PSYCHIATRIC/MENTAL HEALTH NURSING
Maintaining a supportive, structured environment
A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective?
Seizure activity
What is the primary concern for a nurse caring for a client who is grossly impaired by stimulants?
Alcoholism involves the entire family.
What is the primary reason that the nurse encourages the family of an alcoholic to become involved in the treatment program?
Unlikely because of interference with so many parameters of function
What is the prognosis for a normal productive life for a child with autism?
Clients do not want to repeat their rituals but feel compelled to do so.
What should a nurse consider when planning care for a client who is using ritualistic behavior?
Motivational readiness
What should a nurse identify as the most important factor in rehabilitation of a client addicted to alcohol?
Routines provide stability for clients with dementia.
What should a nurse who is caring for a hospitalized older client with dementia consider before planning care?
Removing as many stimuli from the client's environment as possible
What should be the nurse's first intervention in the care of a client with a generalized anxiety disorder?
It is important to include the family in the treatment plan.
What should nurses consider when working with depressed young children?
React to the feeling tone of the client's delusion
What should the nurse do when a client with the diagnosis of schizophrenia talks about being controlled by others?
Encouraging the client to tear pictures out of magazines for a scrapbook
What therapeutic nursing intervention may redirect a hyperactive, manic client?
Imagery
A client in the mental health clinic has a phobia about closed spaces. Which desensitization method should the nurse expect to be used successfully with this client?
Delusion of persecution
A client in the mental health clinic tells the nurse, "The FBI is out to kill me." What should the nurse document that the client is experiencing?
Accepting the client's statements as the client's beliefs
What is the best initial nursing approach to take with a self-accusatory, guilt-ridden client?
Developing an awareness of self and the professional role in the relationship
What is the most difficult initial task in the development of a nurse-client relationship?
The need to follow the prescribed medication regimen
What is the most important information for a nurse to teach to prevent relapse in a client with a psychiatric illness?
"You feel worried that someone wants to poison you?"
A delusional client has refused to eat for the past 24 hours because, he says, "the food is poisoned." How should the nurse respond?
An uncomplicated daily schedule
A nurse is caring for a group of depressed clients. What should the nurse attempt to provide?
Stating that the food is not poisoned
A delusional client refuses to eat because she believes that the food is poisoned. What is the most appropriate initial nursing intervention?
Echolalia
A nurse recalls that language development in the autistic child resembles:
Sleep will be induced and the treatment will not cause pain.
A severely depressed client is to have electroconvulsive therapy (ECT). What should a nurse include when discussing this therapy with the client?
Mild
A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions?
Immediately after the client's admission to the hospital
A widow who is hospitalized for a medical problem has dementia of the Alzheimer type and is no longer able to live alone. The client is to be transferred from the hospital to a long-term care facility. When should the staff begin preparation for the transfer?
Illusion
A young client is admitted to the hospital with a diagnosis of acute schizophrenia. The family reports that one day the client looked at a linen sheet on a clothesline and thought it was a ghost. What is the most appropriate conclusion to make about what the client was experiencing?
"Don't be afraid. I'm your nurse, and everyone here in the hospital is here to help you."
An older adult, accompanied by family members, is admitted to a long-term care facility with symptoms of dementia. During the admission procedure the initial statement by the nurse most helpful to this client is:
"Was reasonable care provided?" "Was there a breach of nursing duty?" "Was there an act of omission that resulted in harm? "Except for the nurse's action, would the injury have occurred?"
Certain questions are applicable in determining nursing negligence. (Select all that apply.)
Anxious over the arrival of new staff members
During the orientation tour for three new staff members, a young, hyperactive manic client greets them by saying, "Welcome to the funny farm. I'm Jo-Jo, the head yo-yo." Which meaning can the nurse assign to the client's statement?
By limiting unnecessary interactions with the client
How can a nurse minimize agitation in a disturbed client?
Reexperiencing the trauma in dreams and flashbacks
Many clients who call a crisis hotline are extremely anxious. The nurse answering the hotline phone considers that the characteristic distinguishing posttraumatic stress disorders from other anxiety disorders is:
Denial Confusion Helplessness
People who are involved in a bioterrorism attack exhibit immediate reactions to the traumatic event. Which responses can a nurse expect in survivors during the period immediately following a traumatic event? (Select all that apply.)
Experiences command hallucinations
Risk for assaultive behavior is highest in the mental health client who:
Ensuring a safe therapeutic milieu
When a client is expressing severe anxiety by sobbing in the fetal position on her bed, the nurse's priority is:
Walking to the end of the hallway where the client is standing
While watching television in the dayroom a client who has demonstrated withdrawn, regressed behavior suddenly screams, bursts into tears, and runs from the room to the far end of the hallway. What is the most therapeutic intervention by the nurse?
Avoidance
The nurse recalls that the major defense mechanism used by an individual with a phobic disorder is:
Feelings of panic
A client arrives at the mental health clinic disheveled, agitated, and demanding that the nurse "do something to make these feeling stop." What clinical manifestation is evident?
Supplying the client with tissues to maintain function until the anxiety eases
A client believes that doorknobs are contaminated and refuses to touch them except with a paper tissue. What nursing intervention will be most therapeutic for this client?
Staying physically close to the client
A client comes to a mental health center with severe anxiety, evidenced by crying, hand-wringing, and pacing. What should the first nursing intervention be?
The client is fearful of the impulses and is seeking protection from them.
A client confides to the nurse, "I've been thinking about suicide lately." What conclusion should the nurse make about the client?
Increased risk for suicide
A client has been hospitalized for 3 weeks while receiving a tricyclic medication for severe depression. One day the client says to the nurse, "I'm really feeling better; my energy level is up." After the encounter an aide tells the nurse that the client has given away his favorite jacket. What should the nurse conclude that the client's statement indicates?
Making certain that the client is swallowing the medication
A client has been in an acute care psychiatric unit for 3 days and is receiving haloperidol (Haldol) tablets orally to reduce agitation and preoccupation with auditory hallucinations. There has been no decrease in the client's agitation or preoccupation with auditory hallucinations since the medication was started. What should the nurse's priority intervention be?
Express anger or frustration
A client has just been admitted with the diagnosis of borderline personality disorder. There is a history of suicidal behavior and self-mutilation. The nurse remembers that the main reason that clients use self-mutilation is to:
"I don't like hearing your threats, but tell me more about your feelings."
A client has been on the psychiatric unit for several days. The client arouses anxiety and frustration in the staff and manipulates them so well that staff members are afraid to approach the client. One morning the client shouts at the nurse, "You've worked it so I can't go for a walk with the group today. You're as cunning as a fox. I hate you! Get out, or I'll hit you!" What is the best response by the nurse?
Scapegoating
A 12-year-old child who has a history of school failure and destructive acting out is admitted to a child psychiatric unit with the diagnosis of conduct disorder. The youngest of three children, the child is identified by both the parents and the siblings as the family problem. The nurse recognizes the family's pattern of relating to the child as:
Refer the mother to the psychiatrist
A 13-year-old boy who recently was suspended from school for consistently bullying other children is brought to the pediatric mental health clinic by his mother. The child is assessed by the psychiatrist and referred to a psychologist for psychological testing. The day after the tests are completed, the mother returns to the clinic and asks the nurse for results of the tests. The nurse should:
Rewarding positive behavior
A 17-year-old client is admitted to the hospital because of weight loss and malnutrition, and the health care provider diagnoses anorexia nervosa. After the client's physical condition is stabilized, the provider, in conjunction with the client and parents, decides to institute a behavior-modification program. What component of behavior modification verbalized by one of the parents leads the nurse to conclude that the parent has an understanding of the therapy?
"I'm going to do my best to fight this awful disease." "Now I can't go to the prom because I have this stupid disease." "This illness is serious, but with treatment I think I have a chance to get better."
A 17-year-old teenager is found to have leukemia. Which statements by the teenager reflect Piaget's cognitive processes associated with adolescence? (Select all that apply.)
Repression
A 20-year-old woman is brought to an emergency department after having been raped. She is very anxious and cannot recall any of the circumstances surrounding the assault or provide the police with a description of the rapist. The nurse knows that the defense mechanism being utilized by this woman is:
"Every time I turn around the kid is falling over something." "I can't understand it. He didn't have a problem using the stairs without my help before this."
A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.)
Responsiveness to the parents
A 3-year-old child is found to have a pervasive developmental disorder not otherwise specified (autistic disorder). What should the nurse consider most unusual for the child to demonstrate?
Reaction formation
A 30-year-old female client asks the nurse to change her room, stating that she hates her roommate and can't stand to be in the same room with her. Just as she finishes speaking, her roommate enters and the client tells her she missed her and has been all over the unit looking for her. The nurse recognizes that the client is using:
Conversion
A 30-year-old woman reports to the mental health clinic on the recommendation of her primary health care provider. She has been unable to carry out everyday activities because of increased pain in her lower back and legs. Numerous neurological and orthopedic workups indicate that her symptoms seem excessive when compared with the physical problems shown on physical examination and repeated MRIs and x-rays. She says that no one understands how difficult it has been to care for her 32-year-old husband, who has an inoperable brain tumor and is undergoing chemotherapy. In light of the history and symptoms, what disorder should the nurse suspect?
Impulsiveness Excessive talking Playing video games for hours on end Failure to follow through or finish tasks
A 4-year-old child is found to have attention deficit-hyperactivity disorder (ADHD). What information about the child's behavior should the nurse expect when obtaining a health history from the parents? (Select all that apply.)
Regression
A 6-year-old child has been wetting the bed at night since the birth of a baby brother. What defense mechanism is the child using to cope with the stress of accepting a new family member?
Use another activity to distract the child
A 6-year-old child who has autism exhibits frequent spinning and hand-flapping behaviors. What should the nurse teach the parents to do to limit these actions?
"You sound upset about not being able to have an erection."
A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse?
The child may be blaming himself for his parents' breakup.
A 7-year-old boy is brought to the clinic by the mother, who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in schoolwork since she and her husband separated 6 months ago. The mother reports that lately her child has not been eating dinner, and she often hears him crying when he is alone. What basis for these behaviors should the nurse consider?
"Everyone is responsible for his own actions."
A client in the outpatient clinic is denying that he is addicted to alcohol. He tells the nurse that he is not an alcoholic and that it is his nagging wife who causes him to drink. What is the most therapeutic response by the nurse?
Bipolar disorder, manic phase
A client is admitted to a psychiatric hospital after a month of unusual behavior that has included eating and sleeping very little, talking and singing constantly, and going on frequent shopping sprees. In the hospital, the client is demanding, bossy, and sarcastic. Which disorder does the nurse associate with these behaviors?
Helping the client learn to trust the staff through selected experiences
A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client?
"I know there's no reason to do these things, but I can't help myself."
A client is admitted to the hospital because of incapacitating obsessive-compulsive behavior. The statement that best describes how clients with obsessive-compulsive behavior view this disorder is:
Saying, "I see that you're crying. Tell me what's going on in your life, and we can work on helping you."
A client is admitted to the mental health unit after attempting suicide. When a nurse approaches, the client is tearful and silent. What is the best initial nursing intervention?
Fluvoxamine (Luvox)
A client is admitted to the psychiatric hospital with a diagnosis of obsessive-compulsive disorder. The client's anxiety level is approaching a panic level, and the client's ritual is interfering with work and daily living. Which selective serotonin reuptake inhibitor (SSRI) should the nurse anticipate that the health care provider may prescribe?
Feelings of self-deprecation
A client is admitted to the psychiatric service with a diagnosis of severe depression. When approached by the nurse, the client says, "You know I'm a sorry, lazy person. I don't deserve a job. I'm just stupid and no good." What does the nurse conclude that the client is experiencing?
"Tell me how you feel about it."
A client is admitted to the surgical unit with superficial wounds of both wrists, the result of a suicide attempt. When the nurse enters the room, the client says, "I suppose you're going to ask me about my suicide attempt." What is the best response by the nurse?
Euphoria Agitation Hypervigilance Impaired judgment
A client is brought to the emergency department by friends because of increasingly bizarre behavior. Which signs does the nurse identify that indicate that the client was using cocaine? (Select all that apply.)
Impulsive
A client is found to have a borderline personality disorder. What behavior does the nurse consider is most typical of these clients?
Low self-esteem
A client is found to have an adjustment disorder with mixed anxiety and depression. What should the nurse anticipate as the client's primary problem?
"The medication will increase your appetite and make you feel better."
A client is lonely and extremely depressed, and the health care provider prescribes a tricyclic antidepressant. The client asks the nurse what the medication will do. What is the best response by the nurse?
Aged cheese Ripe avocados Delicatessen meats
A client is prescribed a monoamine oxidase inhibitor. The nurse teaches the client about what foods to avoid when taking this medication. (Select all that apply.)
Symptoms of the heroin overdose may return after the naloxone is metabolized.
A client is responding within an hour of receiving naloxone to combat respiratory depression from an overdose of heroin. Why should a nurse continue to closely monitor this client's status?
Denial of this activity may precipitate a panic level of anxiety.
A client is using ritualistic behaviors. Why should a nurse give the client ample time in which to perform the ritual?
By reminding the nurse that once the content is known, there is no need to focus on the hallucinations because doing so reinforces them
A client newly admitted to the psychiatric unit because of an acute psychotic episode is actively hallucinating. The admitting nurse has documented the content of the auditory hallucinations, which center on the theme of powerlessness. Later the primary nurse approaches the client, who appears to be listening to voices, and comments, "You seem to be listening to something. Tell me what you hear." The primary nurse requests feedback from the psychiatric clinical specialist regarding this nursing intervention. How should the clinical specialist respond?
Waking the client early so the ritual can be completed before breakfast
A client on a psychiatric unit misses breakfast because of an elaborate hand-washing ritual. What is the most important therapeutic intervention during the early period of the client's hospitalization?
Delusion of grandeur
A client on the psychiatric unit tells the nurse, "I'm a movie star, and the other clients are my audience." What is an appropriate conclusion for the nurse to document about what the client is experiencing?
Leaving the bedroom when unable to sleep Exercising in the afternoon rather than in the evening Counting backward from 100 to 0 when his mind is racing
A client tells a nurse, "I have been having trouble sleeping and feel wide awake as soon as I get into bed." Which strategies should the nurse teach the client that will promote sleep? (Select all that apply.)
Idea of reference
A client tells the nurse, "That man on the television is talking only to me." What should the nurse document that the client is exhibiting?
"I understand that these voices are real to you, but I want you to know that I don't hear them."
A client tells the nurse, "The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles." What is the best initial response by the nurse?
"I'll help you take your shower now."
A client with schizophrenia is admitted to a psychiatric unit. The client is talking while walking in the hall, is unkempt, and obviously has not washed in several days. What should the nurse say when trying to help this client shower?
Obtaining vital signs Assessing for suicidal thoughts Instituting continuous monitoring Initiating a therapeutic relationship Inspecting the bandages for bleeding
A client who attempted suicide by slashing her wrists is transferred from the emergency department to a mental health unit. What important nursing interventions must be implanted when the client arrives on the unit? (Select all that apply.)
"What emotion were you feeling before you felt the weakness?"
A client who has a history of a conversion reaction that involves weakness in the right arm that periodically progresses to paralysis is hospitalized on the mental health unit of the local community hospital. While listening to instructions for a group project, the client experiences a feeling of weakness and is unable to move the right arm. After evaluating the client, what should the nurse ask?
Somatic delusion
A client who has been hospitalized with schizophrenia tells the nurse, "My heart has stopped and my veins have turned to glass!" What should the nurse conclude that the client is experiencing?
Recognizing that the behavior is part of the illness but setting limits on it
A client who is hallucinating actively approaches the nurse and reports, "I'm hearing voices that are saying bad things about me." What should the nurse do?
Reply, "I'll stay with you for a while because you seem frightened."
A client who is hallucinating actively approaches the nurse and reports, "I'm hearing voices that are saying bad things about me." What should the nurse do?
Diversional activities Limit-setting Medication administration Seclusion Restraints
A client who is in a manic phase of bipolar disorder threatens staff and clients on a psychiatric acute care unit. Place the following interventions in priority order, from the least to the most restrictive.
Diaphoresis Tachycardia Hypertension
A client who is on the third day of detoxification therapy becomes agitated and restless. What are the signs and symptoms that indicate impending alcohol withdrawal delirium? (Select all that apply.)
Increase alertness to the environment
A client who is to begin a physical therapy regimen after orthopedic surgery expresses anxiety about starting this new therapy. The nurse responds that some of this apprehension can be an asset because it will:
Place the client in a private room to provide a quiet atmosphere
A client with a diagnosis of bipolar disorder, manic episode, is admitted to the mental health unit. Because the environment is important, what should the nurse do?
Splitting
A client with a diagnosis of borderline personality disorder (BPD) has negative feelings toward the other clients on the unit and considers them all "bad." Which defense is the client using when identifying the other clients thusly?
"What were you doing yesterday when you first noticed the feeling?"
A client with a diagnosis of panic disorder who had a panic attack on the previous day says to the nurse, "That was a terrible feeling I had yesterday. I'm so afraid to talk about it." What is the most therapeutic response by the nurse?
Fluphenazine
A client with a diagnosis of schizophrenia is discharged from the hospital. At home the client forgets to take the medication, is unable to function, and must be rehospitalized. What medication may be prescribed that can be administered on an outpatient basis every 2 to 3 weeks?
Intramuscular injections of thiamine
A client with a history of alcoholism is found to have Wernicke encephalopathy associated with Korsakoff syndrome. What does the nurse anticipate will be prescribed?
Firm
A client with a history of schizophrenia attends the mental health clinic for a regularly scheduled group therapy session. The client arrives agitated and exhibits behaviors that indicates that she is hearing voices. When a nurse begins to walk toward her, the client pulls out a large knife. What is the best approach by the nurse?
Intrusive involvement with environmental activities
A client with a history of sleeplessness, lack of interest in eating, and excessive purchases on charge accounts is seen in the mental health clinic. The adaptation that the nurse should expect the client to exhibit is:
Methamphetamine
A client with a history of substance abuse is brought to the emergency department. The client is having seizures, is hypertensive, and has hyperthermia. What drug should the nurse consider that the client may have been abusing?
Community-based self-help group
A client with a long history of alcohol dependence spends 28 days in an alcohol-rehabilitation unit. What type of referral does the nurse anticipate will be included in the discharge plan?
"No, I don't see any bugs."
A client with alcohol dependence problem asks whether the nurse can see the bugs that are crawling on the bed. What is the nurse's initial reply?
Angry
A client with bipolar disorder, manic episode, has a superior, authoritative manner and constantly instructs other clients in how to dress, what to eat, and where to sit. The nurse should intervene because these behaviors eventually will cause the other clients to feel:
Managing the behavior
A client with dementia has been cared for by the spouse for 5 years. During the last month the client has become agitated and aggressive and is incontinent of urine and feces. What is the priority nursing care while this client is in an inpatient mental health facility?
The blood level may not be sufficient to cause noticeable improvement for 2 to 4 weeks.
A client with depression is to be given fluoxetine (Prozac). What precaution should the nurse consider when initiating treatment with this drug?
Denying this activity may precipitate an increased level of anxiety.
A client with obsessive-compulsive disorder performs a specific ritual. Why should the nurse give the client time to perform the ritual?
Describing the thoughts and feelings experienced in terrifying situations
A client with phobias about elevators and large crowds comes to the clinic for help because of feelings of depression related to these fears. What is an appropriate short-term goal for this client?
Hyperactivity, auditory hallucinations, loose associations
A client with schizophrenia is admitted to an acute care psychiatric unit. Which clinical findings indicate positive signs and symptoms of schizophrenia?
Passive range-of-motion exercises three times a day for effective joint health
A client with schizophrenia is demonstrating waxy flexibility. Which intervention is the best way to manage the possible outcome of this behavior?
"It's time for you to go for a walk now."
A client with schizophrenia plans an activity schedule with the help of the treatment team. A written copy is posted in the client's room. What should the nurse say when it is time for the client to go for a walk?
Neologism
A client with schizophrenia repeatedly says to the nurse, "No moley, jandu!" The nurse determines that the client is exhibiting:
Loose association
A client with schizophrenia says to the nurse, "I've been here 5 days. There are 5 players on a basketball team. I like to play the piano." How should the nurse document this cognitive disorder?
Ideas of reference
A client with schizophrenia sees a group of visitors sitting together talking. The client tells the nurse, "I know they're talking about me." Which altered thought process should the nurse identify?
Allow the client to undress when ready to help maintain identity
A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs?
Rationalization
A client with the diagnosis of alcoholism explains to the nurse that alcohol has a calming effect and states, "I function better when I'm drinking than when I'm sober." What defense mechanism does the nurse identify?
Talking with the nurse several times during the day
A client with the diagnosis of bipolar disorder, depressive episode, has been hospitalized on a psychiatric unit for 1 week. What is the most appropriate activity for this client?
Dehydration
A client with the diagnosis of bulimia nervosa, purging type, is admitted to the mental health unit after an acute episode of bingeing. Which clinical manifestation is most important for the nurse to evaluate?
By allowing the behavior for the time being
A client with the diagnosis of obsessive-compulsive disorder uses paper towels to open doors to avoid touching dirty doorknobs. How should the nurse respond initially to this behavior?
Having a staff member sit with the client in a quiet area during mealtimes
A client with the diagnosis of schizophrenia refuses to eat meals. Which nursing action is most beneficial for this client?
Divide the staff into opposing factions to gain self-esteem
A client's history demonstrates a pervasive pattern of unstable and intense relationships, impulsiveness, inappropriate anger, manipulation, offensive behavior, and hostility. The admitting diagnosis is borderline personality disorder. What does the nurse anticipate that this client may attempt to do?
Identity versus role confusion
A college student visits the health center and describes anxiety about having to declare an academic major. What developmental conflict, according to Erikson, is this client still attempting to resolve?
"It can be frightening to feel that way."
A confused hallucinating client says, "My arms are turning to stone." What is the most therapeutic response by the nurse?
Role experimentation
A constructive but lengthy method of confronting the stress of adolescence and preventing a negative and unhealthy developmental outcome is:
Moving the client to a quiet place on the unit
A delusional client verbalizes the belief that others are out to harm him. A nurse notes the client's worsening pacing and agitation. What is the best nursing intervention?
Stay with the client during meals
A depressed client has been sitting alone in a chair most of the day and displays no interest in eating. How should the nurse plan to meet this client's nutritional needs?
Impending anniversary of the loss of a loved one
A depressed client is admitted to the mental health unit. What factor should the nurse consider most important when evaluating the client's current risk for suicide?
Involve the client in activities in which success can be ensured
A depressed client is very resistive and complains about inabilities and worthlessness. The best nursing approach is to:
"You would rather not live."
A depressed client tells a nurse, "I want to die." What is the most therapeutic response by the nurse?
Dependence versus independence
A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of the conflict of:
Keep the client under closer observation
A hospitalized, depressed, suicidal client has been taking a mood-elevating medication for several weeks. The client's energy is returning and the client no longer talks about suicide. What should the nurse do in response to this client's behavior?
Talking with the child about the importance of using a seat belt
A hyperactive 9-year-old child with a history of attention deficit-hyperactivity disorder is admitted for observation after a motor vehicle collision. On what should nursing actions be focused when the nurse is teaching about personal safety?
Placing the child in a short time-out
A hyperactive, acting-out 9-year-old boy is started on a behavior modification program in which tokens are given for acceptable behavior. When he begins to lose a game he is playing with other children, he begins to kick the other children under the table and call them names. What is the most appropriate behavior modification technique for the nurse to use?
"Everyone has a bed. This one is yours."
A male client with the diagnosis of a bipolar disorder, depressed episode, is found lying on the floor in his room in the psychiatric unit. He states, "I don't deserve a comfortable bed; give it to someone else." The best response response by the nurse is:
Command hallucination
A man is admitted to the psychiatric unit after attempting suicide. The client's history reveals that his first child died of sudden infant death syndrome 2 years ago, that he has been unable to work since the death of the child, and that he has attempted suicide before. When talking with the nurse he says, "I hear my son telling me to come over to the other side." What should the nurse conclude that the client is experiencing?
Grandeur
A man with bipolar disorder, manic episode, has been traveling around the country, dating multiple women, and buying his dates expensive gifts. He is admitted to the hospital when he becomes exhausted and runs out of money. The nurse anticipates that during a manic episode the client is most likely experiencing feelings of:
Aged cheeses
A monoamine oxidase inhibitor (MAOI) is prescribed. What should the nurse instruct the client to avoid while taking this drug?
Shorten the rest of the story
A mother of a 6-year-old boy with the diagnosis of attention deficit-hyperactivity disorder (ADHD) tells the nurse that when she is reading storybooks to her son, about halfway through the story he becomes distracted, fidgets, and stops paying attention. The nurse suggests that the mother:
Perform a relaxation exercise
A nurse concludes that a client has successfully achieved the long-term goal of mobilizing effective coping responses when the client states that when he feels himself getting anxious he will:
Malingering
A nurse determines that a client is pretending to be ill. What does this behavior usually indicate?
"Tell me again how your child fell down the stairs."
A nurse determines that the information about falling down the stairs given by a parent suspected of child abuse contradicts the information given by the child. What should the nurse say to the parent?
"I don't hear anyone else talking, but I can see that you're upset."
A nurse enters a client's room and notes that the client appears preoccupied. Turning to the nurse, the client says, "They're saying terrible things about me. Can't you hear them?" What is the most therapeutic response by the nurse?
Dissociation
A nurse greets a client who has been experiencing delusions of persecution and auditory hallucinations by saying, "Good evening. How are you?" The client, who has been referring to himself as "the man," answers, "The man is bad." Of what is this an example?
Do not want to repeat the ritual but feel compelled to do so
A nurse has been assigned to care for a client with the diagnosis of obsessive-compulsive disorder (OCD). Before providing care for this client, the nurse should consider that clients with OCD:
"I know you don't feel like getting up, but you might feel better if you did. Let me help you get started."
A nurse has been assigned to work with a depressed client on a one-on-one basis. The next morning the client refuses to get out of bed, saying, "I'm too sick to be helped, and I don't want to be bothered." What is the best response by the nurse?
Increased risk of suicide
A nurse has been caring for a suicidal client for 3 weeks on an inpatient unit. One morning the client greets the nurse cheerfully and states, "Everything is looking up. I'm not going to have problems for very long." What does the client's behavior and statement indicate?
By visiting frequently for short periods with the client each day
A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished?
A group can offer increased support.
A nurse in a community therapeutic recreation program is working with a client with dysthymia. The treatment plan suggests group activities when possible for this client. What is the priority rationale for this intervention?
It combats the extrapyramidal side effects of the other drug.
A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine (Cogentin) or trihexyphenidyl in conjunction with the phenothiazine derivatives neuroleptic medications?
Attempting to establish a meaningful relationship with the client
A nurse is assigned to care for a college student who has been talking to unseen people and refusing to get out of bed, go to class, or participate in daily grooming activities. What is the nurse's initial effort toward helping this client?
Confusion immediately after the treatment
A nurse is assisting with the administration of electroconvulsive therapy (ECT) to a severely depressed client. What side effect of the therapy should the nurse anticipate?
Order foods that the client can hold in the hand to eat while moving around
A nurse is caring for a client during the manic phase of bipolar disorder. What should the nurse do to best help meet the nutritional needs of this client?
Switches the user from illicit opioid use to use of a legal drug
A nurse is caring for a client who is addicted to opioids and who has undergone major surgery. The client is receiving methadone. What is the purpose of this medication?
Fluvoxamine (Luvox)
A nurse is caring for a client who uses ritualistic behavior. What common antiobsessional medication does the nurse anticipate will be prescribed?
Feeling comfortable with the nurse
A nurse is caring for a client with a bipolar disorder depressive episode. What should the nurse's objective for this client be?
Avoiding focusing on the client's physical symptoms
A nurse is caring for a client with a diagnosis of conversion disorder manifesting as paralysis of the legs. Which is the most therapeutic nursing intervention?
That their problems are not unique
The nurse refers a client to a self-help group. What does the nurse anticipate that a self-help groups such as Alcoholics Anonymous (AA) will help its members learn?
Assuring the client that the symptoms are part of the withdrawal syndrome
A nurse is caring for a client with the diagnosis of alcohol withdrawal delirium. Which action is most appropriate for the nurse to implement?
Disordered thinking
A nurse is caring for a client with the diagnosis of schizophrenia. What is a common problem for clients with this diagnosis?
Calm Matter-of-fact (In their head)
A nurse is caring for a client with the diagnosis of somatoform disorder, conversion type. What type of affect does the nurse expect this client to exhibit? (Select all that apply.)
Difficulty recalling recent events related to cerebral hypoxia
A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status?
Repetitive activities Self-injurious behaviors Lack of communication with others
A nurse is caring for a group of children with the diagnosis of autism. Which signs and symptoms are associated with this disorder? (Select all that apply.)
Is too busy to take the time to eat
A nurse is caring for a hyperactive, manic client who exhibits flight of ideas and is not eating. What may be the reason why the client is not eating?
Play
A nurse is caring for a preschool-aged child with a history of physical and sexual abuse. What type of therapy will be the most advantageous for this child?
Keeping the child from inflicting any self-injury
A nurse is caring for a young, hyperactive child with attention deficit-hyperactivity disorder who engages in self-destructive behavior. What is the most important nursing objective in the planning of care for this child?
Loosened associations and hallucinations
A nurse is caring for an adolescent client with the diagnosis of schizophrenia, undifferentiated type. Which signs and symptoms should the nurse expect the client to experience?
Are dependent on it
A nurse is caring for several clients who are going through withdrawal from alcohol. The primary reason for the ingestion of alcohol by clients with a history of alcohol abuse is that they:
Guilt
A nurse is caring for several clients with the diagnosis of bulimia nervosa. What primary feeling does the nurse anticipate that these clients experience after an episode of bingeing?
State three random words mentioned earlier in the exam
A nurse is conducting the Mini-Mental Status examination on an older client. What should the nurse ask the client to do when testing short-term memory?
Active membership in Alcoholics Anonymous
A nurse is discussing plans with a client who has decided to withdraw from alcohol. What should the nurse recommend as one of the most effective treatments for alcoholism?
2 years
A nurse is evaluating a child with suspected autism. At what age does the nurse determine that the signs of autism initially may be evident?
Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress
A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? (Select all that apply.)
Loneliness Hopelessness
A nurse is interacting with a depressed, suicidal client. What themes in the client's conversation are of most concern to the nurse? (Select all that apply.)
Ambivalence
A nurse is monitoring a client with the diagnosis of schizophrenia who is experiencing opposing emotions simultaneously. When providing a change-of-shift report, how should the nurse refer to this emotional experience of the client?
Going for a walk with the nurse
A nurse is planning activities for a withdrawn client who is hallucinating. Which activity will be most therapeutic for the client?
Chlorpromazine
A nurse is teaching a client about side effects of medications. Which drug will cause a heightened skin reaction to sunlight?
Blurs reality
A nurse is working in a clinic that provides services to clients who abuse drugs. What effect of cocaine should the nurse consider as the reason that it easily causes dependence?
Provide physical outlets for aggressive feelings Establish a contract regarding manipulative behavior Develop activities that provide opportunities for success
A nurse is working with an adolescent client with conduct disorder. Which strategies should the nurse implement while working on the goal of increasing the client's ability to meet personal needs without manipulating others? (Select all that apply.)
Experience perceptual difficulties that interfere with learning
A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children:
"How will you manage the next time your problems start piling up?"
A nurse moves into the working phase of a therapeutic relationship with a depressed client who has a history of suicide attempts. What question should the nurse ask the client when exploring alternative coping strategies?
Tremors Anorexia
A nurse notes that a client in the detoxification unit is exhibiting early signs of alcohol withdrawal. What clinical manifestations might the nurse have noticed? (Select all that apply.)
Early onset, before 36 months of age
A nurse understands that autism is a form of a pervasive developmental disorder (PDD). Which factor unique to autism differentiates it from other forms of PDD?
Hug with praise
A nurse uses behavior modification to foster toilet-training efforts in a cognitively impaired child. What reward should the nurse provide to reinforce appropriate use of the toilet?
"Have you ever felt bad or guilty about your drinking?"
A nurse uses the CAGE screening test for alcoholism to determine an individual's potential for a drinking problem. What is one of the four questions included on this test?
Antisocial personality
A nurse works with school-age children who have conduct disorder, childhood-onset type. The nurse knows that these children are at risk for progression to another disorder during adolescence. For signs of which disorder should the nurse evaluate their current behavior?
Double-bind message
A parent of a 17-year-old girl who has been hospitalized for extremely disturbed acting-out behavior leaves a gift for the daughter but says, "I'm too busy to visit today." The daughter becomes upset and tearful after being given the message and opening the package. What does the nurse conclude that the parent's actions represent?
Accepting that the client is unable to control this behavior and setting appropriate limits
A psychologist has been a client on a mental health unit for 3 days. The client has questioned the authority of the treatment team, advised other clients that their treatment plans are wrong, and been disruptive in group therapy. What is the most appropriate nursing intervention?
Administering chlordiazepoxide as indicated by the client's CIWA score
Oral chlordiazepoxide (Librium) 100 mg/ hr is prescribed for a client with a Clinical Institute Withdrawal Assessment (CIWA) score of 25. The client has had 300 mg in 3 hours but is still displaying acute alcohol withdrawal symptoms. What is the next nursing action?
Spending time with the client to build trust and demonstrate acceptance
An acutely ill client with the diagnosis of schizophrenia has just been admitted to the mental health unit. What is the most therapeutic initial nursing intervention?
"Set clear limits, explain the consequences if she disregards them, and firmly and consistently apply them."
An adolescent female with an antisocial personality disorder plans to live with her parents after discharge. The parents request advice on how to respond to their daughter's unruly behavior. What is the most therapeutic response by the nurse?
Demonstration of respect for the rights of others
An adolescent with a conduct disorder is undergoing behavioral therapy in an attempt to limit behaviors that violate societal norms. A specific outcome criterion unique to adolescents with this problem is:
Blurred vision Suicidal ideation Difficult urination
An adolescent with a major depressive disorder is prescribed venlafaxine (Effexor). What signs or symptoms related to the medication should the nurse communicate immediately to the prescribing provider? (Select all that apply.)
The client arrives on time for meals without being told
An adolescent with anorexia nervosa frequently telephones home just before mealtimes. The client uses the phone calls to avoid eating. What client behavior supports the nurse's conclusion that the nursing plan to set limits on this avoidance behavior has been effective?
"You sound upset; let's talk about it."
An adult client charged with molesting a child is admitted for psychiatric evaluation. When a nurse invites the client to come to dinner, the client refuses and says, "I don't want anyone to see me. Leave me alone." What is the best response by the nurse?
Asking the client, "Have you ever acted on these thoughts?"
An adult client confides to a clinic nurse, "I fantasize about having sex with children, and I get the urge to do it, too." What is the most appropriate response by the nurse?
Somatization
An anxious client reports experiencing pain in the abdomen and feeling empty and hollow. A diagnostic workup reveals no physical causes of these clinical findings. What term best reflects what the client is experiencing?
Denial
An older adult who lives alone tells a nurse at the community health center, "I really don't need anyone to talk to. The TV is my best friend." The nurse identifies the defense mechanism known as:
Giving the client one simple direction at a time in a firm low-pitched voice
An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention?
"Around 2:30 in the afternoon is the best time to visit."
An older client with a diagnosis of dementia is living in a long-term care facility. The client's daughter, who lives 300 miles away, calls the unit to speak to the nurse about her upcoming visit. What should the nurse say in response to her question about the best time of day to visit?
Projection
An older depressed person at an independent living facility constantly complains about her health problems to anyone who will listen. One day the client says, "I'm not going to any more activities. All these old crabby people do is talk about their problems." What defense mechanism does the nurse conclude that the client is using?
"You seem upset. Let's talk about what's bothering you."
An older widower who is sitting by himself in a lounge in the nursing home, says, "I'm all alone; no one has any use for me." Which response by the nurse is most therapeutic?
Stating that this behavior is unacceptable
On the afternoon of admission to a psychiatric unit, an adolescent boy with the diagnosis of schizophrenia exposes his genitals to a female nurse. What should the nurse's immediate therapeutic response be?
Offer to accompany the client to the dining room
On the fifth day of hospitalization the nurse notes that a depressed client remains lying on her bed when the clients are called to the dining room for lunch. What should the nurse do to encourage the client to eat?
"When I look at you I see a person, not a devil."
One day the nurse and a young adult client sit together and draw. The client draws a face with horns and says, "This is me. I'm a devil." What is the best response by the nurse?
Confined when the nurse walked into the room
As a nurse enters a room and approaches a client who has schizophrenia, the client shouts, "Get out of here before I hit you! Go away!" The nurse concludes that this aggressive behavior is probably related to the fact that the client felt:
Simple declarative statements
At mealtime a client with schizophrenia moves to the counter to choose food but is unable to decide what to do next. The nurse, recognizing the client's ambivalence, assists by using:
Leaving a dim light on in the client's room at night
At night an older client with dementia sleeps very little and becomes more disoriented. How can the nurse best limit this confusion resulting from sleep deprivation?
Seeking consensual validation
At times a client's anxiety level is so high that it blocks attempts at communication and the nurse is unsure of what is being said. To clarify understanding, the nurse says, "Let's see whether we mean the same thing." What communication technique is being used by the nurse?
"You're going to kill yourself?"
One day while shaving, a male client with the diagnosis of bipolar disorder tells the nurse, "I've hidden a razor blade, and tonight I'm going to kill myself." What is the best reply by the nurse?
"You're frightened. Come with me to your room, and we can talk about it."
One evening a nurse finds a client who has been experiencing persecutory delusions trying to get out the door. The client begs, "Please let me go. I trust you. The Mafia is going to kill me tonight." Which response is most therapeutic?
"You really seem to be upset about this."
One morning a client with the diagnosis of acute depression says to the nurse, "God is punishing me for my past sins." What is the best response by the nurse?
Delusion
Despite repeated nursing interventions to improve reality orientation, a client insists that he is the commander of an alien spaceship. What is the client experiencing?
"Let's discuss this concern a little more."
During a routine yearly physical an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be?
Clinical depression
Electroconvulsive therapy (ECT) is a mode of treatment that is used primarily to treat:
The client has gained 6 lb since admission 3 weeks ago.
Evaluation of clients with anorexia nervosa requires reassessment of behaviors after admission. Which finding indicates that the therapy is beginning to be effective?
Increased blood glucose level
How should a nurse expect a client's anxiety to be manifested physiologically?
Offering high-calorie snacks frequently that the client can hold
How should the nursing staff fulfill the nutritional needs of a client experiencing periods of extreme mania and hyperactivity?
Delusional thinking
In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting:
When coming into contact with the feared object
In what situation should a nurse anticipate that a client will experience a phobic reaction?
Referred to the employee assistance program
It is determined that a staff nurse has a drug abuse problem. As an initial intervention the staff nurse should be:
Informing the client in a matter-of-fact tone that everyone must remain with the group
The clients on a mental health unit go on a supervised day trip to a baseball game. When returning to the bus, a client with a narcissistic personality disorder insists on leaving the group to get an autograph from a player. What is the most appropriate response by the nurse?
Encourage the expression of their feelings
The day after the birth of their baby, the parents are upset to learn that the baby has a heart defect. At this time it is most helpful for the nurse to:
Prefill a weekly drug box with the medications for the spouse to self-administer
The health care provider prescribes donepezil (Aricept) 5 mg by mouth once a day for a client exhibiting initial signs of dementia of the Alzheimer type. The client is already taking digoxin (Lanoxin) 0.125 mg in the morning and alprazolam (Xanax) 0.5 mg twice a day. What should the nurse teach the client's spouse to do?
Lorazepam (Ativan)
The nurse anticipates that the medication that will be used to prevent symptoms of withdrawal in clients with a long history of alcohol abuse is:
"I didn't hear anyone talking; come with me to your room."
The nurse finds a client with schizophrenia lying under a bench in the hall. The client says, "God told me to lie here." What is the best response by the nurse?
For attempts at eating inedible objects
The nurse is caring for a client with Alzheimer's disease who exhibits behaviors associated with hyperorality. To meet the client's need for a safe milieu, the nurse will instruct staff to monitor the client:
Disruptions in cerebral blood flow, resulting in thrombi or emboli
The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem?
"My stomach has disintegrated." A somatic delusion is a false belief that one has a disease or a physical defect. A delusion about being a person of importance is a grandiose delusion. A delusion about death is a nihilistic delusion. A delusion that others are out to cause personal harm is a paranoid delusion.
The nurse notes that a client has been experiencing a somatic delusion. Which statement led to this conclusion?
"It must be frustrating to deal with your child's behavior."
The parent of a child with a tentative diagnosis of attention deficit-hyperactivity disorder (ADHD) arrives at the pediatric clinic insisting on getting a prescription for medication that will control the child's behavior. What is best response by the nurse?
"That hurts a lot when you want to be liked."
The parents of an overweight 12-year-old bring their child to the mental health clinic. One parent says, "You've got to do something to help us—just look how huge he is." The child tells the nurse, "I hate school. The other kids tease me about my weight. I'm always last when they pick teams in gym." What is the most therapeutic response by the nurse?
Verbalizing an honest desire for help
What behavior by a client with a long history of alcohol abuse is an indication that the client may be ready for treatment?
Based on realistic limits
What characteristic of the environment is most therapeutic for clients with the diagnosis of bulimia nervosa?
Underlying pathophysiology
What characteristic uniquely associated with psychophysiological disorders differentiates them from somatoform disorders?
Intimacy versus isolation
What conflict associated with Erikson's psychosocial stages of development should the nurse remember when caring for a client 30 years of age?
Regression
What defense mechanism should the nurse anticipate that a client with the diagnosis of schizophrenia, undifferentiated type, will most often exhibit?
Sitting down next to the client at frequent intervals
What is a therapeutic nursing action in the care of a depressed client?
Help the client acquire skills with which to face stressful events
What is an appropriate way for a nurse to help a client ease anxiety?
Providing the client with opportunities for nonthreatening social interaction
What is important when the nurse plans care for a client with paranoid ideation?
Self
What is the basic therapeutic tool used by the nurse to foster a client's psychological coping?
Supporting rituals while setting realistic limits
What is the best nursing intervention during the working phase of the therapeutic relationship with which to meet the needs of individuals who demonstrate obsessive-compulsive behavior?
quality of depression
What is the greatest difficulty for nurses caring for the severely depressed client?
Helping the client fulfill personal hygiene needs
What is the most appropriate way for the nurse to help a severely depressed adolescent client accept the realities of daily living?
Electroconvulsive therapy
What treatment should a nurse anticipate will be prescribed for a client with severe, persistent, intractable depression and suicidal ideation?
Listen to what the client is saying
When a newly admitted client with paranoid ideation tells the nurse about people coming through the doors to commit murder, the nurse should:
Imitating and participating in the child's activities
When a nurse sits next to a depressed client and begins to talk, the client responds, "I'm stupid and useless. Talk with the other people who are more important." Which response is most therapeutic?
Planning for future safety Validating the experiences Promoting access to community services
When intimate partner violence (IPV) is suspected, the nurse plays an important role as an advocate for the victim. The advocate role includes several important components. (Select all that apply.)
Denial Anger Bargaining Depression Acceptance
When planning nursing care for clients who are grieving the potential death of a family member, it is helpful to draw on the understanding of the five stages of grieving identified and described by Elisabeth Kübler-Ross. Place these stages in order of progression from first to last.
Project involving drawing
Which activity is most appropriate for a nurse to introduce to a depressed client during the early part of hospitalization?
Suspicious feelings
Which client characteristic is an initial concern for the nurse when caring for a client with the diagnosis of paranoid schizophrenia?
Promoting verbalization of feelings by the client
Which nursing intervention is indicated for a client with an anxiety disorder?
