of the disorder?
8
A client can expect symptoms of alcohol withdrawal to begin how many hours after the last drink?
somatic
A client diagnosed with delusional disorder who uses excessive health care resources most likely has which type of delusions?
Self-monitoring
A client has been diagnosed with bulimia. Which cognitive behavioral technique would be useful for the client?
Explain to the client that untreated depression often becomes increasingly severe and frequent over time
A client has been diagnosed with depression and states that the client is reluctant to receive treatment, stating that the client "would prefer to just wait this out." What is the nurse's most appropriate action?
Middle insomnia
A client has been diagnosed with major depression. The client reports of waking up during the night and has trouble returning to sleep. A nurse interprets this finding as suggesting what?
A significant decrease in appetite
A client has been diagnosed with major depressive disorder. The clinical symptom that would be included when the clinician makes this diagnosis is what?
One of the common side effects is dry mouth.
A client has been prescribed quetiapine for delusional disorder. In teaching the client about this medication, the nurse must be certain to include which information?
Suspiciousness and neologisms
A client has been taking neuroleptic medications for many years as a treatment for schizophrenia. The client is exhibiting tongue protrusion, facial grimacing, and excessive blinking. These manifestations are characteristic of which side effect?
The client is likely to experience stigma around the suicide attempt from some people.
A client has been treated following a suicide attempt. When providing anticipatory guidance during the client's discharge education, the nurse should teach the client that:
"What negative consequences have resulted from your drinking?"
A client has entered treatment for alcohol dependency at the client's spouse's insistence. The client's spouse has threatened to leave the marriage unless the client seeks treatment. The client admits that the client drinks every day, but that the drinking is well in control. The nurse recognizes the client's comments as denial. What is the best response by the nurse?
"You'll need to continue the medication for about 6 to 12 months to see how things go."
A client has experienced a first episode of major depression and has received medication and treatment, which has led to a complete remission of the symptoms. The client asks the nurse, "How much longer will I need to take the medication?" Which response by the nurse would be most appropriate?
Client will express that the client feels safe on the unit
A client has just been admitted to the inpatient psychiatry unit following a suicide attempt. During the client's first 24 hours of care, what outcome should be identified?
Monitoring blood levels of the medication.
A client in an acute manic phase is pacing the halls and talking in a loud voice with pressured speech. The client is overly involved with coclients and frequently threatens and disrupts others on the unit. After administering lithium treatment for the client, the nurse can expect the plan of care to include which additional intervention?
Self-mutilation
A client in the emergency department has self-inflicted wounds on both arms. Assessment reveals that the client was diagnosed with borderline personality disorder 6 months ago, for which the client has been receiving outpatient treatment. The client tells the nurse that the client recently found out the client's therapist is moving and will no longer be able to work with the client. What is the priority nursing diagnosis for this client?
Anorexia nervosa, restricting type
A client is 5 feet 6 inches tall, weighs 105 pounds, exercises 4 hours per day, and does not engage in any binging or purging behaviors. The client believes that he or she is becoming obese and states, "I'm shocked that you think I'm underweight. You don't understand me." The most likely diagnosis for this client is what?
monday morning
A client is admitted to the detoxification unit on Sunday evening. The client discloses that the client's last alcoholic drink was just before the client was admitted to the unit. When can the nurse expect that the client's alcohol withdrawal symptoms will begin?
Borderline personality disorder
A client is admitted to the mental health unit after the client's spouse brings the client to the emergency department. Upon arrival, the spouse explained that the client had been crying all weekend and stating that the client wanted to die. Upon further assessment, the spouse reports that the client always has difficulty controlling anger and frequently worries that the spouse will leave the client. Recently, the client has been getting drunk every night, which the client never used to do. What diagnosis should the nurse suspect applies to this client?
Bipolar I
A client is admitted to the unit in an acute manic episode. The client has had three major depressive episodes in the past 10 years and two other hospitalizations for mania. Which disorders would reflect the client's symptom profile?
Paranoid thoughts
A client is admitted with a diagnosis of schizotypal personality disorder. Which characteristic would this client exhibit during social situations?
Shared psychotic disorder
A client is being seen in the health clinic. The nurse observes a shuffling gait, drooling, and slowness of movement. The client is currently taking an antipsychotic for treatment of schizophrenia. The nurse knows that which side effect is occurring?
- Timidity - Fear of rejection - Sensitivity to negative comments
A client is diagnosed with avoidant personality disorder. When assessing the client, which would be evident? Select all that apply.
- Marked diaphoresis - Auditory hallucinations - Gross uncontrollable tremors
A client is experiencing severe alcohol withdrawal. Which would the nurse identify during the assessment that correlates with the withdrawal symptoms? Select all that apply.
The client says the client feels better, with more energy to interact with others
A client is hospitalized on a psychiatric unit secondary to a suicide attempt. The client has been diagnosed with depression and is consistently depressed. When assessing the client, which finding would alert the nurse that the client's suicidal risk has increased?
The spouse will refrain from the enabling the client's drinking behaviors.
A client is in treatment for depression and alcohol abuse. The client is unwilling to confront substance abuse issues, stating the client uses alcohol to ease feelings of depression. The client's spouse reports that the spouse often has to care for the client when the client is hung over, calling in sick for the client and doing what the spouse can to help the client catch up with household or job responsibilities. The nurse diagnoses the client's family with dysfunctional family processes. The nurse and clients develop a plan of care. Which goal indicates an understanding of the family situation and the linkages between the diagnosis and the outcomes?
Escitalopram
A client is prescribed a selective serotonin reuptake inhibitor (SSRI) as treatment for depression. Which would the nurse most likely administer?
"It can help to prevent you from drinking."
A client is prescribed disulfiram as part of the alcohol treatment program to prevent relapse. The client asks a nurse, "How will this drug help me?" Which response by a nurse would be most appropriate?
"I should eat small frequent meals if I get nauseated."
A client is receiving methadone maintenance therapy. After teaching the client about this treatment, a nurse determines that the education was successful when the client makes which statement?
Bradycardia
A client is suspected of having anorexia nervosa and meets the diagnostic criteria for the disorder. When conducting the physical examination, which would be a probable finding from the assessment?
"Some people experience mild confusion after ECT. Generally it clears in a few days, though it may take longer."
A client is to receive three treatments of electroconvulsive therapy (ECT) per week for 3 weeks. After the third treatment, the client is forgetful and confused. When the client's spouse arrives to take the client home, the nurse discusses the client's condition with the spouse. Which statement is best?
Setting limits
A client on an inpatient psychiatric unit has features of borderline personality disorder. The client is frequently angry, has an unstable sense of self, and is highly impulsive. The client can be verbally abusive to staff, who feel manipulated by the client's behaviors. Which intervention does the nurse determine as priority?
- Withhold additional doses of lithium. - Obtain a blood sample for lithium level. - Push fluids. - Contact the physician.
A client taking lithium for bipolar disorder comes to the clinic and reports symptoms which the nurse interprets as consistent with moderate lithium toxicity. Which action should the nurse perform? Select all that apply.
Maintain daily sodium intake.
A client taking lithium therapy has a serum therapeutic level of 0.8 mEq/L. What priority dietary instruction should the nurse include in the teaching plan?
The client had a blackout.
A client tells the nurse that the client went to a party and had several drinks. When the client woke up the next morning, the client could not remember driving home. What does the nurse suspect?
Developing a personal plan for managing suicidal thoughts when they occur
A client was admitted to the psychiatric unit 3 days ago because of suicidal ideation. The client's suicidal risk has lessened considerably, and the client currently denies having any desire to perform suicide. In addition, the client is able to identify reasons to be alive. Which nursing intervention is appropriate?
Psychomotor retardation
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to the client's feelings of sadness and hopelessness, the nurse would expect to assess what?
Ensuring that the client is not permitted to use anything that would be potentially dangerous.
A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client?
Short history of drug use
A client who is abusing substances is to undergo brief intervention. The nurse understands that this technique is most effective for a client who exhibits which symptoms?
help the client to identify and explore other options.
A client who is depressed tells the nurse, "If I'm honest, I really see suicide as the only way out." In order to challenge the client's belief, the nurse should ...
- Current substance use or abuse - Life and environmental stressors - Lack of coping abilities
A client who otherwise is healthy is admitted for depression and reports feeling "all alone" following a recent divorce. The client admits to drinking at least 12 beers every day. The client has which risk factors for the depression? Select all that apply.
Client safety
A client who suffers from bipolar disorder is admitted to a mental health unit for a manic episode. The nurse knows that which takes priority?
The client will differentiate between reality and fantasy.
A client with a delusional disorder has been undergoing individual psychotherapy. The therapy would be deemed ultimately successful when the client meets which outcome?
Provide frequent contact and communication with the client
A client with a diagnosis of schizophrenia has a history of auditory and visual hallucinations. Which intervention is most likely to minimize the client's hallucinations?
Monitor for Korsakoff syndrome from long-term effects of alcohol use.
A client with a history of alcohol use disorder has presented to the emergency department with hallucinations and relays being followed by the police. Which action will the nurse take given this information?
Splitting
A client with borderline personality disorder (BPD) tells a nurse, "You are good but the nurse on the afternoon shift is bad. The doctor is bad, too, but the therapist is good." The nurse interprets this statement as reflecting which function?
Protection from self-mutilation
A client with borderline personality disorder has been admitted to the inpatient unit after being found in the client's parents' bedroom, burning the client's arm with an iron. This injury required a brief stay in the hospital's burn unit prior to transfer to your psychiatric unit. Which is the nursing care priority for this client during the first 24 hours of admission?
"The client's behavior seems personal, but it's really not. Clients with borderline personality disorder act out to relieve anxiety. I suspect having the pass provoked a great deal of anxiety."
A client with borderline personality disorder has had 21 admissions to the mental health unit, each of which was precipitated by a suicide attempt resulting in superficial cuts. During this admission, the client has developed a relationship with a highly supportive nurse and has progressed to having a pass to spend an afternoon in a nearby shopping mall. Later the day that the client uses the pass, the nurse is shocked when the emergency department calls to say that the client has just been brought in with multiple self-inflicted lacerations. The nurse asks a supervisor, "Everything was going well. How could this happen?" What response by the supervisor reflects an understanding of borderline personality disorder?
The client eats six small meals per day.
A client with bulimia is being discharged from care. The nurse considers which indicator most important when evaluating the effectiveness of the care plan?
Thiamine, or vitamin B1, deficiency
A client with chronic alcoholism has been found to have Wernicke encephalopathy. This irreversible complication is characterized by what?
The drug helps to satisfy the craving for the opioid.
A client with opioid addiction is prescribed methadone maintenance therapy. When explaining this treatment to the client, which of the following would the nurse need to keep in mind?
Delusional thinking
A client with schizophrenia states that the client is God's messenger and the client's mission is to become president. The nurse documents these comments as evidence of what?
Assess the client's blood pressure
A client's depression is being treated in the community with phenelzine. The client has presented to the clinic stating, "I had a few beers and I'm feeling absolutely miserable." What is the nurse's best action?
Previous suicide attempt
A family member of an adolescent who has expressed a desire to commit suicide asks a nurse, "What might predict the possibility of future suicide attempts?" Which would the nurse include in the response?
Lethality
A group of nurses are reviewing information about suicide and associated concepts. The group leader believes understanding of the information has taken place when the leader asks, "What is the probability that a person will successfully complete suicide called?" Which is the appropriate response from the group?
Naloxone
A group of nursing students is reviewing information about nutritional supplementation used during alcohol detoxification. The students demonstrate the need for additional review when they identify which of the following as being used?
Agranulocytosis
A mental health client has been prescribed clozapine for the treatment of schizophrenia. The nurse should be alert to which potentially life-threatening adverse effects of this medication?
Persecutory
A mental health client insists that the client's spouse is trying to poison the client. In this instance, the client is exhibiting which type of delusion?
Maladaptive expression of emotions
A nurse caring for a client with borderline personality disorder (BPD) consistently informs the client of the length of the relationship and routinely prepares the client for termination and the end of hospitalization. Which is the nurse trying to prevent?
- Shyness - Feelings of inadequacy
A nurse is assessing a client diagnosed with avoidant personality disorder. Which characteristic(s) would the nurse most likely expect to find? Select all that apply.
physical safety will be maintained and no injury will be experienced
A nurse is assessing a client with bizarre and aggressive behavior in the emergency department. Upon questioning, the client's partner discloses that the client had been smoking PCP. While in the emergency department, the client continues to exhibit signs of PCP-induced psychosis and needs to be physically restrained. Which nursing outcome will the nurse prioritize in the care of this client?
This disorder produces defensive, guarded, and impulsive behavior that is easily provoked into anger when the client feels threatened.
A nurse is careful to provide a quiet, comfortable, safe environment when conducting an assessment interview. What is the reason this is particularly important when working with a client believed to be exhibiting characteristics of a personality disorder?
Liver function
A nurse is caring for a client diagnosed with bipolar disorder who has been prescribed divalproex. The nurse knows that the client should have which test completed before initiation of drug therapy?
"I should start by stating my feelings as an 'I' statement."
A nurse is caring for a client diagnosed with borderline personality disorder. The nurse has instructed the client about effective ways to communicate. The nurse determines that the client has understood the teaching when the client makes which statement?
Social skills training
A nurse is caring for a client diagnosed with schizoid personality trait. When developing a plan of care for the client, which would a nurse most likely include?
Hallucinogen
A nurse is caring for a client who uses phencyclidine (PCP). PCP is classified as which type of substance?
Users of marijuana always experience relaxation and euphoria.
A nurse is conducting a class for a group of high school students about marijuana use and abuse. The nurse determines that the class needs further discussion when they state which of the following?
Cognitive behavioral therapy
A nurse is developing a plan of care for a client newly diagnosed with bulimia nervosa. Which would the nurse expect to implement in conjunction with pharmacologic therapy?
The risk for suicide is high with either depression or mania.
A nurse is developing a presentation for families who have members diagnosed with bipolar disorders. When describing this condition to the group, which would the nurse most likely include?
"You sound irritated; tell me about what is bothering you."
A nurse is initiating a group for adolescent girls diagnosed with anorexia nervosa. Many of the clients in the group are irritable and resent having to attend. One of them comments, "This is a stupid waste of time!" Which response by the nurse would be most appropriate?
Clang association
A nurse is interviewing a client diagnosed with schizophrenia when the client begins to say, "Kite, night, right, height, fright." What term would the nurse use to document this action?
Include family members to provide a better understanding of symptoms of the illness
A nurse is preparing a client for discharge. As part of the discharge process, the nurse provides education to the client regarding safety from self-harm. Which intervention should the nurse employ?
18 years
A nurse is preparing a presentation for a group of staff nurses on personality disorders. When describing antisocial personality disorders (ASPD), the nurse would explain that for a person to be diagnosed with the disorder, the person must be at least which age?
- Substance abuse is an illness like any other. - An individual with substance abuse issues typically cannot use drugs socially.
A nurse is preparing an educational session for family members affected by substance abuse. Which point should the nurse include in the session? Select all that apply.
Nonsuicidal self-injury
A nurse is preparing an inservice program for a group of mental health nurses on the topic of borderline personality disorder. When discussing the need for hospitalization, which would the nurse include as the most likely reason for inpatient hospitalization?
Substance use disorders
A nurse is providing a presentation about suicide for a group of health professionals. Which element would the nurse include as a major contributor to the rising suicide rate among men?
Ability to concentrate and process the information
A nurse is providing psycho-education to a client who has been admitted to the inpatient mental health unit for a manic episode. In order to ensure the teaching is effective, the nurse must first determine which regarding the client?
Anticonvulsants
A nurse is reviewing information about medications used to treat bipolar disorders. The nurse demonstrates understanding by identifying which medication classification as effective in stabilizing moods in people with bipolar disorder?
report the nurse colleague's behavior to the supervisor on the floor
A nurse observes a fellow nurse colleague who has an unsteady gait and slurred speech. The nurse suspects that the colleague is impaired. Which would be the appropriate action to take?
Elevated temperature
A nurse suspects that a client is experiencing alcohol withdrawal based on assessment of which of the following?
- disruption in concentration - disruption in sleep - disruption in appetite - excessive guilt
A nurse taking an admission history from a client suspects that the physician will diagnose major depression. For the physician to make this diagnosis, the client will have to demonstrate specific symptoms. What are some of these symptoms? Select all that apply.
Situational low self-esteem related to medical condition
A nurse who started recovering from alcohol abuse 3 months earlier is ready to return to work. When speaking with the therapist, the nurse states the nurse is nervous about how coworkers will respond to the nurse now that "they all know I'm a drunk." Which diagnosis best targets the problem implicit in the nurse's remarks?
Tolerate stress without self-mutilation
A nurse working with a client with borderline personality disorder could establish which as outcome criteria?
Mood disturbance
A nursing instructor is developing an education plan for a group of students about schizophrenia and schizoaffective disorders. The instructor identifies that in addition to psychosis, what other condition must be present at the same time for a diagnosis of schizoaffective disorder?
Bipolar disorder
A nursing instructor is reviewing a case study with students about a client with mania who was admitted to a mental health unit. The instructor asks the students what medical diagnosis is most likely responsible for the mania. Which would be the best answer by a student?
Substance abuse disorders
A nursing student is aware that which accounts for more deaths, illnesses, and disabilities across the life span than any other preventable condition?
Clients are often misdiagnosed as having schizophrenia.
A psychiatric-mental health nurse is conducting a review class for a group of colleagues about schizoaffective disorder. The nurse determines that the class was successful based on which description of the condition by the group?
Asking the client to describe the client's childhood relationship with the client's parents
According to the psychodynamic theory regarding addiction, it is most important that the nurse assesses the client with an alcohol use disorder by considering what?
Methadone
After a long history of intravenous heroin use, a client has expressed willingness to stop using heroin. The nurse would expect the client to receive which medication to decrease the severity of withdrawal?
Exposure to repetitive sub-threshold stressors at vulnerable times
After educating a client's family on the etiology of bipolar disorders, a nurse determines that the education was successful when the family describes the kindling theory as involving what?
Adolescence
After teaching a group of nurses about borderline personality disorder, the leader determines that the education was successful when the group identifies that symptoms typically begin in which age group?
Set up a strict eating plan for the client
An adolescent client has been diagnosed with anorexia nervosa. Which intervention should be included in the client's plan of care?
Verbalize feeling safe and comfortable.
An appropriate goal for a client newly admitted to the unit for alcohol withdrawal is what?
Dehydration
An elderly client is admitted to the hospital with fatigue and weight loss of 20 pounds in 1 month. Upon further assessment, the client is diagnosed with depression. What other thing should the nurse assess this client for based on the weight loss?
Whether any family members have been diagnosed with schizophrenia
Assessment of genetic predisposition supports asking a client who is exhibiting symptoms of a delusional disorder what?
"Has something occurred that caused you to measure your thighs?"
During a therapy session, a client with anorexia tells the nurse, "I measured my thighs today. They are a quarter-inch larger than they were yesterday. I feel like a pig; I'm so fat." Which potential response by the nurse is most therapeutic?
Hallucinogen
Ecstasy is an example of which type of substance?
Establishing a support system for the woman and teaching her some coping measures
Following the failure of a woman's recent in vitro fertilization (IVF), the nurse recognizes that she may be at risk of depression. Which intervention is considered a primary suicide prevention measure?
Establishing adequate daily nutritional intake
For a client diagnosed with anorexia nervosa, which goal takes priority?
The client with depression who has been using alcohol and owns a gun
For which client would the nurse be obligated to take immediate and focused action to prevent imminent death?
Older adult depression is often seen as "normal aging."
For which reason is depression in older adults often undiagnosed and untreated?
Impulsivity
Gambling, binge eating, and engaging in unsafe sex are examples of what?
Vomiting
High doses of alcohol produce which effect?
Personality disorder causes impairment in social and occupational functioning, whereas traits do not.
How does personality disorder differ from personality traits?
Every week for the first 6 months
How often must clients receiving clozapine get white blood cell counts drawn?
12 hours
In a person who abuses alcohol or is a chronic drinker, alcohol withdrawal syndrome usually begins within which time frame from abrupt discontinuation or an attempt to decrease consumption?
Controlling food intake
Individuals with anorexia nervosa concentrate on which body cue?
Dopamine
Positive symptoms of schizophrenia, specifically hallucinations and delusions, are thought to be caused by hyperactivity of which neurotransmitter?
The disorder is thought to arise from the interaction of a biological predisposition and environmental stressors.
Research related to the development of schizophrenia has shown what?
Thought disturbances and hallucinations
Schizophrenia is most often characterized by which assessment finding?
Having several clients complain that their pain medication is not working
Suspicion that a nursing professional is impaired by a substance abuse problem is most supported by which situation?
The client most likely has a dual diagnosis since she has both a substance dependence and depression.
The client was diagnosed with cocaine abuse at age 30. When the client was 23, the client was diagnosed with major depressive episode, and has continued to have depression off and on since then. Which statement would reflect this situation?
Client is avoiding eye contact and visibly shaking.
The client's spouse calls the health clinic stating that the client is having a manic episode. What information should alert the nurse to recommend that the client should go to the emergency room for treatment?
Bulimia nervosa, purging type
The dentist of a client noticed that the client's teeth were losing enamel. The client is of average weight. The dentist refers the client for follow up based on the understanding that eating disorder is most often associated with enamel loss?
Dopamine
The ingestion of mood-altering substances stimulates which neurotransmitter pathway in the limbic system to produce a "high" that is a pleasant experience?
Clients with bipolar II disorder do not have symptoms of mania that interfere enough to cause marked functional disturbances.
The major difference between bipolar I and bipolar II disorder is what?
Observe the client for cheeking.
The mental health nurse provides care to clients who are hospitalized for the treatment of depression. Which is the priority nursing action when administering medications to a client who was admitted after a suicide attempt?
Asians
The mental health nurse recognizes that genetic intolerance of alcohol has been documented among which ethnic group?
Both genders between the age of 12 and 17
The mental health nurse should focus on preventative efforts including educational interventions related to the abuse of prescription drugs on which client group?
Self-injury
The most serious consequence of behaviors seen in borderline personality disorder includes what?
- "Are you experiencing insomnia every day?" - "Have you recently lost weight without dieting?" - "Have you experienced difficulty with concentration when working?"
The nurse assesses a client who reports being depressed for over 2 weeks. Which question does the nurse include in the interview portion of the assessment process to determine if the client meets the criteria for major depressive disorder (MDD)? Select all that apply.
Help them to identify appropriate diversional activities.
The nurse in an outpatient rehabilitation program is speaking with a group of clients who have recently recovered from alcohol abuse. Which issue should the nurse raise before the clients leave for the day?
Self-dramatization
The nurse is admitting a client with histrionic personality disorder to the inpatient unit. The nurse would anticipate that this client may exhibit which behavior?
The client overdosed on pills 2 years earlier
The nurse is assessing a client who has presented to the emergency department in emotional distress. What client data represents the greatest risk for suicide?
This is an indication of long-term use of alcohol for this client
The nurse is assessing a client who is suspected of having an alcohol use disorder. The nurse asks about daily alcohol intake. The client replies, "The important point is that if I have 10 drinks, I don't get drunk." The nurse determines the client's response as what?
"There's no demonstrated benefit of no-suicide contracts, though they're not believed to be harmful."
The nurse is assessing a client with depression and a colleague suggests that the client be encouraged to sign a no-suicide contract. What is the nurse's best response to the colleague?
Administer fixed-dose chlordiazepoxide as prescribed.
The nurse is caring for a client experiencing alcohol withdrawal. Which intervention will the nurse perform to alleviate the physical effects associated with alcohol withdrawal?
"I developed a tolerance to alcohol over this period of time."
The nurse is caring for a client who began drinking a six-pack of beer every day in freshman year of college. By sophomore year, the client was drinking two six-packs to get the same effect. After educating the client on the chronic use of alcohol, the nurse determines education has been effective when the client makes which statement describing this phenomena?
"You'll be expected to attend group therapy each day."
The nurse is caring for a client with antisocial personality disorder. Which statement is most appropriate for the nurse to make when explaining unit rules and expectations to the client?
decreased thiamine level
The nurse is caring for a client with chronic alcohol use disorder that is experiencing an alteration in memory function. Which laboratory result will the nurse correlate with this assessment finding?
flushed face, headache, and tremors
The nurse is caring for an adult client that has been admitted to the detoxification unit. Due to acute withdrawal, what cues will the nurse likely assess?
Heart rate and rhythm
The nurse is performing the history and physical examination on a client who is being admitted for anorexia nervosa. The client, a 23-year-old, is 5 feet 2 inches, and weighs 88 pounds. The nurse assesses the client's history of weight gain and loss, typical daily food intake, electrolyte and other blood studies, and elimination patterns. The nurse observes typical physical findings such as dry skin, lanugo, and brittle hair and nails. Which factor is a priority for the nurse to assess next?
"Your parent's alcohol use problem is a chronic disease but can be treated."
The nurse is providing support to a client's child regarding the parent's alcohol use disorder. When integrating the disease concept treatment approach about this type of disorder, which statement by the nurse would be most effective?
Administering a mental status exam to assess for psychosis
The nurse is told by a client that the client is having suicidal thoughts. Which intervention has lowest priority?
A client with schizophrenia who has had a previous suicide attempt
The nurse is working in a psychiatric-mental health facility and assessing the clients' risk for suicidal behaviors. Which client would be at highest risk?
The client recently purchased a large bottle of over-the-counter analgesics
The nurse is working with an outpatient who has a history of depression and suicide attempts. What assessment finding should the nurse interpret as indicating a high degree of planning for a future attempt?
First 3 months
The nurse knows that the most dangerous time period following a previous suicide attempt is what?
Provide the client with a feeling of responsibility and control over the client's behavior
The nurse on an inpatient psychiatric unit is developing the plan of care for a 17-year-old client admitted with anorexia nervosa. The client's weight is 20% below normal. The client engages in many rituals related to eating, asks to be weighed several times per day, and complains that access to the bathroom is limited. The nurse develops a contract with the client. The purpose of the contract is to do what?
- Use sugarless gum and/or lozenges. - Drink 6 to 8 cup of water per day.
The nurse provides care to a client who is experiencing side effects due to prescribed antidepressant medication. Which nonpharmacologic intervention does the nurse include in the plan of care for the client who is experiencing dry mouth? Select all that apply.
Grandiose delusions
The police bring a client to the hospital. They found the client in a hospital gown, swimming in a local creek. The client states that the client was "being baptized by Mother Nature, who loves and worships me." How would the nurse describe the client's current alterations in mental status?
Tactile hallucinations
The psychiatric nurse managing the care of a client experiencing alcohol withdrawal instructs unit staff to anticipate that the client may experience which neurological response?
Used in addition to psychotherapy
The use of pharmacotherapy in the treatment of personality disorders is optimized if this intervention is what?
Helping the client identify positive coping mechanisms
When a client is working toward the prevention of an alcohol abuse relapse, the nurse is acting in a therapeutic role when doing what?
Communicate concern and empathy to the client
When a nurse assesses prior self-harm behavior, this can provide information about the motivation behind the client's actions and allows the nurse to do what?
Anhedonia
When assessing a client with depression, the client states, "I just feel so sad and hopeless. I just don't care anymore. I don't even enjoy doing the crossword puzzles like I used to." A nurse documents this finding as indicative of what condition?
Unusual self-confidence
When caring for a client with mania, which effect would a nurse most likely find during assessment?
Splitting
When clients diagnosed with borderline personality disorder (BPD) see nurses as either all good or all bad, the client is using which primitive defense?
A 50-year-old male client who lives on a farm outside the city
When conducting a risk assessment for suicide, the nurse most likely identifies which client as having the greatest risk for completing suicide?
"There are no solutions to my problems."
When conducting a suicide risk assessment with a client, the nurse should identify the client as a high imminent risk if which statement is made?
It decreases the severity of heroin withdrawal symptoms.
When discussing methadone treatment with a client, the nurse should include what?
Instructing the staff to enforce all unit rules consistently
When providing care to a client who consistently attempts to manipulate the staff, the nurse can best maintain the therapeutic milieu by doing what?
- Lack of remorse for actions - Episodes involving scams for personal gain - Repeated incidents involving assaults
When reviewing the history of a client with antisocial personality disorder, which would the nurse expect to find? Select all that apply.
Giving away valued personal items
When teaching prevention to the parents of a 15-year-old client who recently attempted suicide by taking an overdose of alprazolam, the nurse describes which behavioral clue?
Fluoxetine
Which antidepressant medication is classified as a selective serotonin reuptake inhibitor (SSRI)?
Hypothalamus
Which area of the brain has been associated with the symptoms of eating disorders?
- Self-induced vomiting - Use of enemas - Misuse of diuretics - use of laxatives
Which behaviors are associated with purging? Select all that apply.
Ambivalence
Which characteristic is most common among suicidal clients?
It is a self-help group that focuses on total abstinence.
Which characteristic of the 12-step program distinguishes it from other programs?
A 20-year-old is experiencing a gradual decrease in the ability to concentrate, be productive, and sleep restfully.
Which client exhibits the characteristics that are typical of the prodromal phase of schizophrenia?
Cluster C
Which cluster of personality disorders is represented by individuals who appear anxious or fearful?
Increase hydration
Which could be incorporated into the plan of care for a client receiving an antidepressant who is experiencing orthostatic hypotension?
The client had six drinks a few hours ago.
Which factor would contraindicate the use of disulfiram in the treatment of a client who has an alcohol use disorder?
Chaotic family
Which is a family risk factor for bulimia nervosa?
social isolation
Which is a primary risk factor for suicide?
Thought stopping
Which is a technique used to help the client with borderline personality disorder gain control over self-critical thoughts?
Norepinephrine, dopamine, and serotonin have been implicated.
Which is a true statement regarding depressive disorders?
Divalproex
Which is an anticonvulsant used as a mood stabilizer?
Depression
Which is the most common disorder found in clients diagnosed with bulimia nervosa?
Traditional methods of treatment have not been very successful for these clients.
Which statement about clients with a dual diagnosis is accurate?
Eating disorders involve dysregulation of multiple neurotransmitter systems, whether as a cause or an effect of the eating disorder, and may be influenced by behavioral, cultural, and familial factors.
Which statement best describes the theories of the etiology of eating disorders?
"This is the most awful thing that has ever happened to me."
Which statement by a client with borderline personality disorder (BPD) is an example of catastrophizing?
"I am a magician, and my magic powers are good when the moon is full."
Which statement made by a client would indicate that the client has delusions of grandeur?
Substance-related disorders result from the interplay of biologic, genetic, and psychosocial factors.
Which statement most accurately describes the etiology of substance-related disorders?
The vast majority of people who commit suicide have a diagnosed mental disorder.
Which statement most accurately describes the relationship between psychiatric illness and suicide risk?
- It is available in tablet form. - It is a legal medication. - It is controlled by a health care provider.
Which statements identify positive aspects of methadone as a substitute for heroin? Select all that apply.
Tolerance break
Which term describes a situation that occurs when very small amounts of alcohol intoxicates the person after continued heavy drinking?
First-generation antipsychotic drugs
Which type of antipsychotic medication is most likely to produce extrapyramidal effects?
Persecutory type
Which type of delusion refers to a situation whereby a person or someone close to person is being malevolently treated in some way?
Risk for self-mutilation
Which would be the priority nursing diagnosis for a client diagnosed with borderline personality disorder (BPD)?
Somatic
While interviewing a client diagnosed with a delusional disorder, the client states, "I have this really strange odor coming out of my mouth. I stop to brush my teeth almost every hour and then rinse with mouthwash every half hour to get rid of this smell. I've seen so many doctors, and they can't tell me what's wrong." The nurse interprets the client's statement as reflecting which type of delusion?
