Psych Mental Health
The nurse implements de-escalation techniques with a client who is extremely angry and exhibiting increasingly agitated behavior. Which de-escalation techniques should the nurse employ? Select all that apply.
1. Avoid verbal struggles 2. Provide clear options to the client 3. Maintain the client's self-esteem and dignity 4. Establish what the client considers to be his or her need.
The nurse is providing home care instructions to the partner of a client who is confused and will be cared for at home. Which instructions should the nurse provide to help minimize the client's confusion? Select all that apply.
1. Maintain a predictable routine. 2. Use simple, clear communication 3. Limit the number of choices given to the client 4. Display a calendar and a clock in the client's room.
The nurse is preparing a plan of care for a client diagnosed with mania. Which interventions should be included in the plan of care? Select all that apply.
1. Use a firm and calm approach 2. Use short and concise explanations and statements 3. Remain neutral and avoid power struggles and value judgements 4. Firmly redirect energy into more appropriate and constructive channels
A client with a diagnosis of schizophrenia is experiencing visual hallucinations. The nurse plans care based on the determination that this symptom is related to an alteration in brain function in which lobe of the cerebrum? Refer to figure.
4. Occipital
A client comes into the emergency department in a severe state of anxiety. What is the priority nursing intervention at this time?
Remain with the client
A client, who is serving a life sentence without parole, has been transferred from maximum security to the infirmary and is being assessed by the prison nurse. In preparing a treatment plan for this client, what should the nurse give priority to?
Assessment for suicidal risk
A client hospitalized in the mental health unit is angry and punches the wall. The nurse recognizes that the client is using which defense mechanism?
Displacement
The nurse is caring for a client who is experiencing psychomotor agitation. Which activity is appropriate for the nurse to plan for the client?
Playing ping-pong
The nurse is bathing a client when the client begins to cry. Which action by the nurse is therapeutic at this time?
Stop the bath, cover the client and sit with the client
A client has undergone two electroconvulsive therapy (ECT) treatments during the past week and confides to the nurse, "I'm starting to feel a little better, but it's scary too, because I'm having trouble remembering things now." Which response by the nurse is therapeutic?
"It must be disturbing to not be able to remember things. ECT causes a temporary memory loss, which many people recover from within a few weeks."
A 34-year-old schizophrenic client says to the nurse, "Since I've been taking this medication, I've noticed some problems performing sexually. Is there any connection to the medication?" The nurse makes which therapeutic and accurate response to the client?
"One of the side effects of this medication is that it produces impotence. I'll report this to your health care provider. There are several other effective medications that your health care provider can select to help you."
A client who is prescribed chlorpromazine (Thorazine) asks the nurse, "Now that I'm feeling better, can I stop my medication?" Which statement is a therapeutic response by the nurse?
"You should not stop taking your medication because suddenly stopping can cause side effects and may allow your symptoms to return. Isn't it better to be on a medicine lifelong than to be ill as you were before the medication?"
Which would the nurse identify as a situational crisis? Select all that apply.
1. Divorce 2. Loss of a job 3. Death of a loved one
The community health nurse is conducting an awareness workshop on adolescent suicide. What should the nurse discuss as risk factors? Select all that apply.
1. Family violence 2. Use of alcohol or drugs 3. Family history of depression
A client on the psychiatric unit is displaying manipulative behavior. Which interventions are appropriate for the nurse to take when working with this client? Select all that apply.
1. Follow appropriate plan of care 2. Identify the manipulative behaviors exhibited by the client 3. Communicate to the client the behaviors that are expected 4. Describe clearly the consequences of not staying within identified limits
A pregnant client, suspected of being physically abused by her husband, is brought to the emergency department by a neighbor after being found bleeding from her head. In evaluating the crisis situation, which questions should the nurse specifically ask to assess the client's perception of the precipitating event? Select all that apply.
1. How does this situation affect your life? 2. Describe how you are feeling right now. 3. How do you see this event as affecting your future?
A client with a severe ulcer of the right foot is told that a right leg amputation may be necessary. Which signs or client behaviors indicative of anticipatory grief should the nurse monitor the client for? Select all that apply.
1. Stating a fear of the future and unknown 2. Engaging in period of weeping or raging 3. Expressing anger at the medical professionals 4. Expressing a feeling of unreality and disbelief 5. Expressing a desire to run away from the situation
The nurse assigned to care for a client with paranoid personality disorder notes that the care plan includes involving the student in noncompetitive tasks. The nurse plans care, knowing that which activity would be appropriate for this client at this time?
A crossword puzzle
A woman is admitted to the inpatient mental health unit. When asked her name, she responds, "I am the First Lady, the President of the United States' wife." The nurse concludes that this client is experiencing which condition?
A grandiose delusion
A client is unwilling to go out of the house for fear of "doing something crazy in public." Because of this, the client remains homebound except when accompanied by the spouse. The nurse analyzes these data and determines that the client's behaviors support which condition?
Agoraphobia
The nurse is assessing a client who was just admitted to the psychiatric unit. The client says, "You won't have to worry about me much longer." How should the nurse interpret this statement?
An intention of suicide
A client comes into the clinic stating, "I spend hours each evening reviewing the events of the day to see if I behaved appropriately or if I should have done something differently. I am amazed when I check my watch after one of these reviews and find that 2 to 3 hours have gone by. I tell myself to snap out of it, but I continue to do it. I also take 2 to 3 hours each morning to get dressed because I want my clothes to be 'just right.'" The nurse analyzes the client's statements and determines that the client's behavior supports which condition?
An obsessive-compulsive disorder
Which aspect(s) of the client should the nurse focus on when assessing a client for the vegetative signs of depression?
Appetite, weight, sleep patterns and psychomotor activity
A client is scheduled to have electroconvulsive therapy (ECT). Which client-focused risk has the greatest priority?
Aspiration
A client is brought to the emergency department by the police after having seriously lacerated both wrists. The initial action that the nurse should take is which step?
Assess and treat the wound sites
The community health nurse is working with residents involved in a recent flood. Many of the older residents were emotionally despondent and refused to leave their homes for days. In planning for the rescue and relocation of these older residents, what is the first thing the nurse needs to consider?
Attending to the nutritional status and basic needs of the older residents
What should the nurse instruct the staff to do when formulating the plan of care for a client with paranoia?
Avoid laughing or whispering in front of the client
The nurse admits a client to the hospital with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse asks questions and expects to elicit which data about bulimia?
Binge eats, then purges
To successfully and appropriately work with a client victimized by physical abuse, the nurse should first consider which action?
Carefully examine own personal attitudes toward the victim and abuser before working with the client.
The nurse employed in a long-term care facility is observing for signs of depression in an older client. Which signs/symptoms should the nurse monitor for?
Change in appetite and social withdrawal
A client with a known history of panic disorder comes to the emergency department and states to the nurse, "Please help me. I think I'm having a heart attack." What is the priority nursing action?
Check the client's vital signs
The nurse is caring for a client who has bipolar disorder and is in a manic state. The nurse determines that which menu choice would be best for this client?
Cheeseburger, banana and milk
The nurse assigned to care for a client with bulimia nervosa notes a problem of improper nutrition in the chart. The nurse determines that which would be appropriate to assess based on this problem?
Client's eating patterns, food preferences, and concerns about eating
A female client diagnosed with bipolar disorder is in an acute manic state. She has slept only 2 to 3 hours per night over the past 5 days. The health care provider has prescribed several endocrine studies to rule out a physiological basis for the sleeplessness. At this time, the nurse should continue to assess the client for which sign/symptom?
Decreased concentration and poor judgment
The nurse is working with a client who is abusing intravenous (IV) drugs. When teaching the client about health maintenance, what is the least appropriate action by the nurse?
Demand that the client stop drug use
The nurse is teaching a client with angina pectoris about home care measures and lifestyle changes. During the teaching session, the client continually changes the subject. Which behavior is being demonstrated by the client?
Denial
The community health nurse has been called in to assist with problem solving for a group of homeless people in a certain area of a city. In planning for the needs of this group, what immediate concern would the nurse attend to?
Ensuring the client's basic needs can be met
The nurse is planning the care of a client who is suicidal who has been newly admitted to the mental health unit. To provide a caring, therapeutic environment, which intervention should be included in the nursing care plan?
Establishing a therapeutic relationship by conveying unconditional positive regard
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
Establishing contracts with available crisis resources
A physical assessment is performed on a suicidal client upon admission to the inpatient unit. The nurse understands its importance because it provides information regarding which priority assessment data?
Evidence of physical self-harm
A client diagnosed with a somatoform disorder asks the nurse, "If I'm feeling better, why should I start exercising?" To provide effective health teaching, the nurse should make which response to the client?
Exercise helps release endorphins, which enhance your feeling of well-being
The nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which approach should the nurse use to help the family cope with this situation?
Explain equipment and procedures on an ongoing basis
The home care nurse suspects that a client's spouse is experiencing caregiver strain. Which action should the nurse take to assess for this condition?
Gathering data from the caregiver and the client
The nurse is employed in a long-term care facility. The nurse determines that an older client may be having suicidal thoughts if the client demonstrates which behaviors?
Gives away possessions of personal importance
The nurse is assessing a client with depression who is at risk for suicide. The nurse should be most concerned about the risk for suicide if the client made which statement?
God has called on me to come to him. He commands me to jump off the bridge tomorrow.
A client is admitted to the inpatient mental health unit. When asked her name, she responds, "I am Elizabeth, the Queen of England." What should the nurse recognize this client statement as indicating?
Grandiose delusion
While assessing a 14-year-old child, the nurse notes bruises and cigarette burns on the child's chest and rope burns on the buttocks. The child states, "I'm afraid to go home because my stepfather will be angry with me for telling on him!" The nurse should make which therapeutic response to the child?
I am sorry that this has happened to you, but you will be safe here until plans can be made.
The nurse teaches the client with a history of anxiety and command hallucinations to harm self or others appropriate management techniques. Which client statement indicates that the client understands these techniques?
I can call my counselor so that i can talk about my feelings and not hurt anyone.
The home health nurse cares for an obese adult client. In the client's medical record, the nurse reads, "The client has a sprained right ankle, has not exercised for more than 1 week, and has missed the last two physical therapy appointments." The client says, "I attend therapy for my ankle and I do my exercises three times a day." Which response should the nurse use with the client?
I see that you missed the last two physical therapy appointments
An agoraphobic client has been hospitalized in the mental health unit for 2 weeks. The client has become cooperative and communicative with peers. The client has also begun to make appropriate suggestions during group discussions. The nurse concludes that the client's behavior is representative of what type of behavior?
Improvement
The nurse is performing an assessment on a client with mania that is being admitted to the inpatient psychiatric unit. Which finding should the nurse expect to note?
Inability to concentrate
The nurse is caring for a client diagnosed with depression who is being treated with a tricyclic antidepressant. Which assessment data would indicate that the client is improving?
Increase in the interest and ability to participate in unit activities
A manic client is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention should the nurse include in her plan of care before seclusion?
Inform the client that she is being secluded to help her regain her self-control
The nurse is planning care for a hallucinating and delusional client who has been rescued from a suicide attempt. Which intervention should the nurse incorporate into the nursing care plan?
Initiate one-to-one suicide precautions immediately
The nurse teaches a client about monoamine oxidase inhibitor (MAOI) toxicity. The nurse determines that the client is aware of the symptoms of toxicity when the client reports which condition?
Insomnia
A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, which action should the nurse perform first?
Inspect the client for injuries resulting from the incident and initiate appropriate treatment
An 8-year-old boy is admitted to the hospital. He was sexually abused by an adult family member, and he is withdrawn and appears frightened. Which describes the best plan for the initial nursing encounter to convey concern and support?
Introduce self and tell the child that you would like to sit with him for a little while.
The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, "I don't think that this ECT will be helpful, especially since it makes people's memory worse." What form of communication should the nurse implement to address the family member's concern?
Involve the family member in a dialogue to ascertain how the family member arrived at this conclusion.
A client says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me she had other clients besides me! I'm very sick, but the nurses don't care!" Which statement from the nurse is therapeutic?
It's hard to be in bed and to have to ask for help. You feel that the nurses do not seem to care?
The spouse of a dying client says to the nurse, "I don't think I can come anymore and watch her die. It's chewing me up too much!" Which therapeutic response should the nurse make to the spouse?
It's hard to watch someone you love die. You've been here with your wife every day. Are you taking any time for yourself?
The nurse is conducting group therapy for sexual addicts, and, at the meeting, sexual behaviors are discussed that would offend many people in the general public. Which understanding does the nurse know is a guiding principle for effectively conducting this group?
Knowledge that being nonjudgmental does not mean you accept the values and beliefs of others
A teenager who has celiac disease arrives at the emergency department complaining of profuse, watery diarrhea after a pizza party the night before. The client states, "I don't want to be different from my friends." What client problem should the nurse focus on when responding to the client?
Low self-esteem
The charge nurse asks a new nurse in orientation about suicide and suicide intentions. The charge nurse determines that the new nurse understands the concepts associated with this topic if the new nurse makes which statement?
Many individuals who commit suicide have talked about their suicidal intentions to others.
A 67-year-old white male arrives at the emergency department complaining of increased anxiety and a sense of being "directionless" and "of no use to anyone." The client has recently retired from his job as a longshoreman. In planning for his care, the nurse knows that the client is experiencing which type of crisis?
Maturational crisis
During electroconvulsive therapy (ECT), the client receives oxygen by mask via positive pressure ventilation. The nurse determines that positive pressure ventilation is necessary for which reason?
Muscle relaxants are given to prevent injury during the seizure
The nurse is caring for a client who has been diagnosed with schizophrenia. The client is unable to speak, although there is no known pathological dysfunction. What type of dysfunctional communication is the client experiencing?
Mutism
A client is not able to leave home without checking several times to be sure that the iron is turned off. The client then rechecks the coffeepot several times to be sure that it is turned off. The client arrives late to many appointments and other functions because of this repetitive ritual and misses other engagements completely. The nurse interprets that the symptoms exhibited by this client are consistent with which disorder?
OCD
The nurse is caring for a young adult client diagnosed with sarcoidosis. The client is angry and tells the nurse that there is no point in learning disease management because there is no possibility of ever being cured. Based on the client's statement, the nurse determines that the client is experiencing which potential problem?
Powerlessness
The nurse in the emergency department is admitting a client with carbon monoxide poisoning as a result of a suicide attempt. Which service should be initiated first?
Psychiatric consult
A female client who is in a manic state emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. Which intervention should the nurse initiate first?
Quietly approach the client, escort her to her room and offer help to get dressed
A client is hospitalized following a motor vehicle crash that resulted in the death of a pedestrian. When the client demonstrates signs of being severely upset, which intervention should the nurse implement initially?
Reflect back to the client that he appears upset
A client with obsessive-compulsive disorder spends many hours during the day and night washing her hands. The nurse should initially allow the client to continue this behavior because it has what effect for the client?
Relieves the client's anxiety
The emergency department nurse is assigned to care for an older client who has been identified as a victim of physical abuse. In planning care for this client, what is the nurse's priority focus?
Removing the client from any immediate danger
An emergency department staff member calls the mental health unit and tells the nurse that a severely depressed client is being transported to the unit. The nurse in the mental health unit expects to note which finding on assessment of this client?
Reports of substantial weight loss, insomnia, and decreased crying spells
A student nurse is developing a plan of care for a paranoid client who is experiencing disturbed thoughts. The registered nurse reviews the interventions and determines that which choice of intervention by the student nurse indicates a need for further teaching?
Sit with client and hold the client's hand
The nurse is caring for a paranoid client who is unable to engage in diversional activity. Which activity should have priority for the client at this time?
Solving a crossword puzzle
The nurse is caring for a client with schizophrenia and documents that the client is experiencing poverty of speech. The nurse documents this finding based on which observation?
Speech is restricted in amount and ranges from brief to monosyllabic 1-word answers
The nurse observes an anxious client blocking the hallway, walking three steps forward and then two steps backward. Other clients are agitated and trying to get past the client. How should the nurse intervene?
Stand alongside the client and say, "You're very anxious today."
A client who is experiencing suicidal thoughts greets the nurse with the following statement, "It just doesn't seem worth it anymore. Why not just end it all?" Which response should the nurse make to further assess the client?
Tell me what you mean by that?
A mental health nurse reviews the activity schedule for the day and determines that the best activity for a manic client would be to participate in which activity?
Tether ball
Which psychosocial factor obtained during an assessment of an older client places the client at risk for abuse?
The client is completely dependent on family members for both food and medicine.
The nurse is caring for a client at risk for suicide. Which client behavior is most indicative that the client may be contemplating suicide?
The client shares that he is finally happy
The nurse is performing an assessment on a client with a diagnosis of depression. Which finding would be most significant?
The client states he is "getting his old personality back" and displays spontaneous and uplifted behavior after being described as depressed.
Which assessment data should indicate to the nurse that the client is experiencing a severe depressive episode?
The client states, "The last 3 weeks, I'm doing all the things i used to do but I'm not enjoying them."
An emergency department nurse is preparing to care for a client with rape-trauma syndrome. Which goal is appropriate for the client at this time?
The client will begin the healthy grieving process
The nurse is developing a plan of care for an older client with dementia. The nurse develops which realistic outcome for the client?
The client will function at the highest level of independence possible
The nurse has been working with a victim of rape in an outpatient setting for the past 4 weeks. The nurse should identify that which client objective is an unrealistic short-term goal?
The client will resolve feelings of fear and anxiety related to the rape trauma
The registered nurse is discussing the characteristics of anorexia nervosa with a nursing student. The registered nurse determines that the nursing student needs further teaching on this disorder if the student states that which is a characteristic of anorexia nervosa?
The client will usually keep her weight near normal
The nurse is caring for a client with schizophrenia and documents that the client has an inappropriate affect. Which statement best describes this type of behavioral response?
The client's emotional response to a situation is not congruent with the tone of the situation
The nurse completes an initial assessment of a client admitted to the psychiatric unit. The nurse analyzes the data and determines which finding to be a priority concern?
The client's report of suicidal thoughts
A depressed client is found with long shreds of torn sheets wrapped around the throat. It is determined that the client is not physically injured. What is the nurse's immediate concern?
The client's risk for further injury
The nurse is analyzing the assessment data obtained from a client with physical injuries and suspected family-related violence. In analyzing the data, what must the nurse consider first?
The client's vital signs
A suicidal client is being discharged home with family. Which statement by a family member might constitute criteria for delaying discharge?
The client's wife asks, "Does he know that i've already moved out and filed for a divorce?"
The nurse is assessing a family experiencing violence. Which factor should the nurse initially address in the assessment?
The coping style of each family member
A client with depression is considering treatment with cognitive therapy. The client says to the nurse, "How does this treatment work?" How should the nurse respond to the client?
The therapy examines how thoughts and feelings contribute to difficulties
The nurse in the emergency department is caring for a 28-year-old victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. In analyzing the client's psychological reaction to the assault, the nurse notes that the client is withdrawn; fearful; anxious; confused; and at times, physically immobile. These behaviors are interpreted by the nurse as supporting which conclusion?
These are normal reactions to a devastating event
A client has a diagnosis of dependent personality disorder. Which goal should the nurse plan for this client?
Uses the problem-solving process effectively
The nurse has conducted a stress management seminar for clients in an ambulatory care setting. Which statement by a client would indicate a need for further teaching?
Using confrontation with coworkers should solve my problems at work quickly
The nurse is caring for a depressed older adult client who asks, "What do you think I should do about my home? My son thinks I should sell it and move into something smaller now that I'm alone." Which response by the nurse is therapeutic?
What would you like to do? Do you feel you'd be happier in a smaller place? As your depression lifts, you'll be able to decide what is best for you.
A client with a dissecting abdominal aortic aneurysm (AAA) is being prepared for surgery. The client asks the nurse, "Will I be OK?" Based on the client's question, the nurse should make which response to the client?
Would you like to talk about the surgery?
Which activity should the nurse provide for the manic client who has a difficulty with social interaction due to hyperactive behavior?
Writing
The nurse is assigned to care for a hospitalized client with a diagnosis of depression. When the nurse enters the client's room, which would be the appropriate statement?
You are wearing a new dress this morning
The nurse is caring for a client diagnosed with depression who appears anxious and withdrawn. Which statement is appropriate for the nurse to make when initially initiating conversation?
You are wearing your new shoes
The partner of a client who has an esophageal tube tells the nurse, "I thought having this tube down her nose the first time would convince her to quit drinking." Which response to the statement should the nurse make?
You sound frustrated with dealing with her drinking problem.
The nurse is assigned to care for a client admitted to the mental health unit with a diagnosis of mania. Which activity should the nurse provide for the client initially?
Writing
A community health nurse visits a recently widowed retired military man. When the nurse visits, the ordinarily immaculate house is in chaos, the client is disheveled and has an alcohol type of odor on his breath. Which therapeutic statement should the nurse make to the client?
You seem to be having a very troubling time
A clinic nurse is performing an initial assessment on a client who states that she broke off a wedding engagement 1 month ago. The client complains of alterations in sleep patterns, appetite, concentration, and activity. Lethality assessment is low, and the client has no depressive history. When assessing the client for a first episode of depression, which question should the nurse ask?
Has anyone in your family ever been depressed or had mood swings?
The nurse prepares to implement suicide precautions for an acutely suicidal client. What nursing interventions are included with regard to these precautions? Select all that apply.
1. Maintain an arm's length distance with the client at all times 2. Ensure that meal trays contain no glass or metal silverware 3. Carefully watch the client swallow each dose of medication 4. Conduct one-on-one nursing observation and interaction 24 hours a day 5. Document client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol.
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse do? Select all that apply.
1. Use distracting techniques when appropriate 2. Be consistently visible and available to the clients 3. Provide reality orientation to the client's as needed 4. Anticipate the needs of the clients as much as possible
The nurse is developing a care plan for a client with a diagnosis of advanced-stage Alzheimer's disease. To address the client's needs with memory deficits, which actions should the nurse implement? Select all that apply.
1. Use pictures to label drawer contents 2. Adhere to client's normal routine 3. Keep a calendar and clock in view of the client
An older client who is a victim of elder abuse and his family have been attending counseling sessions for the past month. Which statement, if made by the abusive family member, would indicate that he or she has learned more positive coping skills?
I feel better equipped to care for my father now that i know where to turn if i need assistance.
The nurse is working with a client during crisis intervention. Which statement by the client indicates a successful outcome of crisis intervention?
I have learned new ways of dealing with things
On the second day of hospitalization, a client with depression comes to the dayroom dressed neatly in slacks and a blouse, with hair combed back in a ponytail. Which statement should the nurse make to the client?
I noticed that your are dressed and that your hair is combed.
The psychiatric nurse is speaking at a local family support group regarding the importance of medication compliance. The nurse determines that additional teaching is necessary to the group when a member makes which statement?
I should be sure that my family member takes all medications just once per day
The nurse is caring for a client who says, "I don't want to talk with you because you're only the nurse. I'll wait for my doctor." What should the nurse say in response to the client?
I understand. So should i call your health care provider?
A client states, "I have decided to stop blaming myself and to mobilize my depression like my doctor said. I intend to take my son's rifle and shoot my husband and his new girlfriend tonight while they're working late at the office." Which is the appropriate nursing response?
I will need to report your intentions to the law and to your husband
The client angrily tells the nurse that the health care provider (HCP) purposefully provided incorrect information. Which response to the client would hinder therapeutic communication?
I'm certain that the HCP would not lie to you.
The nurse employed in a mental health unit is caring for a client who has been placed in seclusion. The nurse is documenting care provided to the client and addresses which items in the client's record?
Vital signs, toiling, feeding and fluid intake, and checking the client based on protocol time frame, such as every 15 minutes
The nurse is caring for a client with multiple sclerosis who has also been diagnosed with depression. The nurse understands which about these concurrent diseases/disorders?
When depression is secondary to a medical condition, it may not be recognized.
The nurse is caring for a client with delirium who has become physically abusive. Which statement should the nurse make to the client?
You are not to hit me or anyone else. Tell me how you feel.
A client says to the nurse, "I don't do anything right. I'm such a loser." Which therapeutic statement should the nurse make to the client?
You don't do anything right?
The client tells the nurse, "I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What happens if something goes wrong after I go home?" Which statement by the nurse is therapeutic?
You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?
A community health nurse is working with disaster relief following a tornado. The nurse's goal with the overall community is to prevent as much injury and death as possible from this crisis. Which interventions would be classified as tertiary level of prevention? Select all that apply.
1. Organizing counseling 2. Providing support to families 3. Finding safe housing for survivors 4. Securing physical care when needed
A battered woman seen in the emergency department requires tertiary intervention because of repeated abuse. Which nursing interventions are appropriate? Select all that apply.
1. Report the abuse to the police 2. Provide medications to relieve pain and anxiety 3. Explore family and friends as support possibilities 4. Focus on the woman's strengths, endurance and abilities
The nurse is working with the psychiatrist in planning a family therapy session on the mental health unit. The nurse understands that the goals of family therapy include which items? Select all that apply.
1. To improve family communication skills 2. To resolve or reduce intra-family conflicts 3. To reduce dysfunctional behavior of individual family members 4. To mobilize family resources and encourage adaptive family problem solving behavior
The nurse is teaching a community group about violence in the family. Which statement by a group member would indicate a need for further teaching?
Abuse occurs more in low-income families
A 29-year-old client injured in a motorcycle crash at 2:00 a.m. has been hospitalized with a broken femur, pelvis, and multiple lacerations and "road burns." Twenty-four hours after admission, the client experiences a seizure. During the 8 hours just before the seizure activity, the client had been displaying increasing tachycardia, irritability, and tremors. What should the nurse interpret that this client is likely experiencing?
Alcohol withdrawal syndrome
The nurse working in the mental health unit is collecting data on a newly admitted client. Which is a primary source of data collection?
Client
The nurse is caring for a client diagnosed with dementia who has needs related to nutrition. Which appropriate goal should the nurse plan for with this client?
Client will feed self with cueing within 24 hours
The nurse is caring for a client with bulimia nervosa and notes in the client's record a lack of proper nutrition. Which behavior found in the client's record indicates an accurate assessment of this problem?
Client's eating patterns and food preferences and concerns about eating
The nurse is preparing to perform an assessment of a client suspected of having Alzheimer's disease. The nurse enters the client's room and asks the client, "How was your weekend?" The client responds by saying, "It was great. I discussed politics with the President, and he took me out to dinner." The nurse interprets that the client has exhibited which defensive maneuvers?
Confabulation
A client who has recently been stabilized on lithium carbonate (Lithobid) says to the nurse, "This medicine upsets my stomach. I need to stop taking it." What is the most therapeutic response by the nurse?
Discontinuing your medicine will result in a return of your symptoms. Have you been taking it with meals to minimize an upset stomach?
The nurse is collecting data from a client who has recently started taking an antipsychotic medication. The nurse should ask the client about which common side effect of antipsychotics?
Dry mouth
A client has begun therapy with fluoxetine (Prozac). Which assessment finding supports the belief that the client is having the intended effects from this medication?
Elevation of mood
The nurse who suspects that another nursing staff member is abusing opioids should encourage the individual to use which resource initially to obtain help for this problem?
Employee assistance program
A client who was a victim of a gunshot incident states, "I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground." Which strategy should the nurse include when initially formulating a therapeutic relationship?
Encouraging the client to talk about the incident and feelings related to it.
A female client arrives at the emergency department and states she was just raped. In preparing a plan of care, which is the priority intervention?
Exploring safety concerns by obtaining permission to notify significant others who can provide shelter
A client has been admitted to the mental health unit with a diagnosis of social phobia disorder. Which behavior should the nurse expect the client to exhibit?
Fear of embarrassing himself in front of others
A client with a diagnosis of social phobia disorder is seen in the clinic for a therapy session. The nurse plans therapy for the client, knowing that this type of phobia is characteristic of which behavior?
Fear of speaking in public
A client with a severe major depressive episode is unable to address activities of daily living (ADL). Which is the appropriate nursing intervention?
Feed, bathe, and dress the client as needed until the client's condition improves so that he/she can perform these activities independently.
A client with nephrotic syndrome states to the nurse, "Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do, if I can never get rid of this kidney problem anyway!" Which potential client problem should the nurse address based on the client's statement?
Feeling powerless
A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention should health promotion focus on?
Helping the client identify and examine dysfunctional thoughts and beliefs
The nurse is reviewing the record of a client who was admitted to the hospital for diagnostic studies after a fainting spell. The nurse notes that the client is receiving olanzapine (Zyprexa). Which disorder or condition should the nurse suspect in the client?
History of schizophrenia
A client with a history of personality disorder has an appointment for counseling at the mental health clinic. On entering through the clinic door, the client begins to describe loudly about what the wind has done to her hair and asks the receptionist if she likes her new lipstick. The nurse interprets that the client likely has which type of personality disorder?
Histrionic
A client diagnosed with cancer of the bladder seems hesitant and uncertain about the outcome of upcoming cystectomy and urinary diversion surgery. Which statement made by the client should the nurse address first?
I'm so afraid i won't live through all this
A community health nurse working in an industrial setting has received a memo indicating that a large number of employees will be laid off during the next 2 weeks. An analysis of previous layoffs suggested that workers experienced role crises, indecision, and depression. Using this information, how should the nurse begin to assist employees?
Identify referral, counseling, and vocational rehabilitative services for the employees being laid off
The nurse working with a chronically mentally ill client can be successful in dealing with a client crisis by implementing which action?
Identifying strengths and the healthy aspects of functioning that may compensate for the weakness
The nurse is caring for a female client who was recently admitted to the hospital with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which nursing action would be therapeutic?
Interrupt the client and offer to take the client for a walk
The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement should the nurse use in response?
Let's discuss how we can solve this problem
An inebriated client waiting to be treated in the emergency department becomes loud and offensive when told there will be a short delay before treatment. The nurse analyzes the situation and provides which intervention?
Offers to take the client to an examination room until he can be treated
A client who is experiencing paranoid thinking involving his food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears?
Open-ended questions and silence
A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?
Orient the client and monitor his or her vital signs
A newly admitted client to the mental health unit experiences several flashbacks each day. The nurse notes that these flashbacks are consistent with which diagnosis?
PTSD
The nurse is assessing a client who is diagnosed with agoraphobia. Which information should the nurse expect to obtain during the assessment?
Palpitations, fear of losing control or dying when driving in a car and traveling over bridges
An older client is brought to the emergency department by a family member with whom she lives. The nurse notes that the client has poor hygiene, contractures, and pressure ulcers on the sacrum, the scapula, and the heels. The client is suspected of which form of victimization?
Physical abuse
A hospitalized client who is demonstrating manic behaviors is not eating enough to maintain proper nutrition. The client gets distracted during meals and has difficulty sitting still to eat all the food on the meal tray. Which approach by the nurse would be effective in improving the client's dietary intake?
Provide a quiet environment during mealtimes
A psychotic client on an acute care psychiatric unit is pacing, agitated, and presenting with aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Which priority nursing intervention should the nurse implement based on these objective data?
Provide safety for the client and other clients on the unit
The nurse is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the health care provider to prescribe?
Psychodrama
The nurse is caring for a client with depression. Which therapeutic intervention should the nurse employ to promote sleep for the client?
Quiet music and relaxation techniques
A client hospitalized with a diagnosis of severe depression is withdrawn and exhibits poor motivation and concentration. The nurse should plan to involve the client in which activity at this time?
Simple one or two person card games
The nurse is assigned to care for a client diagnosed with catatonic stupor. On entering the client's room, the nurse finds the client lying on the bed with the body pulled into a fetal position. What is the appropriate nursing action?
Sit beside the client in silence
A client diagnosed with catatonic posturing demonstrates severe withdrawal by lying on the bed with his body pulled into a fetal position. Which intervention should the nurse take to increase interpersonal communication?
Sit beside the client in silence and occasionally ask open-ended questions
An 85-year-old client is 2 days postoperative following repair of a fractured hip, and the nurse notes that the client has become extremely agitated. Which nursing action is appropriate when approaching the client?
Speak and move slowly toward the client
An English-speaking Hispanic man with a newly applied long leg cast has a right proximal fractured tibia. During rounds at night, the nurse finds the client restless, withdrawn, and quiet. Which nursing statement would be appropriate?
Tell me what you are feeling
The nurse is caring for a client who has a long history of antisocial and acting-out behavior. The client's behavior has included drug abuse, numerous suicidal self-mutilation attempts, and prostitution. The client says to the nurse, "I'm ready to go straight now." Which response by the nurse would be therapeutic?
Tell me what you believe will be different this time
A home care nurse is caring for an older client who lives with a son and daughter-in-law. The client is unusually confused, somewhat fearful, and has gaps of missing information about daily activities, and the caregivers seem indifferent to the client. On assessment, the nurse notes a bruise on the client's forearm. How should the nurse appropriately interpret these signs/symptoms?
The client might be a victim of elder abuse
A client says to the nurse, "What good does it do to be assertive, when people only say no anyway?" Which response by the nurse is therapeutic?
The purpose of being assertive is to express one's feelings openly without causing hurt or anger
A clinic nurse is assessing a client who will be taking tranylcypromine (Parnate) and notes that the client has been taking sertraline (Zoloft) for the past several weeks. After consulting with the health care provider who prescribed the tranylcypromine, the nurse ensures that which action has taken place?
The sertraline is discontinued for 2 weeks before starting tranylcypromine.
A female client who has been raped arrives at the emergency department. Which client statement should be most important for the nurse to consider when planning the immediate care for the client?
The victim states the rapist knows where she lives and said he will kill her if she tells anyone about the rape.
A client diagnosed as having catatonic excitement has been pacing rapidly nonstop for several hours and is not eating or drinking. The nurse recognizes that, in this situation, which needs to be taken into consideration?
There is an urgent need for physical and medical control
A client with a history of depression will be participating in cognitive therapy for health maintenance. The client asks the nurse, "How does this treatment work?" Which statement is most appropriate for the nurse to make to the client?
This treatment helps examine how your thoughts and feelings contribute to your difficulties.
The nurse is caring for a 12-year-old client who has been physically and sexually abused by her father. The father angrily approaches the nurse and says, "I'm taking my daughter home. She's told me what you people are up to, and we're out of here!" Which therapeutic response should the nurse make?
You seem very upset. Let's talk at the nurse's station. I know you're very concerned and that you want to help your daughter. It will be best if you agree to let your daughter stay here for now.
An older client is admitted to the hospital after falling from a chair at home. During the night the nurse wakes the client to perform a neurological assessment. The client states, "I'm so scared. Where am I? What's happening?" Based on the client's statement, the nurse makes which response?
You're in the hospital after a fall. Do you feel frightened?
A client is hospitalized during an acute period of mania. The client is restless and pacing in the hallway, and slaps another client who is walking down the hall en route to a group meeting. Which statement to the client would be least appropriate?
You're lucky that client you slapped didn't hit you right back!
A client with a diagnosis of depression says to the nurse, "I should have died. I've always been a failure." Which therapeutic response should the nurse make to the client?
You've been feeling like a failure for some time now?
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further assessment?
I exercise 3 to 4 hours every day to keep my slim figure
The nurse is caring for a client diagnosed with delirium who states, "Look at the spiders on the wall." How should the nurse respond?
I know that you are frightened, but i do not see any spiders on the wall.
When planning the discharge of a client with chronic anxiety, the nurse develops goals to promote a safe environment at home. Which area should the appropriate maintenance goal for the client focus on?
Identifying anxiety-producing situations
An adolescent is preparing to return home after psychiatric hospitalization for a suicide attempt. Which would be the least effective for preparing the client to return home?
Ask that the mother's boyfriend move out of the home
A client is admitted to the psychiatric unit after a suicide attempt by hanging. The nurse should plan which intervention as the most important aspect of care to maintain client safety?
Assign a staff member who will remain with the client at all times
The nurse cares for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because she is in a professional job where she works with the public. With this assessment data, what client problem would be the priority?
Body image insecurity
A client tells the nurse, "I am a spy for the FBI. I am an eye, an eye in the sky." Which abnormal thought process is the client exhibiting?
Clang associations
The nurse is caring for a depressed, withdrawn client who was responsible for an automobile accident that recently resulted in the death of a child. What is the nurse's initial action?
Communicate in a manner that acknowledges and respects the client's depressed state
A client who recently had a gastrostomy feeding tube inserted refuses to participate in the plan of care, will not make eye contact, and does not speak to family or visitors. Which type of coping mechanism should the nurse assess that the client is using?
Distancing
The nurse is assessing a client's suicide potential. Which most important question should the nurse ask the client?
Do you have a plan to commit suicide?
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
Do you have any thoughts of killing yourself?
The nurse is planning care for a suicidal client. At which time should the nurse implement additional precautions?
During the unit shift change
The nurse is caring for a child who is a victim of abuse and has determined that the child uses repression to cope with past life experiences. Which activity should the nurse implement as part of the nursing care plan?
Encourage the child to use therapeutic play to act out past experiences.
The nurse is developing a plan of care for a client scheduled for an above-the-knee leg amputation. Which action should the nurse include in the plan of care when addressing the psychosocial needs of the client?
Encourage the client to express feelings about body changes
The nurse observes a client wringing her hands and looking frightened. The client reports to the nurse that she "feels out of control." Which approach by the nurse is most appropriate to maintain a safe environment?
Encourage the client to talk about her feelings in a quiet setting.
A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "Call the doctor. I'm finally cured." Which modification to the treatment plan should occur based on the behavioral cues of the client?
Increasing the level of suicide precautions
The nurse is leading a crisis intervention group comprised of high school students who have experienced the recent death of a classmate who committed suicide. The students are experiencing disbelief as they review the details of finding the classmate dead in a bathroom. Which should be the initial step by the nurse?
Inquire about the students' perception of their classmate's suicide
A client who is quadriplegic frequently makes lewd sexual suggestions and uses profanity. The nurse interprets that the client is inappropriately using displacement. Which problem should the nurse identify as being appropriate for this client?
Lack of coping skills
An older adult client at the retirement center spits her food out and throws it on the floor. She yells, "This turkey is dry and cold! I can't stand the food here!" How should the nurse respond to the client?
Let me get you another serving that is more to your liking. Would you like to see the chef and select your own serving?
A client and her infant have undergone testing for human immunodeficiency virus (HIV), and both clients were found to be positive. The mother is crying. The nurse determines that which intervention will meet the client's initial needs at this time?
Listening quietly while the mother talks and cries
The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is complaining of insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse recognizes these complaints to be indications of which disorder?
Post traumatic stress disorder
A client reports having difficulty concentrating and outbursts of anger, as well as feeling "keyed up" all the time. The nurse obtaining the client's history discovers that the symptoms started about 6 months ago. The client reveals that, around that same time, a best friend was killed in a drive-by shooting while they were talking together. The nurse should suspect which stressor before communicating with the client?
Post traumatic stress disorder (PTSD)
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit and is planning an on-unit supper. The nurse should encourage which activity to decrease stimulation with the clients?
Postpone organizing the dance and supper and engage the client in a writing activity
The nurse is caring for an 11-year-old child who has been abused. Which therapeutic action should the nurse include in the plan of care?
Provide a care environment that allows for the development of trust.
The nurse is planning activities for a depressed client who was just admitted to the hospital. Which activity should be part of the nurse's plan?
Provide a structured daily program of activities and encourage the client to participate
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." Which therapeutic response should the nurse make to the client?
You're feeling angry that your family continues to hope for you to be cured?
An older adult client has been identified as a victim of physical abuse. Which is the priority nursing intervention?
Removing the client from any situation that presents immediate danger
A client who has urticaria (hives) and pruritus is anxious and says to the nurse, "What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy." Which statement made by the nurse is the most therapeutic?
You're troubled that this will extend into your wedding?
The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse-client relationship. Which intervention is representative of this phase of the relationship?
The nurse and client determine the contract for time
A client diagnosed with type 2 diabetes mellitus was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). Upon discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. How should the nurse respond to promote communication with the client?
You have concerns about the treatment of your condition?
A hospitalized client has participated in substance abuse therapy group sessions. The nurse is monitoring the client's response to these sessions. Which statement by the client would best indicate that the client has assimilated session topics, understood coping response styles, and processed information effectively for self-use?
I'm looking forward to leaving here, but 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 all have been. I know it isn't going to be easy, but I'm going to try as hard as I can.
The nurse manager is discussing seclusion procedures with the nursing staff for clients with a mental health disorder. Under which circumstances is seclusion contraindicated? Select all that apply.
1. The client has severe dementia 2. The client expressed a severe drug overdose. 3. The client has an unstable mental health disorder and nursing staff needs to attend a monthly staff meeting.
While inebriated, a client received a severe full-thickness burn to his left leg. Following an unsuccessful response to treatment, an amputation is required. After signing of the informed consent form, the nurse observes that the client appears withdrawn. Which action should the nurse take at this time?
Communicate with the client in a manner that reflects back to the client that he appears to be upset
The mother of a teenage client with an anxiety disorder is concerned about her daughter's progress after discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." To assist the mother with preparing for her daughter's discharge, the nurse advises the mother to implement which action in order to promote optimal health?
Limit the amount of chocolate and caffeine products that are available in the home
A client who initially denied abusing alcohol is being discharged from the mental health unit. The client now states that he will "get some help" to live a healthier lifestyle. For which support group should the nurse provide the client with information?
Alcoholics Anonymous
A client who is diagnosed with diabetes mellitus and requires the immediate amputation of a leg is very upset and states, "This is the doctor's fault! I did everything that I was told to do!" How should the nurse respond to the client's statement?
Allow the client to use anger as a coping mechanism
A 26-year-old client is being successfully treated for a first episode of depression. The client says to the nurse, "My mother and grandmother were always getting depressed, so I guess I inherited it. Will I be like them and get sick again?" The nurse makes which therapeutic response to the client?
Although some people with depression experience only one episode in their lifetime or may not become depressed for 2 years or more, there is a chance of experiencing a second episode within 6 months. Knowing when you're becoming depressed and obtaining immediate treatment are important. It seems as if you have some concerns about your illness."
A client says to the nurse, "On the track, have a Big Mac, or get in the sack." How should the nurse interpret this language pattern?
Clang associations
The nurse assigned to care for a client with anorexia nervosa notes that the client has a distorted body image. The nurse determines that which would be an appropriate goal for this client?
Client verbalizes body size accurately and states a beginning acceptance of a more mature-appearing body.
The nurse is counseling a female client with an alcohol disorder and her husband. The husband tells the nurse that he worries about his wife "all the time" and has helped "cover up" her drinking. The nurse plans to refer the husband to which support group?
Codependents
A forensic psychiatric nurse is conducting a group session for clients who are female offenders. Which should the nurse include in the group session with these clients?
Coping skills and stress management
The nurse has taught a client who has been placed on disulfiram (Antabuse) about the medication's use and effects. The nurse determines that the client understands the information presented when the client makes which statement?
I must check the labels carefully on over-the-counter medications
The nurse determines that the partner of an alcoholic client is benefiting from attending an Al-Anon group. This conclusion is supported when the nurse hears the partner make which statement?
I no longer feel that i deserve the beatings my partner inflicts on me
A client admitted to a psychiatric unit for manic behavior is observed running around, banging on doors, and yelling, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse interprets these behaviors as use of which coping mechanism?
Denial
A client who has just been raped is very quiet and calm. The nurse should assess this behavior as indicative of which defense mechanism?
Denial
Which clinical manifestation should the nurse expect to note when caring for a schizophrenic client who has a disintegrated sense of self?
Depersonalization
The nurse is using an abnormal involuntary movement scale (AIMS) on a client. What is the purpose of this scale?
Detecting tardive dyskinesia
A female client diagnosed with anorexia nervosa is a member of a predischarge support group. The client verbalized that she would like to buy some new clothes but that her finances were limited. Subsequently group members brought some used clothes to the client to replace her old clothes. The client believed that the new clothes were much too tight and reduced her calorie intake to 800 calories daily. The nurse analyzes this behavior as an example of what?
Evidence of the client's distorted body image
A client with a psychotic disorder is being treated with haloperidol (Haldol). Which sign/symptom should the nurse monitor the client for that indicates an adverse effect of this medication?
Excessive drooling
The nurse is preparing a client for electroconvulsive therapy (ECT). The client is pacing and states to the nurse, "How do I know this will work? I really don't understand how it can help me now. It may kill me." The nurse should take which initial action?
Explain the meaning of the client's comment in a calm, supportive manner.
The nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a major depressive disorder. Which assessment finding should the nurse identify as an unexpected side effect of ECT that requires notifying the health care provider?
Hypertension
The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary?
I am in control of myself now
A female client who was attacked outside a shopping mall is experiencing posttraumatic stress disorder. The client is visibly anxious about shopping in general and specifically avoids crowds and parking lots. The client expresses concern about these events and tells the nurse how upset she is about feeling this way. Which response should the nurse make to the client?
I can see that you are upset about this. Can we talk some more about it?
A client diagnosed with obsessive-compulsive disorder is upset and agitated, walking repeatedly around the nursing unit, following the same route each time late into the night. The client asks the nurse working the evening shift to walk with him. Which response by the nurse would be appropriate?
I can see that you're upset. I will walk with you and talk for a while.
Family members of a client who attempted suicide are tearful. Which statement by the nurse would be therapeutic?
I certainly can see that you are terribly worried about your loved one.
A nursing student says to the psychiatric nurse, "Now that the client is responding to the antidepressant, the suicidal risk is over." After analyzing this statement, how should the psychiatric nurse respond?
I disagree. Suicides occur within about 3 months after improvement begins because the client now has the energy to carry out the suicidal intentions.
A 16-year-old client has been diagnosed with anorexia nervosa. Which statement by the client should indicate to the nurse the need for follow-up?
I exercise 2 to 3 hours every day to keep my figure
Methylphenidate hydrochloride (Ritalin) is prescribed for a 10-year-old child diagnosed with attention deficit hyperactivity disorder. When the nurse provides instructions to the mother about administration of the medication, it is determined that the mother understands the instructions when the mother makes which statement?
I will give my child the medication at breakfast and lunch to prevent insomnia
The nurse is caring for a client who is taking lithium carbonate (Lithobid). The client states, "My doctor told me not to reduce my sodium intake or water intake." Which response should the nurse make to the client?
If the lithium increases its level in your body, it causes side effects. That's why you need to drink 2 to 3 L of water daily and eat a diet adequate in sodium."
The nurse employed in a prison is caring for a client who is recuperating in the prison infirmary. The client says, "You have beautiful eyes and you smell nice, nurse." Which nursing response or action would be therapeutic?
Im not here to discuss my eyes or how i smell
A client who has a spinal cord injury and is paralyzed from the neck down frequently makes lewd sexual suggestions and uses profanity. The nurse realizes that the client is inappropriately using the defense mechanism of displacement and identifies which problem for the client?
Inability to cope with situation
A client experiencing delusions is taken to the laboratory for routine blood work and while in the laboratory begins shouting, "You're all vampires. Get me out of here." Based on the client's behavior, the nurse should make which therapeutic response to the client?
It must be scary to think others want to hurt you
A home care nurse is caring for an older client. The client is a widower and competent, but his son, daughter-in-law, and their three children have unexpectedly moved into the house "to care for him." Which statement by the client should indicate to the nurse that the client is being exploited?
My son wants me to turn over the deed to the house to him. He says i'll always have a place there, but ill feel like a tenant in my own home. What do you think?
A client diagnosed with obsessive-compulsive rituals often misses the unit's morning activities because of a bed-making ritual. What nursing action would be therapeutic?
Offer reflective feedback such as, I see that you have made your bed several times.
The nurse is assigned to care for a client with anorexia nervosa. The nurse reviews the client's health record and notes documentation of difficulty maintaining appropriate nutritional guidelines. Based on this documentation, the nurse should specifically collect data regarding which factor?
Previous and current coping skills
A client is hospitalized with a diagnosis of posttraumatic stress disorder. The nurse notes that the client lies in bed, communicates only when approached by the nurse, and states to the nurse, "I'm very sick now. I can't do anything for myself. I can't feed myself. I can't eat." The nurse interprets the client's behavior as which coping/defense mechanism?
Regression
A mother comes to the pediatric clinic because her previously continent 6-year-old son has resumed bedwetting. The nurse assesses the home environment and discovers there is a new baby at home. Which explanation by the nurse describes for the mother the defense mechanism the son is using?
Regression
A client wanders in and out of other clients' rooms, taking their possessions while singing to herself and then giggling for no apparent reason. The nurse reacts therapeutically by taking which action?
Saying, "I can see you are very anxious today. Lets go and play the piano."
The client is being prepared for electroconvulsive therapy (ECT). Which intervention should be included in the nurse's plan of care for the night before the ECT treatment?
Shampooing and drying her hair to eliminate all hair spray and creams
A client with paranoia tells the nurse that she will not attend the group therapy session because a student nurse has been sent to spy on her. Which response should the nurse make to the client?
Student nurses attend group therapy as part of their education
The nurse is caring for the client with silicosis who has massive pulmonary fibrosis. The nurse monitors the client for emotional reactions related to the chronic respiratory disease. Which emotional reaction, if expressed by the client, indicates a need for immediate intervention?
Suicidal ideation
A client is being admitted to the inpatient mental health unit with a diagnosis of cluster A personality disorder. The nurse assesses this client for which behavior characteristic(s)?
Suspicious and eccentric
The nurse is performing an assessment on a client with a diagnosis of anorexia nervosa to the nursing unit. The nurse reviews the client's medical record before performing the assessment and expects to note which finding in the record?
The client is knowledgable about the caloric value of food
A family is experiencing the impending death of their youngest child who is 4 years old. The siblings are ages 6, 9, and 10. Which appropriate goal should the nurse develop for the family?
The parents and siblings will spend private family time together with the dying child
A client in a mental health unit throws a chair across the kitchen area. The client then verbally threatens another client, saying, "Get out of my way or I'll do the same to you! I'll break your bones just like the legs of this chair!" What does the nurse base the need for immediate seclusion on?
The potential for imminent harm to the client and others and to prevent significant damage to the environment
A client hospitalized with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to be more irritable with staff and family. The nurse interprets the client's behavior as supporting which conclusion?
This client is at increased risk for suicide
An adolescent is hospitalized for evaluation and treatment of Tourette's disorder. The nurse reviews the client's record and notes that the client is exhibiting motor tics. What should the nurse likely expect to note on assessment of the client?
Tongue protrusion
A client reports 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 are not fitting well. What should the nurse interpret that further assessment should focus on?
Weight loss
The nurse is caring for a client who is divorced and is now homeless because she has just been evicted from her apartment because of joblessness. The client says to the nurse, "I can't tell my son. He lives 80 miles away and barely gets by himself. I'm not his problem." Which response by the nurse would be therapeutic?
What I'm hearing is that you don't want to be a burden to your son
A client with a diagnosis of schizophrenia tells the nurse that there are voices outside the window telling him what to do all the time. The client asks the nurse, "Can you hear them? What do you think I should tell them?" What is an appropriate response by the nurse?
What are the voices telling you?
An extremely angry client on a mental health inpatient unit has been placed in restraints because of aggressive behavior. When will the nurse plan to remove the restraints?
When the client initiates no aggressive acts for an hour after the release of two leg restraints
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
Why don't you feel like getting up?
A prison client, who killed an abusive spouse, is eligible for parole and asks the nurse, "Do you think I have a chance of being paroled?" Which nursing response would be therapeutic?
You have a promise of employment and regaining your children already lined up. I believe that the parole board will view your problem solving as a positive criterion.
The nurse is planning the discharge instructions from the emergency department for an adult client who is a victim of family violence. The nurse should understand that it is most important that which information is included in the discharge plans?
Specific information regarding "safe havens" or shelters in the client's neighborhood
A client has been admitted to the mental health unit on a voluntary basis. The client has reported a history of depression over the past 5 years. Which question by the nurse would elicit the most thorough assessment data regarding the client's recent sleeping patterns?
Tell me about your sleeping patterns
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels "as though the rape just happened yesterday." How should the nurse respond?
Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.
The nurse is caring for a client who is a survivor of a disaster event. The client begins to display behaviors not demonstrated before. Which manifestations would indicate to the nurse that the client may be experiencing posttraumatic stress disorder (PTSD)? Select all that apply.
1. Irritability and sleep disturbances 2. Flashbacks or recollections of the disaster 3. A feeling of estrangement or detachment from others 4. Repression or the inability to remember an important aspect associated with the disaster
