Psych
A nurse on the telemetry unit receives a client admitted from the emergency department with acute alcohol intoxication, confusion, and a diabetic toe ulcer. Which intervention would be the priority?
Alcohol is a toxin that causes central nervous system depression. Acute alcohol intoxication can cause confusion, coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions. Alcohol can also cause hypoglycemia, especially in clients with diabetes mellitus. Although the client is intoxicated, it is difficult to determine if the confusion is caused by alcohol or hypoglycemia or both. The priority is to monitor blood glucose during the night to watch for hypoglycemia, which would require immediate intervention. Alcohol can cause hypoglycemia, but intoxication can make it difficult to differentiate between the effects of alcohol and hypoglycemia. Clients with acute alcohol intoxication, especially those who have diabetes mellitus, should have their blood glucose levels monitored.
Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply.
Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance Lanugo (fine terminal hair) can be seen in extreme cases
The nurse is caring for a client with a history of heroin abuse. Which clinical finding may indicate withdrawal?
Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone [Narcan]) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4). Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions. Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped or dosage is reduced. Symptoms of opioid withdrawal (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity.
A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply.
Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows (Option 3). Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions (Option 2). For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real."
A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take?
Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal, poor social interaction skills) are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a poor quality of life. Nursing interventions directed at improving the social interaction skills of a client with schizophrenia include the following: Making brief, frequent contacts Accepting the client unconditionally by minimizing expectations and demands Assessing the client's readiness for longer contacts with the nurse and/or other staff and clients Being with or close by the client during group activities Offering positive reinforcement when the client interacts with others
A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply.
Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self-observation and to apply more adaptive coping interventions. CBT involves 5 basic components: Education about the client's specific disorder Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity Physical control strategies - deep breathing and muscle relaxation exercises Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events
The mental health nurse is planning care for a client newly admitted with dissociative identity disorder. Which interventions will the nurse include? Select all that apply.
Dissociative identity disorder is a condition in which 2 or more identities alternately control the client's behavior. The alternate identities likely develop as a response to abuse or traumatic events and serve to protect the client from stressful memories. The client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory. Switching between identities occurs as a reaction to stress and individual triggers. The goal of treatment is to integrate the identities into one personality while maintaining safety. The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep breathing, rubbing a stone, counting coins) to counter dissociative episodes (Options 2 and 5). Identities may be volatile and should be monitored for indications of harm to self or others (Option 4). The nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate identity integration
A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following?
Disturbance in logical form of thought is characteristic and one of the positive symptoms of schizophrenia. The client will often have trouble concentrating and maintaining a train of thought. Thought disturbances are often accompanied by a high level of functional impairment, and the client may also be agitated and behave aggressively. Types of impaired thought processes seen in individuals with schizophrenia include the following: Neologisms - made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox." Concrete thinking - literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener (Option 1). Loose associations - rapid shifting from one idea to another, with little or no connection to logic or rationality (Option 2) Echolalia - repetition of words, usually uttered by someone else Tangentiality - going from one topic to the next without getting to the point of the original idea or topic (Option 3) Word salad - a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple." (Option 4) Clang associations - rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke." Perseveration - repeating the same words or phrases in response to different questions
The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include?
Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2). Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: Avoid hidden alcohol in: liquid cold and cough medications aftershave lotions, colognes, and mouthwashes foods such as sauces, vinegars, and flavor extracts Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur Wear a bracelet alerting others of being on disulfiram therap
The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene?
Electroconvulsive therapy (ECT) induces a generalized seizure by passing an electrical current through electrodes applied to the scalp. Although the exact mechanism is unknown, 15-20-second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia. Client teaching includes: NPO status is required for 6-8 hours prior to treatment except for sips of water with medications (Option 4). Anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure. Driving is not permitted during the course of ECT treatment (Option 2). Temporary memory loss and confusion in the immediate recovery period are common side effects of ECT (Option 3). Post-treatment nursing care includes monitoring vital signs, ensuring a patent airway, assessing mental status, and providing frequent reorientation during periods of postictal confusion.
The nurse is caring for a client with paranoid personality disorder. When the nurse directs the client to go to the dining room for dinner, the client says, "And eat that poisonous food? You better not make me go anywhere near that room." Which statement best explains the client's behavior?
Individuals with paranoid personality disorder have a pervasive distrust and suspicion of others; they believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive them. These thoughts permeate every aspect of their lives and interfere with their relationships. Individuals with paranoid personality disorder are usually difficult to get along with as they may express their suspicion and hostility by arguing, complaining, making sarcastic comments, or being stubborn. Because these clients do not trust others, they have a strong need to be self-sufficient and maintain a high degree of control over their environment.
A client with severe major depressive disorder is lying in bed and has not moved for 3 hours. The client will respond slowly to "yes" and "no" questions; otherwise, the client does not respond when spoken to. The clinical manifestations exhibited by the client are known as:
Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of psychomotor retardation include slowed speech, decreased movement, and impaired cognitive function. The individual may not have the energy or ability to perform activities of daily living or to interact with others. Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior). Specific clinical findings of psychomotor retardation include the following: Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait Lack of facial expression Downcast gaze Speech impairment - reduced voice volume, slurring of speech, delayed verbal responses, short responses Social interaction - reduced or non-interaction Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement. Psychomotor retardation is a clinical finding in some clients diagnosed with major depressive disorder. The key features include decreased movement, inability or decreased ability to talk, and impaired cognitive function.
The nurse in a psychiatric clinic is evaluating the client's response to treatment for somatic symptom disorder with cardiac manifestations. Which client statement indicates a need for further treatment?
Somatic symptom disorder (SSD) is a psychological disorder in response to stress that results in symptoms of physical disorders (eg, chest pain, syncope) for which there is no identifiable medical source (eg, myocardial infarction, hypotension). Periods of increased stress (eg, work demands, family events) frequently precede the onset, or worsening, of physical symptoms and result in frequent requests for medical attention and treatment. SSD and care-seeking behaviors may then be reinforced and perpetuated by secondary gains (eg, social affirmation, "sick role," avoidance of unpleasant activities). When evaluating clients' responses to treatment for SSD, the nurse should monitor for the following indicators of positive progress: Identification of alternate support systems for stress (eg, spouse, friends) (Option 2) Identification of perceived benefits (ie, secondary gains) of behaviors Use of stress-reducing strategies (eg, drawing, meditating) rather than fixation on symptoms (Option 3) Verbalization of factors causing or worsening symptoms (Option 4)
The nurse is caring for a client admitted with abdominal pain, who has been diagnosed with somatic symptom disorder after a thorough evaluation finds no medical cause for the symptoms. Which intervention should the nurse include in the plan of care?
Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight. To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: Redirect somatic complaints to unrelated, neutral topics Limit time spent discussing physical symptoms (Option 2) To promote insight and healthy coping mechanisms, the nurse should assist the client to: Identify secondary gains (eg, increased attention, freedom from responsibilities) Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) Incorporate appropriate coping strategies (eg, relaxation training, physical activity)
A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss?
Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and motivation to change, which can be assessed using the Stages of Change Model. With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next: Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating) (Option 4). Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress) (Option 3). Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse. Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is always possible. Successful behavior modification requires client readiness and motivation to change, as evidenced by the client developing and acting on a plan. Clients often do not initially see the need for change, but with the appropriate support they begin contemplating change, preparing to change (eg, goal setting), and then actively changing.
An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate?
Sundowning refers to the increased confusion experienced by an individual with dementia; it occurs at night, when lighting is inadequate, or when the client is excessively fatigued. Wandering is a common associated behavior. A client with mild-to-moderate dementia may need frequent reality reorientation to promote appropriate behaviors. However, with advanced dementia, reality orientation may not be effective and might cause the client to feel anxious, leading to inappropriate behaviors and aggression. In this situation, validation therapy is more appropriate and involves recognizing and exploring the client's feelings and concerns but not reinforcing or arguing with any incorrect perceptions.
The registered nurse is counseling the parent of a child recently diagnosed with attention-deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an intervention?
Symptoms of ADHD usually continue into adulthood; current research indicates that children do not outgrow the condition. However, individuals with ADHD learn to cope with and manage the symptoms and achieve their full potential, leading healthy and satisfying lives. They may move into a condition of being "recovered," but this is usually a dynamic and ongoing state.
The nurse is caring for a hospitalized elderly client who is admitted with pneumonia. Which assessment finding is most consistent with the diagnosis of delirium?
The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain. Delirium has an abrupt onset and is a symptom of other problems. Up to 60% of hospitalized elderly clients have delirium prior to or during hospitalization, but it is often missed by nursing.
The student nurse is performing an assessment of a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the student nurse expect to find during the assessment?
The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: Poor self-esteem Increased risk for depression and anxiety Increased risk for substance abuse Academic or work failure Trouble interacting with peers and adults
The nurse is providing care to a client experiencing posttraumatic stress disorder following a terrorist attack at the client's place of worship. What is the priority nursing action?
The first step toward resolution of posttraumatic stress disorder (PTSD) is the client's readiness (ability and willingness) to discuss the details of the traumatic event without experiencing high levels of anxiety. The nurse must assess clients with PTSD for their readiness to talk about the experience and encourage them to discuss the trauma at their own pace. The nurse should also use active listening as a therapeutic approach to build trust and allow clients to vent. This will assist in decreasing their feelings of isolation. The nurse can also guide the client in identifying event details that are most troubling and trigger a sense of loss of control. The effectiveness of the client's coping mechanisms can be identified, and alternate strategies to replace maladaptive ones can be explored.
A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms?
The most common defense mechanism used by persons with alcoholism is denial, the refusal to accept the reality of threatening situations, or painful thoughts, feelings, or events. Projection involves placing one's own thoughts, feelings, or impulses onto someone else.
The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate?
Displacement, one of many ego defense mechanisms, occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses.
Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply.
In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is characterized by the following: Excessive psychomotor activity Euphoric mood Poor impulse control Flight of ideas, non-stop talking Poor attention span, distractibility Hallucinations and delusions Insomnia Wearing bizarre or inappropriate clothing, jewelry, and makeup Neglected hygiene and inadequate nutritional intake The care plan for a client experiencing an acute manic episode includes the following: Reduction of environmental stimuli Providing a quiet, calm environment Limiting the number of people who come in contact with the client One-on-one interactions rather than group activities Low lighting A structured schedule of activities to help the client stay focused Physical activities to help relieve excess energy Providing high-protein, high-calorie meals and snacks that are easy to eat Setting limits on behavior
Which statement by a client with a diagnosis of dependent personality disorder would the nurse recognize as progress toward a positive therapeutic outcome?
Individuals with dependent personality disorder have a persistent and extreme need to be taken care of that manifests as submissive and clinging behaviors and fear of separation. Additional characteristics of dependent personality disorder may include: Difficulty in making day-to-day decisions An excessive need for advice, reassurance, and nurturance from others Lack of self-confidence - afraid to do things on one's own Afraid of confrontation or expressing disagreement with others Feelings of helplessness and anxiety when alone; fear of being unable to take care of oneself A client making a decision about and carrying out a daily activity on his/her own would be indicative of progress toward a therapeutic outcome.
The client with narcissistic personality disorder often behaves in grandiose and entitled ways, believes that he/she is perfect, and relies on constant reinforcement and admiration from people perceived as ideal. What is the best explanation for these clinical characteristics?
A client with narcissistic personality disorder (NPD) exhibits a recurrent pattern of grandiosity, need for admiration, and lack of empathy. Clients with NPD may project a picture of superiority, uniqueness, and independence that hides their true sense of emptiness. From a psychodynamic perspective, individuals with NPD have a fragile and damaged ego resulting from a childhood environment that fostered a sense of inferiority, poor self-esteem, and severe self-criticism. Narcissistic characteristics develop as a way to regulate self-esteem and protect the ego from further psychic injury.
A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action?
A structured routine and consistency during hospitalization are critical in the care of clients with autism spectrum disorder (ASD). The nurse should talk with the parent and/or caregiver to determine the client's usual patterns and habits for a typical day at home, including meal times, bath time, and play time. In the unfamiliar and often unpredictable environment of the acute care setting, a schedule of activities can decrease anxiety and help the client with ASD anticipate what will happen next.
The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being most at risk for suicide?
A suicide screening considers demographics, mental and physical health history, support systems, coping strategies, family history of suicide, previous attempts, and behavioral patterns. In addition to depression, the divorced male client with Parkinson disease and recent job loss is the most at risk for suicide, with 5 risk factors
A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child?
Activities for children with intellectual disabilities should be based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status. A child with moderate intellectual disability: Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop Performs self-care activities with some supervision Participates in simple activities May have limited speech capabilities Appropriate play activities for this child include simple puzzles, coloring books and crayons, modeling clay, watching cartoons or favorite movies, sticker books, playing with a large ball (eg, inflatable beach ball), simple card and board games, and being read to aloud.
The nurse cares for a client newly diagnosed with acute stress disorder following a traumatic event. Which of the following communications by the nurse are appropriate? Select all that apply.
Acute stress disorder (ASD) occurs following a traumatic or extremely stressful event. ASD is characterized by intrusive memories of the event, negative mood, dissociative symptoms (eg, altered sense of reality), and arousal and reactivity symptoms (eg, hyperactive sensory state, sleep disturbances, difficulty concentrating, easily startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress disorder. Nursing interventions for a client with ASD include: Assessing for ideas and plans to commit self-harm (Option 5) Assessing for ineffective coping (eg, use of drugs and alcohol) (Option 4) Assessing impact of ASD on the client's job performance, relationships, sleep pattern, and ability to perform activities of daily living (Option 1) Explaining that feelings and/or symptoms occurring after traumatic events are normal, as this can help alleviate the client's anxiety (Option 3) Exploring coping strategies used in previous stressful situations Clients with acute stress disorder (ASD) should be encouraged to discuss the traumatic event and explore the associated feelings. The nurse should validate the client's feelings; assess risk for self-harm and ineffective coping (eg, drug and alcohol use); and evaluate the impact of ASD on the client's sleep, occupation, and relationships.
The nurse is admitting a client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate to include in the care of this client? Select all that apply.
Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight (Option 2) Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain (Option 3) Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors (Option 4) Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk]) Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing to assess efficacy of nutritional support (Option 5) Limiting physical activity initially and gradually increasing as oral intake improves Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight Clients admitted with anorexia nervosa must increase caloric intake and stop exercising to promote weight gain. The nurse should record consumed calories, weigh the client daily, remain with the client during and for 1 hour following meals, and encourage discussion about dysfunctional eating triggers.
The nurse plans care for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome will the nurse prioritize?
Anorexia nervosa is an eating disorder characterized by distorted body image, profound fear of weight gain, a strong desire to be thin, and being unwilling to maintain a healthy body weight. The client engages in behaviors to lose weight, including not eating, purging, extreme exercise, and use of laxatives and diet pills. Psychosocial issues leading to anorexia are the focus of ongoing therapy, usually on an outpatient basis. However, certain criteria require hospitalization and include body weight below 75% of ideal, suicidal behavior, or medical conditions resulting from starvation. The priority focuses during inpatient care are the short-term outcomes of restoring caloric intake, promoting gradual weight gain, and treating medical conditions caused by starvation.
A nurse performs the initial assessments for 4 assigned clients. The nurse identifies which client as being at greatest risk for the development of delirium?
Major predisposing factors for the development of delirium in hospitalized clients include: Advanced age Underlying neurodegenerative disease (stroke, dementia) Polypharmacy Coexisting medical conditions (eg, infection) Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) Metabolic and electrolyte disturbances Impaired mobility - early ambulation prevents delirium Surgery (postoperative setting) Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium.
The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take?
Any client who cannot definitively say that currently he/she is not suicidal should be considered a "yes" and appropriate protective measures should be instituted to prevent suicidal actions. The client is under the hospital's care and the department must assume responsibility for the client's safety. Placing the client in an inside hallway can prevent the client from running outside. The client needs constant supervision by a hospital employee until a secure room is available. The client should never be left alone without hospital supervision.
The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition?
Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania. Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-making that can result in high-risk behavior (eg, hypersexuality, excessive spending). Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep, hygiene) and the need for medical intervention. When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal
A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse?
Clients with antisocial personality disorder often disregard the rules, have a history of irresponsible behavior, and blame others for their behavior. They avoid responsibility for their own behavior and the consequences of their actions using numerous excuses and justifications. Nursing interventions include setting firm limits and making clients with antisocial personality disorder aware of the rules and acceptable behaviors. The nurse should require the client to take responsibility for his/her own behavior and the consequences of not following the rules and regulations of the unit.
The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am I going to die?" Which statement by the nurse is appropriate?
Clients with life-limiting diagnoses often experience anxiety, frustration, and the phases of grief. The nurse must assess the client's knowledge and feelings regarding the illness. Use of therapeutic communication (eg, active listening, reflection, focusing) allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the client cope with difficult information (Option 2). The health care provider (HCP) should inform the client of biopsy results so that the prognosis and plan of treatment can be discussed. Although a cancer diagnosis may be difficult for the client to receive, a complete, factual discussion of the diagnosis can help the client feel more in control.
The partner of a client with borderline personality disorder calls the clinic and reports coming home from work to find the client with self-inflicted superficial cuts to the arm. The partner tells the nurse, "My partner does something like this every time I have to go away on business. My partner is not serious about doing something really harmful, just trying to stop me from going away." What is the best response by the nurse?
Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other. All suicidal behavior should be taken seriously; the client's current self-injurious action needs to be evaluated to assess whether it involved suicidal intent. Clients with BPD have been known to demonstrate years of benign suicide threats and gestures before completing a suicide. Predicting a client's risk for completing a suicide is difficult due to the impulsive nature of the behavior.
A client with moderate Alzheimer disease becomes agitated during mealtime and throws a plate of food on the floor. Which of the following responses by the nurse are appropriate? Select all that apply.
Clients with Alzheimer disease (AD) often exhibit behavioral problems (eg, agitation, resisting care) due to cognitive decline. Behavioral management techniques include: Acknowledgement of the client's emotions, which reduces feelings of being isolated and misunderstood (Option 5) Reassurance that the client will be kept safe from harm Distraction (eg, photographs, music, television) to divert the client's attention Redirection to simple tasks (eg, folding towels/napkins, stacking plates)
A young client is diagnosed with major depressive disorder. Three weeks prior, the client's fiancé broke off their engagement, claiming the client was "too fat and ugly." During a one-on-one interaction with the nurse, the client says, "My fiancé is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything." What is the best response by the nurse?
Clients with major depressive disorder experience feelings of worthlessness, low self-esteem, hopelessness, and guilt. Anger is turned inward and they may misinterpret reality and have an idealistic perception of a lost entity. They may blame themselves for what has happened, such as losing a loved one or being fired from a job. The nurse needs to remain nonjudgmental, listen to the client attentively, and convey a caring and accepting attitude to promote trust. Allowing the client to identify and verbalize feelings, including anger, in a comfortable environment will help the client see the situation in a more realistic way and come to terms with what has happened.
The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom?
Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs, newspaper articles, and other events are personal and significant to them. Other examples of delusions are below: Grandeur - "I need to get to Washington for my meeting with the president." Control - "Don't drink the tap water. That's how the government controls us." Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." Somatic - "The doctor said I'm fine, but I really have lung cancer."
The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply.
Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical, psychological, or sexual abuse by a caregiver. Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or neglect include: Dehydration, malnutrition, and weight loss (Option 2) Poor hygiene, soiled bedding or clothing, and pressure ulcers Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired
A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks?
Major depressive disorder (also known as unipolar depression) is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. For the diagnosis to be made, 5 or more of the following symptoms must be present almost every day for at least 2 weeks, and 1 of the symptoms must be depressed mood or loss of interest or pleasure. The 2 key clinical features of major depressive disorder (unipolar depression) are depressed mood and loss of interest or pleasure. One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made.
Clients with major depressive disorder experience feelings of worthlessness, low self-esteem, hopelessness, and guilt. Anger is turned inward and they may misinterpret reality and have an idealistic perception of a lost entity. They may blame themselves for what has happened, such as losing a loved one or being fired from a job. The nurse needs to remain nonjudgmental, listen to the client attentively, and convey a caring and accepting attitude to promote trust. Allowing the client to identify and verbalize feelings, including anger, in a comfortable environment will help the client see the situation in a more realistic way and come to terms with what has happened.
Memantine is used to ease the symptoms of moderate to severe Alzheimer disease (AD), thereby improving the quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate (NMDA) antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels of glutamate contribute to brain cell death). Clients with moderate to severe AD may experience improvement in: Cognition - memory, thinking, language Daily functioning - dressing, bathing, grooming, eating Behavioral problems - agitation, depression, hallucinations
The nurse is managing the care of a client diagnosed with chronic anxiety. Which behavior demonstrates to the nurse that the client possesses resilience?
Resilient people readily deal with the stress they face by using interventions such as deep breathing, meditation, thought interruption, and muscle relaxation.
A nurse working at a mental health clinic is reviewing four messages from clients requesting a same-day appointment. Which client does the nurse prioritize to call back first?
Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (eg, St. John's wort), placing clients at risk for serotonin syndrome. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). The nurse should call this client back to investigate the symptoms further
A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy?
Social anxiety disorder (SAD) is characterized by an excessive and persistent fear of social or performance situations in which the client is exposed to strangers and the possibility of scrutiny by others. Examples of such social interactions include meeting unfamiliar people, being observed eating or drinking in public, and giving a speech. The client may fear criticism, embarrassment, humiliation, and rejection from unfamiliar people in unfamiliar social situations and will exhibit physical symptoms of anxiety such as sweating, trembling, palpitations, diarrhea, and blushing. Although all these situations could provoke some degree of anxiety in a client with SAD, having to represent the company at a convention with hundreds of strangers is most likely what brought this client to the community mental health center. Clients with SAD often have anticipatory anxiety and worry for days or weeks before a feared event. They may recognize that their fear is exaggerated and will seek assistance and counseling.
client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse?
The best response should acknowledge the reality of the sibling's concern, provide information, and open the door to further discussion about the development of the disease. Research studies indicate that identical twins have about a 50% chance of developing schizophrenia if one twin develops the disease. This points to a genetic component, but schizophrenia is not entirely a genetic disease. The exact cause is unknown; it most likely results from the interaction and combination of a number of different risk factors. Theories about the cause of schizophrenia include the following: Biochemical theories - abnormalities affecting the neurotransmitters dopamine, serotonin, norepinephrine, and glutamate Structural brain abnormalities - reduced size of certain brain areas Developmental factors - prenatal factors such as faulty neuronal connections Miscellaneous factors - birth trauma, epilepsy, maternal influenza during pregnancy
The nurse is caring for a client with bulimia nervosa. Which is the most important time for the nurse to monitor the client's behavior?
The eating behavior of a client with bulimia nervosa typically consists of binge eating followed by an inappropriate behavior to prevent weight gain, such as self-induced vomiting, exercise, and/or excessive use of laxatives. Although it is important to provide one-on-one supervision to a client with bulimia during every meal, it is most important to monitor the client's activities for 1-2 hours after each meal to prevent self-induced vomiting (Option 2). Clients with bulimia nervosa will often go to extreme lengths to engage in purging activity, especially at the beginning of a treatment program, as a way of gaining control. After mealtime, it may be necessary to restrict clients to the dayroom or a specified area with no bathroom privileges for a set period. Clients will also need to be monitored at all times for engaging in excessive exercise.
The emergency department nurse cares for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client's spouse is at the bedside and appears angry. Which action is the priority at this time?
The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff
An 87-year-old client has been admitted to the hospital with signs and symptoms of a urinary tract infection along with agitation, confusion, and disorientation to time and place. What is the most important nursing action?
This client is experiencing impairment in cognitive and psychomotor functioning and most likely has delirium brought on by the urinary tract infection. This is not an uncommon occurrence in elderly clients. The client's most immediate needs are safety and prevention of physical injury. Initially, the client should be placed in a room near the nurses' station with one-on-one supervision and frequent reorientation to time, place, and situation. As the condition improves, the client will continue to require frequent observation.
The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply.
When the nurse suspects that a child may be the victim of child abuse, the parent or caregiver should be questioned, and all possibilities (eg, alternate caregivers) should be explored to find the source of the abuse. If possible, the interview should be done without the child present. The nurse should remain supportive and empathetic and convey a nonjudgmental, nonthreatening attitude, avoiding words such as "abuse" and "violence." Open-ended questions are less threatening and provide more detailed responses. Information to gather includes: Caregiver's perspective on the child's behavior (Option 1) Methods of discipline used with the child (Option 3) Routine caregivers for the child Caregiver stress, coping, and support systems (Option 4) Person or persons who care for the child when regular caregivers are away (Option 5)
