Psych EAQ
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is the priority nursing action during the first 48 hours after the client's admission?
A. Monitor the client's vital signs. Rationale: A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is contraindicated initially because it may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.
An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." What defense mechanism does the nurse identify?
A. Denial Rationale: The client's statement is an example of the use of denial, a defense that blocks problems by unconsciously refusing to admit that they exist. Projection is a defense that is used to deny unacceptable feelings and emotions and attribute them to others. Sublimation is a defense in which socially acceptable behavior is substituted for unacceptable instincts. Displacement is a defense that is used to allow the shifting of feeling from an emotionally charged person or object to a safe substitute person or object.
What does the nurse determine is the therapy that has the highest success rate for people with phobias?
A. Desensitization involving relaxation techniques Rationale: The most successful therapy for people with phobias consists of behavior modification techniques involving desensitization. Insight into the origin of the phobia will not necessarily help the client overcome the problem. Psychotherapy aimed at rearranging maladaptive thought processes may increase understanding of the phobia but may not help the client cope with the fear; there is no maladaptive thought process associated with phobias. Psychoanalysis may increase understanding of the phobia but may not help the client cope successfully with the unreasonable fear.
A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning and the client no longer talks about suicide. What should the nurse do in response to this client's behavior?
A. Keep the client under closer observation Rationale: As the client's motivation and energy return, the likelihood that suicidal ideation will be acted out increases. There are no data regarding visitation rights; the priority concern is the greater risk for suicide. Although engaging the client in preliminary discharge planning eventually will be done, the priority is determining the potential for suicide. Although the client should be observed for side effects of the medication, the greater risk of suicide takes precedence.
The nurse anticipates that which medication will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse?
A. Lorazepam (Ativan) Rationale: Lorazepam (Ativan) is most effective in preventing the signs and symptoms associated with withdrawal from alcohol. It depresses the central nervous system by potentiating Γ-aminobutyric acid, an inhibitory neurotransmitter. Phenobarbital (Luminal) is used to prevent withdrawal symptoms associated with barbiturate use. Chlorpromazine (Thorazine), an antipsychotic medication, is not used for alcohol withdrawal. Methadone hydrochloride (Methadone) is used to prevent withdrawal symptoms associated with opioid use.
A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions?
A. Mild Rationale: A person with mild anxiety has a broad perceptual field and increased problem-solving abilities. A moderately anxious person shuts out peripheral events and focuses on central concerns but has a decreased ability to problem solve. Panic is characterized by a completely disruptive perceptual field. With severe anxiety, the perceptual field is reduced, as is the ability to focus on details.
A nursing student compares differences in the predominant health beliefs, communication, and birth rites of different cultures in the United States. Which cultures have been correctly mapped with their cultural norms?
A. Native Americans - Day to day living experiences formed by values and beliefs intrinsic to culture and religion - Eye contact considered a form of disrespect - Disproportionately high infant death rate Rationale: In Native American culture, religious and healing practices are blended, and values and beliefs intrinsic to culture and religion form the day-to-day living experiences. Members of this culture avoid eye contact because it is considered a sign of disrespect. The infant death rate remains disproportionately high. Muslim Americans generally follow a holistic health belief system. Many women in this culture are extremely modest; signs should be posted to alert male staff members to avoid a room housing a female Muslim client. Muslim women also prefer female physicians to attend them during childbirth. The health belief system of African Americans involves the concurrent practice of biomedical and folk methods. Eye contact is sometimes uncomfortable, especially among members of older generations. Some members of this culture do not believe that the father should not see the mother or baby until both are cleaned and dressed; this is prevalent among Mexican Americans. Chinese Americans primarily believe in a holistic system. In this culture, touch may be acceptable among same-sex acquaintances, but touching in public between members of the opposite sex is not acceptable. Many Chinese Americans prefer acupuncture for pain control. The predominant health belief system among Mexican Americans is biomedical, heavily mixed with folk. Many Mexican Americans believe that touch has the potential to neutralize the evil eye. They have no specific cultural practices that discourage breastfeeding.
The nurse identifies that a client who had extensive abdominal surgery appears depressed. What is the most appropriate nursing action?
A. Talking with the client and encouraging exploration of feelings Rationale: The nurse must first explore the client's feelings; an honest discussion with emphasis on concerns helps promote adjustment. Asking the client's health care provider to prescribe an antidepressant medication may be necessary if the depression continues but is not warranted at this time without further exploration of the situation. Postoperative depression is not an expected response to surgery. Reassuring the client that feelings of depression will lift after returning home is false reassurance because there is no guarantee that the depression will lift at home.
During a follow-up appointment, a client at 21 weeks gestation is diagnosed with hyperemesis gravidarum. The client says, "Why is this happening to me? I don't know whether I can go on like this." What is the ideal response by the nurse?
B. "This must be physically and emotionally challenging for you." Rationale: An open-ended statement validates what the client is experiencing and will encourage further client expression. It is not clear that the client has expressed a desire to have an abortion. It is important to open the lines of communication so the client may express her concerns. Becoming defensive is not in the best interest of the client. This would close down communication. It is true that there are dietary and medication options that can help, but validation of the client's feeling and encouraging open expression is the first priority; only after this is done will the client be ready to listen.
A 37-year-old woman is admitted to the unit with severe menorrhagia. During assessment the nurse learns that she has a history of fibroids, menorrhagia, pelvic pain, and depression. The client has been undergoing hormone therapy in hopes of easing the symptoms and reducing the size of the fibroids, without success. The lab reports hemoglobin and hematocrit readings of 6.8 g/dL (68 mmol/l) and 20.2 (20%), respectively. The client begins to sob and cries, "I don't know what to do, my primary healthcare provider is recommending a hysterectomy, but I haven't had children yet!" What is the bestresponse by the nurse?
B. "This must be so difficult for you. Children are really important to you?" Rationale: Validating the client's feelings and including an open-ended question will encourage further expression. Previous problems and health conditions could later be included in the conversation to help the client make the best decision. Adoption is certainly an option for this person, but this is not what she needs to hear at this time. This statement also closes down communication. The client does have a choice, and telling her that she does not could preclude further communication and cause anger and defensiveness. Telling the client that she's better off without children is not what the client needs to hear, especially when she is facing an operation that could end her chance of giving birth to children.
A client at 38 weeks' gestation is scheduled for a nonstress test. The woman asks the nurse, "Do you think this test is necessary?" What is the most appropriate response by the nurse?
B. "You seem to have doubts about this test." Rationale: Observing that the client is having doubts encourages her to discuss her fears and anxieties. Telling the client that the test is fast, harmless, or routine cuts off communication and does not allow the client to express her fears and anxiety. The mention of risk may frighten the client and does not encourage the client to discuss the situation further.
While caring for a client with schizophrenia, a nurse understands that psychotherapy is against the client's religious beliefs. To which religious community does the client likely belong?
B. Christian Science Rationale: The Christian Science community is against certain therapies including psychotherapy. The Mormon, Disciples of Christ, and Assemblies of God communities do not prohibit psychotherapy.
A 68-year-old client who has metastatic carcinoma is told by the practitioner that death will occur within a month or two. Later the nurse enters the client's room and finds the client crying. Before responding, which factor should the nurse consider?
B. Crying releases tension and frees psychic energy for coping. Rationale: Crying is an expression of an emotion that, if not expressed, increases anxiety and tension; the increased anxiety and tension use additional psychic energy and hinder coping. Crying does not relieve depression, nor does it help a client face reality. It is not universally true that nurses should not interfere with a client's behavior and defenses. In most instances the client's defenses should not be taken away until they can be replaced by more healthy coping mechanisms. The nurse must interfere with behavior and defenses that may place the client in danger, but the client's current behavior poses no threat to the client. It is not always true that accepting a client's crying maintains and strengthens the nurse-client bond. Many clients are embarrassed by what they consider a "show of weakness" and have difficulty relating to the individual who witnessed it. The nurse must do more than just accept the crying to strengthen the nurse-client relationship.
A toddler who was physically abused is admitted to the pediatric unit. What behavior does the nurse expect when approaching the child?
B. Exhibiting fear of physical contact initiated by anyone Rationale: Abused children distrust anyone who touches them because it may be a precursor to abuse. Abused children are fearful of others and generally do not smile when approached. Abused children usually do not cry because they have learned not to expect comforting behavior from others. An abused child is acutely aware of anyone at the bedside; he or she is alert to the possibility of an attack.
What characteristic is the nurse likely to identify when planning care for a client who has abused multiple drugs?
B. Inability to delay gratification Rationale: The addict is unable to delay gratification. The addict failed to develop coping skills and instead depends on substance abuse to cope. Drug users are concerned with reality; their drug use is an attempt to blur the pains of reality. These clients are insensitive to the needs of others. They are overly concerned about themselves and obtaining drugs. Education of the public has been extensive, but the new user of drugs does not believe that addiction will occur.
An adolescent who has had type 1 diabetes for 5 years stops adhering to the therapeutic regimen. In light of the client's developmental level, what does the nurse conclude that the behavior is a reflection of?
B. Struggle for identity Rationale: Striving to attain identity and independence are tasks of the adolescent, and rebellion against established norms may be exhibited. Nonadherence to a regimen is not a bid for attention; rather, it is an attempt to establish an identity, which is a developmental task of adolescence. Although the adolescent may be using denial, denial is not developmentally related to adolescence. Noncompliance is not a sign of regression; it is an attempt to attain identity through rebellion against established norms.
A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." What does the nurse identify the client's communication as?
C. A reflection of depression that is causing feelings of hopelessness Rationale: This statement provides clues that the client feels no one cares, so there is no reason the client should care. These feelings are common in depression. The clues presented do not lead to the other conclusions.
A client with the diagnosis of bipolar disorder, manic episode, is extremely active, talks constantly, and tends to badger the other clients, some of whom are becoming agitated. What is the best strategy for a nurse to use with this client?
C. Distraction Rationale: During periods of hyperactivity the client has a short attention span and can be distracted easily; distraction will serve as a therapeutic intervention for all of the clients. The nurse should be empathetic, not sympathetic. Humor and confrontation may each worsen anxiety, increase activity, and aggravate aggressive behavior.
Which reactions does a nurse expect of a four-year-old child in response to illness and hospitalization?
C. Out-of-control behavior, regression to overdependency, and fear of bodily mutilation Rationale: Preschoolers experience loss of control caused by physical restriction, loss of routines, and enforced dependency, which may make them feel out of control. Preschoolers are also likely to experience feelings of regression or overdependency and fear of bodily mutilation. Anger, resentment over depersonalization, and loss of peer support are typical feelings expressed in adolescence. Boredom, depression over separation from family, and fear of death are typical feelings expressed by school-age children. Intense panic, loss of security over separation from parents, and low frustration tolerance are feelings usually experienced by toddlers.
An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While sitting with him the nurse notices that he is jumpy and exhibits startle reactions and poor concentration. The nurse identifies these as symptoms of what?
C. Posttraumtic stress disorder (PTSD) Rationale: PTSD is a syndrome characterized by the development of symptoms after an extremely traumatic event. Symptoms include helplessness, flashbacks, intrusive thoughts, memories, images, emotional numbing, loss of interest, avoidance of any place that reminds the affected person of the traumatic event, poor concentration, irritability, startle reactions, jumpiness, and hypervigilance. Delusions are beliefs that guide one's interpretation of events and help make sense of disorder. Common delusions among older adults involve being poisoned, having their assets taken by their children, being held prisoner, and being deceived by a spouse or lover. Hallucinations are visual or auditory perceptions of nonexistent objects and sounds. Older adults with hearing and vision deficits may hear voices or see people who are not actually present. OCD is characterized by recurrent and persistent thoughts, impulses, and images that are repetitive and purposeful and intentional urges of ritualistic behaviors that improve the affected person's comfort level.
During the first month in a nursing home, an older client with dementia demonstrates numerous disruptive behaviors related to disorientation and cognitive impairment. What should the nurse take into consideration when planning care?
C. Stressors that appears precipitate the client's disruptive behavior Rationale: Additional information must be collected to determine what may be precipitating the disruptive behavior. Clients with cognitive impairment may have difficulty controlling behaviors and may need the environment to provide the structure needed to act appropriately. The client's disorientation is documented and will not change, although some day-to-day variations may occur. Disorientation alone usually does not lead to disrupted behavior. The client's ability to perform daily activities is important, but it is not necessarily related to disruptive behavior. The client may never achieve adjustment to the nursing home.
What behavior does the nurse suggest a parent will notice in her 2-year-old child after the death of a family member?
C. The child exhibits changes in sleeping patterns. Rationale: The parent will notice that after the death of a family member, her child is exhibits changes in eating and sleeping patterns. Older adults, not toddlers, show resiliency over the loss of a family member. Toddlers do not understand the cause of the loss. The loss of a family member may disrupt the development of autonomy in young adults.
A nursing student is learning about cultural competence. Which statement by the nurse reflects ethnocentrism?
D. "I sincerely believe that the beliefs and practices of the culture I was born into are the best." Rationale: Ethnocentrism is the belief by an individual that that the beliefs and practices of his or her particular culture are best. An individual who learns to value the beliefs of others and realizes that practices of other cultures can be valuable in health care is not ethnocentric. Cultural influences vary with the individual; the belief that all members of an ethnic group act or think the same way is called ethnic stereotyping. The awareness of one's own cultural beliefs and practices and their relation to differing cultural beliefs is known as cultural competence.
A client being admitted for alcoholism reports having had alcoholic blackouts. The nurse knows that an alcoholic blackout is best described how?
D. Absence of memory in relation to drinking episodes Rationale: Although the exact cause is unclear, alcoholic blackouts appear to result from responses of central nervous system cells to the substance. The individual does not have any type of seizure during the blackout. Fainting is not associated with the blackout. The individual loses memory but not consciousness.
A terminally ill client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kubler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions?
D. Acceptance Rationale: Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication.
What should a nurse conclude that a client is doing when he makes up stories to fill in blank spaces of memory?
D. Confabulating Rationale: The individual is unaware of gaps in memory and therefore uses stories in an attempt to deny or cover up the gaps. Lying is a deliberate attempt to deceive rather than a face-saving device for loss of memory. Denying is a blocking out of conscious awareness rather than a cover-up for loss of memory. Rationalization is used to explain and justify the behavior rather than to cover up the loss of memory.
A client who suspects that she is 6 weeks pregnant appears mildly anxious as she is waiting for her first obstetric appointment. What symptom of mild anxiety does the nurse expect this client to experience?
D. Increased alertness Rationale: Increased alertness is an expected common behavior that occurs in new or different situations when a person is mildly anxious. Dizziness, breathlessness, and abdominal cramps are all common signs of moderate to severe anxiety.
A client whose depression is beginning to lift remains aloof from the other clients on the mental health unit. How can a nurse help the client participate in an activity?
D. Invite another client to take part in a joint activity with the nurse and the client Rationale: Bringing another client into a set situation is the most therapeutic, least threatening approach. At this point in time it is not therapeutic to allow the client to follow solitary pursuits; it will promote isolation. Explanations will not necessarily change behavior. Asking the health care provider to speak to the client about participating transfers the nurse's responsibility to the health care provider.
A health care provider prescribes oxazepam (Serax) for a client who is beginning to experience withdrawal symptoms while undergoing detoxification. What are the primary reasons that oxazepam is given during detoxification?
D. Reduces the anxiety-tremor state and prevents more serious withdrawal symptoms Rationale: Oxazepam (Serax) potentiates the actions of Γ-aminobutyric acid, especially in the limbic system and reticular formation and thus minimizes withdrawal symptoms. This drug helps reduce the risk for seizures but does not prevent injury or protect the client during a seizure. Enabling the client to sleep and eat better during periods of agitation is not the purpose of the drug. The ability of the client to accept treatment depends on the client's readiness to accept the reality of the problem.
The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's bestresponse?
D. This behavior is a common response over which the client has very little control. Rationale: If the client exhibits emotional instability, this usually is caused by lesions that affect the thalamic area in the part of the neural system most responsible for emotions. Attention-getting behavior requires cognitive thinking, and lability of mood is unrelated to this. The client may have remote memory, but there is no selective process that determines which events are remembered. There are no data to come to the conclusion that the client is experiencing feelings of guilt.