psych 2

A hospitalized client who is experiencing delusions and has a diagnosis of schizophrenia says to the nurse, "I know that the doctor is talking to the CIA to get rid of me." The nurse's best response is:

"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?"

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is to:

Use a night light and turn off the television.

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse who is present at the time should respond by stating which of the following?

"Are you fearful and think that others may want to hurt you?"

A nurse is caring for a client who is suspected of being dependent on drugs. Which question would be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you?"

A nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client states:

"I can call my therapist when I'm hallucinating so that I can talk about my feelings and plans and not hurt anyone."

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member would indicate the client has learned positive coping skills?

"I feel better able to care for my father now that I know where to obtain assistance."

A client hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." The appropriate response by the nurse is:

"I hear what you are saying, but I don't share your belief."

A nurse is providing care to a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" The appropriate nursing response is which of the following?

"I cannot promise to keep a secret."

The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this—it's private and personal." Which statement by the nurse indicates a therapeutic response?

"I know that some of these questions are difficult for you, but, as a nurse, I must legally respect your confidentiality."

A nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife say:

"I no longer feel that I deserve the beatings my husband inflicts on me."

A client has been hospitalized and has participated in substance abuse therapy group sessions. On discharge, the client has consented to participate in Alcoholics Anonymous (AA) community groups. Which statement by the client would best indicate to the nurse that the client has assimilated therapy session topics and coping response styles and has processed information effectively for self-use?

"I'm looking forward to leaving here; I know that I will miss all of you. So, I'm happy and I'm sad, I'm excited and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you people."

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which appropriate response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

A client says to the home care nurse, "I can't believe that my wife died yesterday. I keep expecting to see her everywhere I go in this house, ready to plan our activities for the day." Which of the following is the therapeutic nursing response?

"It must be hard to accept that she has passed away."

A client is admitted to the inpatient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse makes which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

"It's okay to grieve and be angry with your daughter and anyone else for a time."

A nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

A nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?

"Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse makes which therapeutic response to the client?

"Tell me about your difficulty sleeping."

A nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for additional information about this self-help group?

"The leader of this self-help group is a nurse or psychiatrist."

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" The nurse appropriately responds by stating:

"What do you and your husband believe is the right thing for your children?"

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse would be:

"What do you find difficult about this situation?"

A nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement would be appropriate to make to this client?

"What is causing you to become agitated?"

A nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropriate question to ask is:

"What leads you to seek help now?"

A nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point."

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

"You sound very upset. Are you thinking of hurting yourself?"

A client who is diagnosed with pedophilia and has been recently paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters of me all over the neighborhood telling about me with my picture on it." Which of the following is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

A client 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." The therapeutic response by the nurse is:

"You're feeling angry that your family continues to hope for you to be 'cured'?"

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse makes which therapeutic response to the client?

"You've been feeling like a failure for a while?"

A nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse avoids which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

A nurse is preparing a client for the termination phase of the nurse-client relationship. Which nursing task would the nurse appropriately plan for this phase?

Assist in making appropriate referrals.

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Parkinson's disease

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client would be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

A nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse will consider which of the following?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

Which behavior should the nurse expect a client diagnosed with agoraphobia to describe when discussing the disorder?

A fear of leaving the house

Therapy that involves pairing a stimulus attractive to the client with an unpleasant event is known as which of the following?

Aversion therapy

A nurse is assisting in a group therapy session. During this session, the members are identifying tasks and boundaries. The nurse understands that these activities are characteristic of which stage of group development?

Beginning stage

A nursing student is asked to identify the characteristics of bulimia nervosa. Which response by the student indicates a need to further research the disorder?

Body weight well below ideal range

A nurse is caring for a client who has been treated with long-term antipsychotic medication. As part of the nursing care plan, the nurse monitors for tardive dyskinesia. In the event that tardive dyskinesia occurs, the nurse would likely observe:

Abnormal movements and involuntary movements of the mouth, tongue, and face

A client is attending a Gamblers Anonymous meeting for the first time. The model used by this group is the 12-step program developed by Alcoholics Anonymous. The nurse understands that the first step in the 12-step program is which of the following?

Admitting to having a problem

A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The nurse determines that the client has:

Agoraphobia

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse would encourage the client to attend which of the following community groups?

Alcoholics Anonymous

A nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, the nurse determines that:

An informed consent needs to be obtained from the client.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. The nurse's most important aspect of care is to maintain client safety and plans to:

Assign a staff member to the client who will remain with him or her at all times.

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. In fact, the client 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. The appropriate nursing action is to:

Call the nursing supervisor

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which of the following?

Client involvement in goal setting

A nurse collects data on a client with a diagnosis of bipolar affective disorder-mania. The finding that requires the nurse's immediate intervention is the:

Client's inadequate attention to activities of daily living (ADL) and poor nutritional intake

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

Communicate expected behaviors to the client. Assist the client in developing means of setting limits on personal behavior. Follow through about the consequences of behavior in a nonpunitive manner. Be clear with the client regarding the consequences of exceeding limits set regarding behavior.

Which data indicates to the nurse that a client may be experiencing ineffective coping?

Constantly neglects personal grooming

A licensed practical nurse (LPN) enters a client's room, and the client is demanding release from the hospital. The LPN reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder, and that the admission was a voluntary admission. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Contact the health care provider (HCP).

A client was admitted to a medical unit with acute blindness. Many tests are performed and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash, in which a family of three was killed. The nurse suspects that the client may be experiencing a:

Conversion disorder

A client is admitted to a psychiatric unit for treatment of psychotic behavior. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as:

Denial

A nurse is caring for a client with severe depression. Which of the following activities would be appropriate for this client?

Drawing

A nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family. Select all that apply.

Encourage expression of feelings, concerns, and fears. Extend touch and hold the client's or family member's hand if appropriate. Be honest and truthful and let the client and family know that you will not abandon them.

In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following is best?

Encourage the client to participate in a structured daily program of activities.

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action would be to:

Escort the manic client to his or her room.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as:

Evidence of the client's altered and distorted body image

The police arrive at the emergency room with a client who has seriously lacerated both wrists. The initial nursing action is to:

Examine and treat the wound sites.

A client experiencing a severe major depressive episode is unable to address activities of daily living. The appropriate nursing intervention is to:

Feed, bathe, and dress the client as needed until the client can perform these activities independently.

Following a group therapy session, a client approaches the licensed practical nurse (LPN) and verbalizes a need for seclusion because of uncontrollable feelings. The LPN reports the findings to the registered nurse (RN) and expects that the RN will take which of the following actions?

Get a written prescription from the health care provider (HCP) and obtain an informed consent.

The best rationale for using group therapy as an accepted way of treatment of clients in the milieu is because:

Group therapy provides a social mechanism in which a client can relate to peers and validate thoughts and feelings in a realistic environment

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. The nurse understands that the purpose of this approach is to:

Help the client identify and examine dysfunctional thoughts and beliefs.

A nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse monitors for which of the following?

Hypertension, disorientation, hallucinations

A psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." The appropriate nursing response is which of the following?

I cannot discuss any client situation with you."

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!" The best nursing action would be to:

Identify recent behaviors or accomplishments that demonstrate skill or ability.

A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client's efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

A nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The appropriate interpretation of the behavior is that the client:

Is displaying typical behaviors that can occur during termination

A nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. The best nursing action is to:

Keep the client talking and signal to another staff member to send help to the client.

Which of the following are appropriate interventions for caring for the client in alcohol withdrawal. Select all that apply

Monitor vital signs. Provide a safe environment. Address hallucinations therapeutically. Provide reality orientation as appropriate.

A nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?

Observe for excessive exercise.

A nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by:

Observing rigid rules and regulations

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. The appropriate initial nursing intervention related to this concern is:

Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

An intoxicated client is brought to the emergency department by local police. The client is told that the health care provider (HCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the HCP immediately. The nurse assisting to care for the client would plan for which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

A nurse is assisting in planning care for a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention will the nurse include in the plan of care?

One-to-one suicide precautions

A nurse is assigned to care for a client who is experiencing disturbed thought processes. The nurse is told that the client believes that the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

A nurse reviews the activity schedule for the day and determines that the best supervised activity that the manic client could participate in is:

Ping-pong

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, the nurse likely expects that the client:

Presents a harm to self

A nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is to:

Provide safety for the client and other clients on the unit.

A nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by:

Psychomotor retardation and side effects of medication

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. The appropriate nursing action is to:

Quietly approach the client, escort her to her room, and assist her in getting dressed.

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves:

Re-experiencing recollections of the trauma

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which of the following are therapeutic communication techniques? Select all that apply.

Restating Listening Maintaining neutral responses Providing acknowledgment and feedback

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse suggests that the mother:

Restrict the amount of chocolate and caffeine products in the home.

A nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which of the following?

Sit beside the client in silence and verbalize occasional open-ended questions.

A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing:

Social phobia

A nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which of the following?

Suggest that the client stop talking and try listening to others.

Which data collection finding would indicate the possibility of the sexual abuse of a child?

Swelling of the genitals

A nurse assists in planning care for a client scheduled to be discharged from a mental health clinic. The nurse understands that the client's unresolved feelings related to loss may resurface during which phase of the therapeutic nurse-client relationship?

Termination phase

A nurse is monitoring a female client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a prized CD and a cherished autographed picture of the performer.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse interprets the client's behavior as:

The client is at increased risk for suicide.

A nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. On review of the client's record, the nurse notes that the admission was a voluntary admission. Based on this type of admission, the nurse would expect which of the following?

The client will participate in the treatment plan.

A nurse is assisting with the data collection on a client admitted to the psychiatric unit. The nurse reviews the data obtained and identifies which of the following as a priority concern?

The client's report of suicidal thoughts

A nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse would determine that this type of crisis could be caused by:

The death of a loved one

A nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which of the following?

The false belief that one is being singled out for harm by others

A client has reported that crying spells have been a major problem over the past several weeks, and that the doctor said that depression is probably the reason. The nurse observes that the client is sitting slumped in the chair and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on:

Weight loss

A nurse is assigned to care for a client at risk for alcohol withdrawal. The nurse monitors the client, knowing that the early signs of withdrawal will usually develop within how much time after cessation or reduction of alcohol intake?

Within a few hours

A nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate initially for this client?

Writing

A nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which clinical manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea