Psych EAQ Quiz: Psychobiological Disorders
A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam (Valium) 7.5 mg intramuscularly stat is prescribed. Valium is available as 5 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. ___ mL
1.5
A severely depressed male client responds to therapy and with the help of the staff begins to set some daily objectives. Which behavior most indicates improvement in this client? 1 Staying clear of people who make him anxious 2 Talking with at least one person on the unit daily 3 Sitting alone several hours a day to think about personal concerns 4 Demonstrating to the staff that he can do what they want him to do
2 Talking with at least one person on the unit daily Initiation of interactions demonstrates that the depressed person is attempting to change behavior patterns. Avoiding people is a reinforcement of the depressed lifestyle. Solitary activities are nonthreatening but do not deal with the problem of impaired relationships. Clients who attempt to modify behavior to please others make only superficial changes.
A nurse is making an assessment of a client's hallucinatory behavior. What is the most common type of hallucination? 1 Visual 2 Tactile 3 Auditory 4 Olfactory
Auditory Most hallucinating clients hear voices without external stimuli. Although hallucinating clients may see things without external stimuli, visual hallucinations are not as common as auditory hallucinations. Tactile hallucinations are not very common; nor are olfactory hallucinations.
A client is admitted for treatment of obsessive-compulsive disorder that is interfering with activities of daily living. Which medication should the nurse anticipate the health care provider will prescribe? 1 Benztropine (Cogentin) 2 Amantadine (Symmetrel) 3 Clomipramine (Anafranil)
Clomipramine (Anafranil Clomipramine (Anafranil) potentiates the effects of serotonin (antiobsessional effect) and norepinephrine in the central nervous system; it diminishes obsessive-compulsive behaviors. Benztropine (Cogentin) is an antiparkinsonian agent, not an antianxiety agent. Amantadine (Symmetrel) is an antiparkinsonian agent, not an antianxiety agent. Diphenhydramine (Benadryl) is an antihistamine, not an antianxiety agent.
The parents of an overweight adolescent girl tell the nurse that they are concerned that their daughter feels inferior to her sister, who is an attractive, successful college senior. They ask the nurse what they can do about this problem. The nurse should: 1 Suggest that they appear to be creating a problem where none exists. 2 Tell them to avoid talking about their older child's accomplishments. 3 Encourage the parents to give the adolescent recognition for her strong points. 4 Advise the parents to tell the adolescent to view her sister's success as a challenge.
Encourage the parents to give the adolescent recognition for her strong points Encouraging the parents to give the adolescent recognition for her strong points will help the parents foster improved self-esteem in the younger daughter. A problem does exist; their child is overeating. The parents cannot avoid talking about the sibling, but they should avoid any comparisons. The child already is viewing the sister's success as a challenge, and it has diminished her self-esteem.
According to Erikson, a young adult must accomplish the tasks associated with the stage known as: 1 Trust versus mistrust 2 Intimacy versus isolation 3 Industry versus inferiority 4 Generativity versus stagnation
Intimacy versus isolation Major tasks of young adulthood are centered on human closeness and sexual fulfillment; lack of love results in isolation. The trust-versus-mistrust stage is associated with infancy. The industry-versus-inferiority stage is associated with middle childhood. The generativity-versus-stagnation stage is associated with middle adulthood.
The parents of a young adult client visit regularly. After one visit the client becomes very agitated. What should the nurse do to relieve the client's distress? 1 Take the client to the coffee shop for a treat. 2 Distract the client by providing a unit activity. 3 Limit the client's future contact with the parents. 4 Explore the client's response to the parents' behavior.
Explore the client's response to the parents' behavior Helping the client understand the meaning of a family member's behavior and responses to it reduces the family member's emotional control over the client. Taking the client to the coffee shop for a treat ignores the necessity of clarifying the family member's behavior. Distraction is not a therapeutic way to deal with realistic feelings. Limiting the client's future contact with the parents is a temporary measure and does not reduce the emotional conflict with the family member.
A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child? Correct1 Play 2 Group 3 Family 4 Psychodrama
Play It will be most effective for the child to play out feelings; when feelings are allowed to surface, the child can then learn to face them by controlling, accepting, or abandoning them. Group, family, and psychodrama therapies are not child-specific and are generally better suited to adolescents, young adults, and adults.
On entering a depressed client's room one morning, the nurse finds the client still in bed. The client says, "I can't get dressed and go to breakfast." How should the nurse respond? Incorrect1 "You can't just lie in bed. You need to get up now and go to breakfast." 2 "I'll get you dressed. I understand that you have difficulty helping yourself." 3 "Promise me you'll get dressed for lunch. If you do I'll let you stay here in bed." Telling the client to take his time and offering to help recognizes the client's capability without adding stress or increasing dependency. Telling the client to get up does not address the client's needs and is punitive. Offering to get the client dressed will increase his dependency, which is not therapeutic. Asking the client to promise to get dressed for lunch if is allowed to stay in bed at breakfast is an attempt to manipulate compliance; the client cannot accept responsibility for the future.
"Take your time. It is not necessary to hurry, and I'll help you if you need me to." Telling the client to take his time and offering to help recognizes the client's capability without adding stress or increasing dependency. Telling the client to get up does not address the client's needs and is punitive. Offering to get the client dressed will increase his dependency, which is not therapeutic. Asking the client to promise to get dressed for lunch if is allowed to stay in bed at breakfast is an attempt to manipulate compliance; the client cannot accept responsibility for the future.
Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse? 1 A 25-year-old man who mimicking the use of a machine gun in front of the nurse's station 2 A 45-year-old man who is sitting quietly in the corner, watching the movements of other clients 3 A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients 4 A 33-year-old woman who wanders aimlessly around the unit, saying, "I just don't know what to do. I feel so lost."
A 50-year-old woman who is pacing back and forth across the dayroom and picking fights with other clients The pacing client is demonstrating increased agitation and poses an immediate threat to the safety of other clients. The behavior requires immediate nursing intervention to prevent injury to herself or others. Although the client mimicking the use of a gun use is probably hallucinating, he poses no immediate threat to the self or others. Although the quiet, watchful client may be suspicious, the data given do not indicate that he presents a danger to himself or to others. Although anxious, the client who expresses a feeling of being lost does not represent a threat to herself or others. Test-Taking Tip: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what would be other answers that would appear right but would in fact be incorrect.
An older client with the diagnosis of dementia, Alzheimer type, is admitted to a nursing home. The client is confused and forgetful, wanders, and has intermittent episodes of urinary incontinence. How should the nurse plan to meet this client's elimination needs? 1 By pointing out the behavior to the client 2 By obtaining incontinence pads for the client 3 By taking the client to the bathroom at regular intervals 4 By encouraging the client to call for help when there is an urge to urinate
By taking the client to the bathroom at regular intervals Taking the client to the bathroom at regular intervals removes responsibility from the client, who is having difficulty recognizing and remembering to follow through on basic needs; routinely emptying the bladder may reduce episodes of incontinence. Pointing out the behavior to the client may precipitate feelings of guilt; forgetfulness is not deliberate but instead is the result of a degenerative process. Incontinence pads may eventually be obtained for the client, but it is not the initial intervention. The client may not be aware of the need to void or have the ability to control this bodily function.
What should a nurse conclude that a client is doing when he makes up stories to fill in blank spaces of memory? 1 Lying Incorrect2 Denying 3 Rationalizing Correct4 Confabulating
Confabulating 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 and the client's spouse are presented with electroconvulsive therapy (ECT) as a treatment option instead of pharmacotherapy after the client experiences adverse effects of medication therapy. The nurse meets with them to discuss the procedure. What should the nurse's first action be? 1 Allowing the client and family members to voice feelings, myths, and fantasies about ECT 2 Clarifying misconceptions and emphasizing the therapeutic value of the procedure for the depressed individual 3 Providing them with a brochure about the treatment and scheduling another time to review and answer their questions 4 Completing a detailed medical and psychiatric history and then starting family and client teaching at their level of comprehension
Correct1 Allowing the client and family members to voice feelings, myths, and fantasies about ECT It is most important for the nurse to facilitate a discussion of feelings before teaching because misconceptions about the presumed effects on the brain, public fears, and lack of accurate information regarding ECT precipitate anxiety. Anxiety interferes with learning. Misconceptions can be clarified only after they are expressed; citing the value of the procedure will be ineffective before fears and feelings are elicited. Although written material should be provided, this is not the first action. Depending on their readiness to learn, another meeting may be necessary to continue teaching. Although teaching should be client/family centered, a structured interview just before teaching will not set the climate for learning to occur.
A client who experiences auditory hallucinations agrees to discuss alternative coping strategies with a nurse. For the next 3 days when the nurse attempts to focus on alternative strategies, the client gets up and leaves the interaction. What is the most therapeutic response by the nurse? 1 "Come back; you agreed that you would discuss other ways to cope." Correct2 "You seem very uncomfortable every time I bring up a new way to cope." 3 "Did you agree to talk about other ways to cope because you thought that was what I wanted?" 4 "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?"
Correct2 "You seem very uncomfortable every time I bring up a new way to cope." "You seem very uncomfortable every time I bring up a new way to cope" focuses on a feeling that the client may be experiencing and provides an opportunity to validate the nurse's statement. "Come back; you agreed that you would discuss other ways to cope" demands that the client stay in an uncomfortable situation without offering any support. "Did you agree to talk about other ways to cope because you thought that was what I wanted?" fails to recognize the part anxiety plays in changing behavior. "You walk out each time I start to discuss the hallucinations; does that mean you've changed your mind?" seems like an attack on the client; also, although it offers an explanation for the behavior, it fails to convey an understanding that changing behavior is anxiety-producing.
A nurse is caring for a terminally ill client who is angry with everything and everyone. The nurse, who has been encouraging the client to make decisions about daily activities, determines that some of the anger may have resolved when the client says: 1 "Leave me alone! I want to do it myself." 2 "You've got a busy morning ahead of you! I'm really a mess." 3 "I can do my face, hands, arms, and chest today, but I think you'd better do the rest." 4 "It's so hard to let someone do so much for me. I don't like it when others do things for me."
Correct3 "I can do my face, hands, arms, and chest today, but I think you'd better do the rest." Allowing the nurse to take care of some of the responsibility demonstrates the client's diminished anger and is a realistic assessment and acceptance of current capabilities and limitations. Anger is still apparent when the client tells the nurse to leave her alone. Telling the nurse that she is a mess shows the client's dependency; the client either has given up or is being sarcastic. Expressing dismay at having to let someone help shows dependency and suggests that the client is still angry.
A male long-distance jumper improves his distance by 3½ inches (7 cm) and earns the praise of his coach, but on another day, when he does not reach his mark, he forcefully kicks the door of his locker. What defense mechanism does his outburst demonstrate? 1 Anger 2 Projection 3 Displacement 4 Rationalization
Displacement Displacement is the discharging of pent-up feelings on a less threatening object, in this case the locker door. Anger is not a defense mechanism. Projection is attributing one's own unacceptable feelings, impulses, or thoughts to another. Rationalization is behavior that attempts to prove that one's feelings or behavior is justifiable.
After 2 days on the unit a female client with the diagnosis of schizophrenia refuses to take a shower. What is the most appropriate intervention by the nurse? 1 Having the staff give the client a shower 2 Simply stating that she must shower now 3 Gently point out that her appearance is upsetting the other clients 4 Gently asking the client whether she would wash her hands and face if given a basin of water
Gently asking the client whether she would wash her hands and face if given a basin of water The client needs to feel comfortable in the environment before establishing enough trust to undress for showering; the nurse's statement allows the client to make the decision. Stating that she must shower now or having the staff give the client a shower may add to the client's anxiety and feelings of loss of control; it may also worsen any delusional thoughts the client is having. Gently pointing out that her appearance is upsetting the other clients will not help the client's self-image, and it does not matter what other clients think.
A client who has been found to have bipolar disorder, manic episode, has been sleeping very little and had not eaten in the 2 weeks preceding hospitalization. The nurse concludes that in the overactive client, feeding problems frequently result from the client's: 1 Feeling of unworthiness 2 Inability to take the time to eat 3 Unconscious desire for punishment 4 Preoccupation with ritualistic behavior
Inability to take the time to eat During a manic episode the affected individual tries to keep active to prevent the feeling of depression from overtaking him or her; avoidance of feelings, not food, is the priority, and manic people do not take the time to eat. Feelings of grandeur have replaced unconscious feelings of unworthiness at this phase of the illness. The manic phase is not characterized by a desire for punishment. Manic clients are usually not aware of unconscious feelings. Clients in the manic phase do not control anxiety by the use of ritualistic behavior; ritualistic behavior is common in clients with an obsessive-compulsive disorder.
The nurse determines that the plan for bolstering an overweight adolescent's self-esteem has been effective when, 3 months later, the adolescent's mother reports that the adolescent: 1 Seems to be doing average work in school 2 Has asked her how to bake bread and cookies 3 Imitates a sibling's manner of speech and dress 4 Joined a dirt bike group that meets at the school
Joined a dirt bike group that meets at the school Joining a dirt bike group demonstrates a movement toward peer group activity and interests; exercise demonstrates an interest in an improved physical condition. There are no data to indicate that school is a problem. Average work in school and an interest in baking do not demonstrate an increase in self-esteem.
During an interview a 32-year-old man describes symptoms of decreased appetite, insomnia, anhedonia, and feelings of worthlessness that have been present for the past few weeks. He reports having had a few episodes of feeling depressed in the past but says that the feelings subsided. Recently he has felt worse, and he is now concerned that his symptoms are negatively affecting his job performance and fears he may lose his job "if someone doesn't help me soon." The nurse suspects these symptoms are related to: 1 Schizophrenia 2 Bipolar disorder 3 Dysthymic disorder
Major depressive disorder The client is describing symptoms of major depressive disorder. Symptoms include depression that has lasted at least 2 weeks, that has resulted in a change in previous function, and that can impair important areas of function such as work performance. The client does not describe feeling depressed for most of his life. For bipolar disorder to be considered, symptoms of mania would need to be included in the findings. There are no symptoms of paranoia or psychosis that would be present in schizophrenia. With dysthymic disorder, depressive symptoms are chronic and present for 2 years or longer. Because of its chronic nature, dysthymia is difficult to distinguish from the person's usual pattern of function. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.
A nurse is caring for a client with the diagnosis of bulimia nervosa. The nurse understands that individuals with bulimia use food to: 1 Gain attention. 2 Control others. 3 Avoid growing up. 4 Meet emotional needs.
Meet emotional needs. Clients with bulimia eat to blunt emotional pain because they frequently feel unloved, inadequate, or unworthy; purging is precipitated to relieve feelings of guilt for binging or out of fear of obesity. The binging and purging are usually done alone and in secret. Clients with bulimia often feel out of control and perform their behaviors in secret. A protest against growing up is one of the psychodynamic theories regarding anorexia nervosa, not to bulimia nervosa.
A man has completed an alcohol detoxification program and is setting goals for rehabilitation. When setting goals it is important for this client to understand the need to: 1 Plan to avoid people who drink. 2 Accept that he is a fragile person. 3 Develop new social drinking skills. 4 Restructure his life without alcohol.Restructure his life without alcohol. Clients must learn new lifestyles and coping skills to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option.
Restructure his life without alcohol. Clients must learn new lifestyles and coping skills to maintain sobriety. Planning to avoid people who drink is an unrealistic, unattainable plan. Accepting that he is a fragile person is judgmental, negative thinking that will lower self-esteem. Abstinence is essential; social drinking is not an option.
A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients? 1 Reviewing the past is depressing. 2 Stimulating new situations are ideal. 3 Dependency increases as age progresses. 4 Staying healthy promotes a quality retirement.
Staying healthy promotes a quality retirement Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved. Reviewing the past is an essential part of the life review that older adults must engage in to eventually reach integrity. The person may be in despair when reviewing the past as depressing. Most older adults prefer familiar routines and environments and desire independence even when coping with the effects of aging and chronic illness.
A client with mental health problems is given a prescription for fluphenazine (Prolixin). The nurse develops a teaching plan about the medication. What should the nurse caution the client to avoid? 1 Eating cheeses 2 Nighttime driving 3 Staying in the sun 4 Taking drugs containing aspirin
Staying in the sun Fluphenazine causes photosensitivity; severe sunburn may occur with exposure to the sun. There are no known side effects of fluphenazine (Prolixin) that affect the ability to drive at night. The client should avoid eating cheese if she is taking a monoamine oxidase inhibitor, not fluphenazine, which is a phenothiazine. Aspirin is not contraindicated for clients taking fluphenazine.
After a conference with the psychiatrist, a client with a borderline personality disorder cries bitterly, pounds the bed in frustration, and threatens suicide. What is the most helpful response by the nurse? 1 Leaving the client for a short period and waiting until the client regains control 2 Patting the client reassuringly on the back and saying, "I know that it's hard to bear." 3 Asking about the client's troubles and answering, "Other people also have problems." 4 Staying with the client and listening attentively if the client wishes to talk about the problem
Staying with the client and listening attentively if the client wishes to talk about the problem Sitting with the client indicates acceptance and demonstrates that the nurse feels that the client is worthy of the nurse's time. It is better to stay with the client quietly until control is regained; staying prevents a follow-through on the client's threat. Patting the client reassuringly on the back and saying, "I know that it's hard to bear" provides little comfort for the client. Asking about the client's troubles and answering, "Other people also have problems" may close off further communication.
After a conference with the psychiatrist, a client with a borderline personality disorder cries bitterly, pounds the bed in frustration, and threatens suicide. What is the most helpful response by the nurse? 1 Leaving the client for a short period and waiting until the client regains control 2 Patting the client reassuringly on the back and saying, "I know that it's hard to bear." 3 Asking about the client's troubles and answering, "Other people also have problems." 4 Staying with the client and listening attentively if the client wishes to talk about the problem
Staying with the client and listening attentively if the client wishes to talk about the problem Sitting with the client indicates acceptance and demonstrates that the nurse feels that the client is worthy of the nurse's time. It is better to stay with the client quietly until control is regained; staying prevents a follow-through on the client's threat. Patting the client reassuringly on the back and saying, "I know that it's hard to bear" provides little comfort for the client. Asking about the client's troubles and answering, "Other people also have problems" may close off further communication.
A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse's initial reply? 1 "No, I don't see any bugs." 2 "I'll get rid of them for you." 3 "I'll stay here until you're calmer." 4 "Those bugs are a part of your sickness.
Correct1 "No, I don't see any bugs." Telling the client that there are no bugs presents reality and answers the client's question. Offering to get rid of the bugs is entering into the misperception of reality. Offering to stay with the client and telling the client that the bugs are part of her sickness both provide comfort and may reduce anxiety but should each follow the priority intervention of pointing out reality.
When developing a plan of care for an older client with a diagnosis of dementia, a nurse should: 1 Explain to the client the details of the regimen 2 Demonstrate interest in the client's various likes and dislikes 3 Be firm when dealing with the client's attitudes and behaviors
Provide consistency in carrying out nursing activities for the client Familiarity with situations and continuity add to the client's sense of security and foster trust in the relationship. Detailed explanations will be forgotten; instructions should be simple and to the point and given when needed. Although demonstrating interest in the client's likes and dislikes helps individualize care, continuity is the priority. Some degree of flexibility by the nurse helps individualize care.
When lithium therapy is instituted, the nurse should teach the client to maintain an adequate daily intake of: 1 Iron 2 Sodium 3 Potassium 4 Magnesium
Sodium Decreased sodium intake can accelerate lithium retention, resulting in toxicity. Iron, potassium, and magnesium are unrelated to the administration of lithium.
A nurse is caring for a client whose behavior is characterized by pathological suspicion. What is the most therapeutic nursing action? 1 Providing distraction with reality-based activities Correct2 Trying to establish trust through consistency of care 3 Helping the client realize that the suspicions are unrealistic Incorrect4 Asking the client to explain the reasons for these suspicions
sking the client to explain the reasons for these suspicions Delusions are protective and can be abandoned only when the individual feels secure and adequate; as the client's sense of security increases, the client's anxiety will decrease. Providing distraction with reality-based activities is more helpful in regard to hallucinations than delusions. Before the client can realize that the suspicions are unrealistic can occur, trust must be developed and the client's anxiety eased. The client will be unable to explain the reason for the feelings.
A nurse notes that a client with dementia tries to cope with anxiety by using confabulation. The nurse plans to teach the family that when confabulating, the client: 1 May fantasize about past experiences 2 Has poor control of disorganized thoughts Correct3 Will make up what cannot be remembered
Correct3 Will make up what cannot be remembered
In what situation should a nurse anticipate that a client will experience a phobic reaction? 1 When seeking attention from others 2 When thinking about the feared object 3 When coming into contact with the feared object 4 When being exposed to an unfamiliar environment
When coming into contact with the feared object With phobias, the individual transfers anxiety to a safer inanimate object or situation. Therefore the anxiety and resulting feelings will be precipitated only when the client is in direct contact with the object or situation. Phobias are severe anxiety reactions, not attention-seeking actions. It is not thinking about the feared object that causes anxiety; it is the possibility of having to come into contact with it. It is the presence of the phobic object or situation that triggers the anxiety, not the unfamiliarity of the environment.
A client tells the nurse, "All my friends experiment with drugs. I like the high I get when I huff paint. Nothing bad is going to happen to me." What is the best response by the nurse? 1 "Inhalants can cause a mild state of intoxication." 2 "Huffing paint can damage your lungs, kidneys, and liver." 3 "Withdrawal problems will start if you continue huffing paint." 4 "Limiting the type of inhalant used decreases respiratory irritation.
"Huffing paint can damage your lungs, kidneys, and liver." Inhaled toxins become systemic and cause damage to major organs such as the lungs, liver, and kidneys. Inhalants tend to produce euphoria, not just a mild state of intoxication. Huffing paint will not produce major withdrawal symptoms. All toxic substances that are inhaled become systemic and cause damage to major organs such as the lungs, liver, and kidneys.
When planning interventions to help a client with bipolar I disorder, manic episode, meet rest and sleep needs, the nurse must remember that the manic client: 1 Experiences few sleep pattern disturbances 2 Requires less sleep than the average person 3 Is easily stimulated, and this interferes with sleep 4 Needs to expend energy to be tired enough to sleep
Is easily stimulated, and this interferes with sleep Manic individuals readily respond to environmental cues. Increased stimulation increases activity; decreased stimulation decreases activity. Sleep pattern disturbances characteristically occur because of psychomotor activity. All individuals require adequate rest and sleep; hyperactive clients may become exhausted because of their high activity level. Expending energy only increases the tendency to remain awake.
A client on the psychiatric unit who has suicidal ideas says to the nurse, "I signed myself in. I'll sign myself out." What concept provides the basis for the nurse's response? 1 Voluntary clients may sign out at any time. 2 Voluntary clients may sign out by following unit procedures. 3 Suicidal clients may sign out if they are able to contract for their safety. 4 Suicidal clients may not sign out even if they voluntarily admitted themselves.
Suicidal clients may not sign out even if they voluntarily admitted themselves. The priority is to keep the client safe; a client admitted on a voluntary basis may be kept involuntarily if professional judgment indicates that the client may harm himself or others. Clients who admit themselves voluntarily may leave if they are not suicidal or homicidal and if unit procedures are followed. The nurse has a duty to maintain the client's safety; a suicidal client may not leave under any circumstances
A nurse enters a client's room and notes that the client appears preoccupied. Turning to the nurse, the client says, "They're saying terrible things about me. Can't you hear them?" What is the most therapeutic response by the nurse? 1 "It seems you heard them before." 2 "Try to get control of your feelings." 3 "There's no one here but me, and I don't hear anything." 4 "I don't hear anyone else talking, but I can see that you're upset."
"I don't hear anyone else talking, but I can see that you're upset." "I don't hear anyone else talking, but I can see that you're upset" interjects reality and focuses on the client's behavior. "It seems you heard them before" elicits a yes-or-no answer and does not foster communication. "Try to get control of your feelings" is a directive response that will be perceived as threatening to a disturbed client experiencing hallucinations. Although this interjects reality, it is not the most therapeutic response because it does not address the client's feelings.
A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis? 1 Chronic confusion 2 Disordered thinking 3 Rigid personal boundaries 4 Violence directed toward others
Disordered thinking The schizophrenic individual has neurobiological changes that cause disorders in thought process and perceiving reality. Chronic confusion and disorientation are not usually associated with this disorder. Illogical thinking and impaired judgment are associated with schizophrenia. Individuals with the diagnosis of schizophrenia often have personal boundary difficulties. They lack a sense of where their bodies end in relation to where others begin. Loss of ego boundaries can result in depersonalization and derealization. Most clients with schizophrenic disorders are not violent.
A client has recently undergone what was personally considered "a third unsuccessful cosmetic surgery." The health care provider diagnoses body dysmorphic disorder. What is the primary nursing objective? 1 Controlling the client's manipulative behavior 2 Teaching the client about relaxation techniques 3 Exploring the issues that influence the client's self-perception 4 Developing a progressive desensitization program with the client
Exploring the issues that influence the client's self-perception The nurse should address the body image disturbance and engage in discussions that focus on body perceptions and provide the client with nonthreatening and realistic feedback. Clients with body dysmorphic disorder do not tend to be manipulative. Although information on relaxation techniques is useful for most clients, it is not the priority for this client, who must address negative self-perceptions. The use of a desensitization program is not an appropriate strategy for a client with body dysmorphic disorder
To further assess a client's suicidal potential, the nurse should be especially alert to the client's expression of: 1 Anger and resentment 2 Loneliness and anxiety 3 Frustration and fear of death 4 Helplessness and hopelessness
Helplessness and hopelessness The expression of these feelings may indicate that this client is unable to continue the struggle of life. Anger and resentment are not indications of potential suicide; the client is still responding to the world, not attempting to leave it. Loneliness and anxiety are usually not sufficient to precipitate a suicide attempt. The client attempting suicide usually sees death as a release.
A young client with schizophrenia says, "I'm starting to hear voices." What is the nurse's most therapeutic response? 1 "How do you feel about the voices, and what do they mean to you?" 2 "You're the only one hearing the voices. Are you sure you hear them?" 3 "The health team members will observe your behavior. We won't leave you alone." 4 "I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?"
I understand that you're hearing voices talking to you and that the voices are very real to you. What are the voices saying to you?" Acknowledging that client is hearing voices talking to him and that the voices are very real to him validates the presence of the client's hallucinations without agreeing with them, which communicates acceptance and can form a foundation for trust; it may help the client return to reality. The nurse also needs to assess the content of the voices to determine the risk of self injury or violence against others. The client's contact with reality is too tenuous to explore what they mean. Saying that the client is the only one hearing the voices and asking whether he is sure that he is hearing demeans the client, which blocks the development of a trusting relationship and future communication. Telling the client that the health team members will observe his behavior and that he won't be left alone is condescending and may impair future communication.
A nurse is caring for a client with the diagnosis of schizophrenia who is started on fluphenazine decanoate (Prolixin Decanoate). What is the primary advantage of this medication? 1 There are no side effects. 2 It has a long-lasting effect. 3 It is safe to use during pregnancy. 4 There is less need for laboratory monitoring
It has a long-lasting effect This medication may be taken every 2 weeks instead of every day. The side effects are the same as those of most other antipsychotic drugs. The action of this drug during pregnancy is uncertain; animal studies have demonstrated an adverse effect on the fetus. The side effects and the routine monitoring of the client's laboratory results are the same as for most other antipsychotic drugs.
A nurse is developing a care plan for a client with obsessive-compulsive behavior disorder. Which nursing intervention will most likely increase the client's anxiety? 1 Helping the client understand the nature of the anxiety Correct2 Limiting the client's ritualistic acts to three times a day 3 Involving the client in establishing the therapeutic plan 4 Providing the client with a nonjudgmental environment
Limiting the client's ritualistic acts to three times a day Limiting the client's ritualistic acts to three times a day sets an unrealistic limit that will increase anxiety by removing a defense that the client needs. Helping the client understand the nature of the anxiety is done in therapy as the client's condition improves. Insight is slowly developed to minimize anxiety. Involving the client in establishing the therapeutic plan will increase self-esteem and self-control, not increase anxiety. Providing the client with a nonjudgmental environment will reduce, not increase, anxiety, because the client will feel free to express feelings.
At a staff meeting, the question of a staff nurse's returning to work after completing a drug rehabilitation program is discussed. What is the most therapeutic way for the staff to handle the nurse's return? Correct1 Offering the nurse support in a straightforward manner 2 Avoiding mention of the problem unless the nurse brings it up 3 Having another staff member keep the nurse under close observation 4 Ensuring that the nurse is assigned to administer only noncontrolled medications
Offering the nurse support in a straightforward manner Offering the nurse support in a straightforward manner allows the individual to include the staff in her support system and removes an opportunity to deny the problem. Avoiding mentioning the problem unless the nurse brings it up supports and permits denial; both the individual and the staff know that a problem exists. Having another staff member keep the nurse under close observation is a nonprofessional approach that is nontherapeutic. Although refraining from handling controlled medications may be part of a return-to-work contract, it is not necessarily therapeutic; it simply reduces legal risks.
A client proclaims that he is "the second son of God." What type of delusion does the nurse identify? 1 Influence Correct2 Religious 3 Reference 4 Persecutory
Religious The delusion expressed by the client is an example of a religious delusion, a belief that one is favored by a higher being or is an instrument of that being. An influence delusion is a fixed false belief that one has the power to control the thoughts of another. A reference delusion is a fixed false belief that casual incidents and external events have direct personal references such as the television is sending special messages. A persecutory delusion is a fixed false belief that one is being mistreated by others. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason.
At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we both mean the same thing." This is an example of the technique of: 1 Reflecting feelings 2 Making observations 3 Seeking consensual validation 4 Attempting to place events in sequence
Seeking consensual validation Seeking consensual validation is a technique that prevents misunderstanding so the client and the nurse can work toward a common goal in the therapeutic relationship. Reflecting feelings, making observations, and trying to place events in sequence do not provide for clarification or understanding.
A client has just awakened from her first electroconvulsive therapy (ECT) treatment. What is the most appropriate initial intervention by the nurse? 1 Immediately getting the client out of bed and back into the unit's routine 2 Sitting the client up and arranging for the dietary staff to deliver a lunch tray 3 Orienting the client to time and place and explaining that the treatment is over 4 Taking the client's pulse and blood pressure every 15 minutes until the client is fully awake
Taking the client's pulse and blood pressure every 15 minutes until the client is fully awake Clients are confused when they awaken after ECT. They have loss of recent memory, so it is important to orient them to time, place, and situation. The client should be monitored until vital signs are stable and the client is alert, oriented, and able to walk without assistance; this generally takes 1 to 3 hours. Sitting the client up may be done later action if the client asks for food. Vital signs are monitored until stable; they may become stable before the client is fully awake.
A client has been receiving lithium for the past 2 weeks for the treatment of bipolar disorder, manic phase. What should the nurse include in the teaching plan for this client? 1 A diuretic is necessary for anyone taking lithium. 2 Lithium must be taken for the rest of the client's life. 3 The blood level of lithium must be checked every month. 4 A low-sodium diet must be followed while lithium is being taken.
The blood level of lithium must be checked every month. Lithium's therapeutic window is very narrow, and a toxic level may accumulate in the body unless routine checks of the drug's concentration in the blood are performed. During the acute phase of mania the therapeutic blood level of lithium should be between 1.0 and 1.5 mEq/L; the maintenance therapeutic blood level of lithium ranges from 0.5 and 1.2 mEq/L. Lithium may or may not need to be taken for the rest of a client's life. Diuretics reduce sodium and should be avoided; lithium is not excreted when the sodium level is decreased, resulting in toxicity. A low-sodium diet can lead to hyponatremia, which must be avoided because it limits the excretion of lithium, resulting in toxicity.
A client with agitation and mood swings approaches the nurse and shouts, "I've been watching you for a few days. You think you're so damned perfect and good. I think you stink!" What is the most appropriate response by the nurse? 1 "Do you mean that I smell?" 2 "You seem to be angry with me." 3 "Wow, you're in a really bad mood." 4 "I can't really be all that bad, can I?"
2 "You seem to be angry with me." Observing that the client seems angry reflects on the client's feelings rather than focusing on the verbalization. Asking whether he client is referring to an odor focuses on the statement rather than on the feelings behind it. Stating that the client is in a bad mood dismisses the client and the client's feelings. Denying being "all that bad" puts the client on the defensive and asks for verification that the nurse is indeed a good person; it fails to focus on the feelings behind the statement.
A client whose wife recently died appears extremely depressed. The client says, "What's the use in talking? I'd rather be dead. I can't go on without my wife." What is the best response by the nurse? 1 "Would you rather be dead?" 2 "What does death mean to you?" 3 "Are you thinking about killing yourself?" 4 "Do you understand why you feel that way?
3 "Are you thinking about killing yourself?" The response "Are you thinking about killing yourself?" is the most important assessment to make because suicide is a possibility with every depressed client. The client has already said that he would rather be dead, and the response addresses only part of the client's statement. The response "What does death mean to you?" is a philosophical approach that will not encourage discussion of feelings. The client is probably unable to explain why he feels the way he does.
What is the priority nursing objective of the therapeutic psychiatric environment for a confused client? 1 Helping the client relate to others 2 Making the hospital atmosphere more homelike 3 Helping the client become accepted in a controlled setting 4 Maintaining the highest level of safe, independent function
4 Maintaining the highest level of safe, independent function The therapeutic milieu is directed toward helping the client develop effective ways of functioning safely and independently. Helping the client relate to others is one small part of the overall objectives. The therapeutic milieu allows some items from home to make the client less anxious; however, the objective is not to duplicate a home situation. Helping the client become accepted in a controlled setting is a worthwhile objective but not as important as working toward the maximal degree of safe, independent function.
A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of binging. Which clinical manifestation is most important for the nurse to assess? 1 Weight gain 2 Dehydration 3 Hyperactivity 4 Hyperglycemia
Dehydration The nurse should be alert for dehydration caused by fluid loss through vomiting in the binge-purge cycle. Weight gain is not expected because purging frequently follows a binge. Hyperactivity is not expected because many individuals with bulimia withdraw and vomit after a binge. Hyperglycemia is not expected because of the vomiting that follows a binge.
For what most common characteristic of autism should a nurse assess a child in whom the disorder is suspected? 1 Responds to any stimulus 2 Responds to physical contact 3 Seems unresponsive to the environment 4 Interacts with children rather than adults
Seems unresponsive to the environment Poor interpersonal relationships, inappropriate behavior, and learning disabilities prevent autistic children from emotionally adapting or responding to the environment even when the intelligence level is high. It is the lack of response to stimuli that is the clue that the child may have autism. Children with autism have an aversion to physical contact; they also have impaired interpersonal relationships regardless of the age of the other person
A client has just been admitted to the psychiatric unit on involuntary admission status. During the admission assessment the client tells the nurse, "I am the second son of God and need to say a prayer." What is the best response by the nurse? 1 Interrupting the client and continuing the assessment 2 Joining the client in the prayer and then refocusing on the assessment 3 Quietly leaving the client and coming back later to complete the assessment Correct4 Waiting until the client finishes the prayer and then completing the assessment
Waiting until the client finishes the prayer and then completing the assessment During the initial assessment it is important for the nurse to learn as much as possible about a client and to establish baseline data; therefore both direct and indirect assessment data are important. Interrupting the client may interfere with the nurse-client relationship and increase the client's anxiety; also, it may interfere with obtaining valuable information about the client. Joining the client in the prayer and then refocusing on the assessment is not therapeutic and may reinforce the client's delusional thinking. Quietly leaving the client and returning later to complete the assessment is not therapeutic and will not meet standards of care; it may precipitate feelings of abandonment.