Psychiatric/Mental Health Review
Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake
3. Correct: They can hold these items in their hand and eat while walking around. 1. Incorrect: Steak requires cutting up with a knife and is time consuming. Do you also see a safety issue here? Knife? Not while the client is manic. They need something that they can eat with their hands because they don't sit long enough to eat. 2. Incorrect: It's hard to walk around and eat beef stew and pudding. 4. Incorrect: It's hard to walk around and eat fish and cubed avocado.
Which signs/symptoms should the nurse assess for when caring for a client diagnosed with bulimia nervosa? Select all that apply 1. Increased thirst 2. Muscle cramps 3. Blurred vision 4. Tingling of lips 5. Constipation
2., 4., 5. Correct: The typical abnormalities associated with bulimia are hypokalemia and metabolic alkalosis because of the binging and purging process. This leads to muscle cramps, weakness, fatigue, constipation, and arrhythmias are all symptoms of this electrolyte and acid-base imbalance. Hypokalemia leads to metabolic alkalosis. 1. Incorrect: Increased thirst is a sign of hyperglycemia and would not be the concern with someone that is purging. This client would be more likely to be hypoglycemic instead. 3. Incorrect: Blurred vision is a sign of hyperglycemia because of the effect of too much glucose in the small vessels of the eye. Microvascular damage is one of the biggest concerns with hyperglycemia; the bulimic client would be hypoglycemic.
A school nurse is planning a lesson on inhalant abuse for a high school health class. Which information does the nurse need to include? Select all that apply 1. Substances used for inhaling include lighter fluid, spray paint, and airplane glue. 2. Inhalants are absorbed through the lungs and cause central nervous system depression rapidly. 3. Although inhaling can make a person very ill, death is highly unlikely. 4. Inhaling substances can cause abdominal pain, lethargy, and renal failure. 5. Inhalants cause the heart to beat slowly.
1, 2, & 4 Correct: Products such as glues, nail polish remover, lighter fluid, spray paints, airplane glue, deodorant and hair sprays, whipped cream canisters, and cleaning fluids are widely available. Many young people inhale the vapors from these sources in search of quick intoxication without being aware that using inhalants, even once, can have serious health consequences. Inhaled chemicals are absorbed rapidly into the bloodstream through the lungs and are quickly distributed to the brain and other organs. Within seconds of inhalation, the user experiences intoxication along with other effects similar to those produced by alcohol. Alcohol-like effects may include slurred speech; the inability to coordinate movements; euphoria; and dizziness. Inhalants also are highly toxic to other organs. It causes abdominal pain and vomiting. Chronic exposure can produce significant damage to the heart, lungs, liver, and kidney. In addition, users may experience lightheadedness, hallucinations, and delusions. This information needs to be included in a teaching plan on inhalant abuse. 3. Incorrect: With inhalant use, death can occur from respiratory depression or cardiac arrest. 5. Incorrect: Inhalants force the heart to beat rapidly and erratically, leading to cardiac arrest.
A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's best response? 1. "What do you think you should do?" 2. "Absolutely, I think you should tell your parents." 3. "Don't you think your parents have the right to know about your sexuality?" 4. "I do not think now is the right time to tell your parents. Wait until you are 21."
1. Correct: It is better to say "What do you think you should do?" This helps the client reflect on options and does not have the nurse tell the client what to do. It is much more therapeutic to help the client make the decision for themselves, instead of the nurse. This prevents any biases from impacting the outcome. 2. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions. 3. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions. 4. Incorrect: All of these responses give advice to the client. Telling the client what to do or how to behave which implies that the nurse knows what is best and that the client is not capable of making any decisions.
A client in a psychiatric unit tells the nurse, "I wanted to take the car to work, but the train station took all the tracks. Driving is the ticket when you want to go to the movies. No one needs money in heaven. We have money in our foods." How should the nurse document this conversation? 1. Associative looseness 2. Circumstantiality 3. Echopraxia 4. Anhedonia
1. Correct: Thinking is characterized by speech in which ideas shift from one unrelated subject to another in an unrelated manner. The person is not aware that the topics are unconnected. Speech may be incoherent at times. 2. Incorrect: With circumstantiality, the person is delayed in reaching the point of a communication because of unnecessary and tedious details. The point or goal is usually met, but only with numerous interruptions by the interviewer to keep the person on track. The person gets caught up in countless details and explanations. 3. Incorrect: The client who exhibits echopraxia may imitate or mimic the movements made by others. 4. Incorrect: Anhedonia is the inability to experience pleasure in acts that are normally pleasurable.
The nurse is working on the inpatient mental health unit and determines that one of the clients has suicidal thoughts. The nurse initiates suicide precautions. Which rationale best validates the action? 1. The client has the right to a safe care environment. 2. The nurse may be sued for malpractice if injury occurs. 3. All clients on mental health units are placed on suicide precautions. 4. Clients are most likely to act on suicidal thoughts when energy is low.
1. Correct: Verbalizing suicidal thoughts is a risk factor for client suicide. Safety must be maintained while the client is in this vulnerable state. The nurse identifies client at risk of suicide and intervenes to prevent harm for those identified as being at risk. 2. Incorrect: Client safety is the primary issue here. 3. Incorrect: This is not a true statement. All clients have the right to a safe environment; however, not all clients on the mental health unit are placed on suicide precautions. Only clients identified at risk for suicide are placed on suicide precautions. 4. Incorrect: This is an untrue statement. Clients are likely to act on suicidal thoughts as energy levels improve. The issue here is client safety, and the client's right to a safe environment.
The client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? 1. Ask the client to take a walk with you and make another pot of coffee. 2. Ask the client to reflect on their behavior to determine if it is appropriate. 3. Ask the group to tell the client how they feel when they are interrupted. 4. Tell the client to perform jumping jacks and count out loud.
1. Correct: Yes, get them away from the group and do something purposeful. Purposeful activities help the client use energy and focus on something. Distractibility is the nurse's most effective tool. 2. Incorrect: That is embarrassing and humiliating to the client. Singling out the client during group activity, does not fix the problem. This may lead to arguing and escalate the client's mania. 3. Incorrect: Sometimes this will be helpful during times of therapy, but the client is manic at this time. They may not believe them. Also, the client may be aggressive toward other group members. 4. Incorrect: This is getting them active, but the group will be interrupted by this behavior. Do not let the client continue with this attention seeking behavior. Remove the client from the group activity. The purpose of the group is to work toward a common goal. The client performing jumping jacks is not working toward a common goal.
Which assessment findings would the nurse expect when assessing a client for dementia? Select all that apply 1. Slow progressive deterioration of cognitive functioning 2. Decreased level of consciousness 3. Personality changes 4. Difficulty paying attention 5. Suicidal thoughts and sadness
1., 3. & 4. Correct: Dementia is characterized by a slow onset of symptoms over months to years. Dementia progresses to noticeable changes in personality. Dementia progresses to noticeable changes in attention span. 2. Incorrect: Dementia is progressive deterioration of cognitive functioning with no change in consciousness. 5. Incorrect: Sadness and suicidal thoughts are signs of depression.
The nurse is caring for a client hospitalized with dissociative amnesia. Which nursing interventions are appropriate for this client? Select all that apply 1. Obtain client likes and dislikes from family members. 2. Expose the client with data regarding the forgotten past. 3. Expose client to stimuli that was a happy memory of the past. 4. Hypnotize the client to help restoration of memory. 5. Ensure client safety.
1., 3. & 5. Correct: Considering likes and dislikes may help the client to remember. Using information to expose the client to stimuli that were happy memories may help the client remember. The client's disorder may lead to inattention to safety. Think safety first! 2. Incorrect: Do not expose the client to data regarding the forgotten past. Clients who are exposed to painful information from which the amnesia is providing protection may decompensate even further into a psychotic state. Dissociative amnesia is marked by an inability to recall important personal information, often traumatic or stressful in nature. 4. Incorrect: This is not a nursing function. Hypnosis is not in the nurse's scope of practice.
An adolescent has been admitted for evaluation of excessive weight loss over several months. When assessing the client, what data gathered by the nurse would be most important to support a diagnosis of anorexia nervosa? Select all that apply 1. Dehydration 2. Poor appetite 3. Amenorrhea 4. Tachycardia 5. Muscle loss 6. Constipation
1., 3., 5., and 6. CORRECT: The client has lost excessive weight over several months, indicating possibly early stages of anorexia nervosa. In the initial stages of starvation, skin becomes very dry and dehydrated. A client suffering from starvation is experiencing a loss of both food and fluids. Not only does the skin provide evidence of dehydration, but hair and nails will also be dry and brittle. This visible sign would be readily noticed by the nurse. (3) The client eventually develops amenorrhea. As the body begins to deteriorate from the effects of starvation, many normal body functions also decrease, or even cease. In women, amenorrhea develops as the normal monthly cycle slows, and finally stops. In fact, many individuals who recover from anorexia nervosa often have difficulty getting pregnant after that. (5) As weight decreases, muscle mass and strength is lost. As weight is lost, fatty tissue also decreases. Eventually, as muscles atrophy, the client will lose muscle mass, appearing quite skeletal. The client still perceives excessive body weight, though the nurse would visibly see atrophy. (6) Poor intake of fiber or fluids can also lead to increased constipation. When the human body is denied proper food and fluids, the gastrointestinal system responds by becoming sluggish. Constipation can become very serious, as waste products are not being eliminated by the body. 2. INCORRECT: With anorexia nervosa clients, the normal appetite still exists but the individual refuses to acknowledge the need to eat. The client will continue to resist the appetite in order to lose weight. 4. INCORRECT: Although the client may begin to experience arrhythmias, the pulse is not consistently tachycardic. The client may also experience episodes of bradycardia, especially at rest.
Which interventions are appropriate for the nurse to identify for a client admitted to the psychiatric unit for management of anorexia nervosa? Select all that apply 1. Weigh daily. 2. Allow only 20 minutes of exercise daily. 3. Allow the client to bargain for privileges as long as the client eats. 4. Stay with the client during the established time for meals. 5. Maintain visual observation for 1 hour following meals.
1.,4. & 5. Correct: Weigh daily, immediately upon rising and following morning void, using same scale and clothes if possible. The established time for meals is usually 30 minutes. This takes the focus off of food and eating and provides the client with attention and reinforcement. The hour following meals may be used to discard food stashed from tray or to engage in self-induced vomiting. 2. Incorrect: The client will work with their primary healthcare provider to create a controlled exercise program. This is usually done once healthy eating habits and some weight gain is achieved. See the word only in this option and think incorrect. 3. Incorrect: Do not argue or bargain with the client who is resistant to treatment. Be matter of fact about which behaviors are unacceptable and how privileges will be restricted for noncompliance. The person who is denying a problem and who also has a weak ego will use manipulation to achieve control.
The community health nurse is developing a presentation for adolescents on dealing with gun violence in school. What initial action should the nurse take? 1. Design a booklet for school districts on handling aggression. 2. Survey students to determine attitudes towards weapons. 3. Provide information on anger management to grade schools. 4. Investigate existing safety procedures in the schools.
2. Correct: Based on teaching/learning theory, the most important initial step is to determine if the client (in this case, a group of adolescents) is receptive to learning. Motivation is vital to successful learning. By first surveying student attitudes, the nurse gathers the data needed to prepare an age appropriate presentation that is more likely to be successful. 1. Incorrect: In this option, the nurse is implementing an action without collecting appropriate data. In addition, a booklet, while useful, is not what the nurse is to prepare. The correct issue is gun violence, not general aggression. 3. Incorrect: While it is true that anger management can influence violence, particularly at a young age, it is not the issue in this question. The idea of presenting information at the grade school level is logical but this nurse is to prepare an adolescent-based presentation. 4. Incorrect: This option does discuss collecting data; however, the information being collected does not address the topic in the question, which is gun violence. Safety procedures in schools could focus on many diverse concerns other than the issue of gun violence.
The nurse is assessing a client who was admitted to the inpatient psychiatric unit five days ago for exacerbation of psychotic symptoms, as evidenced by delusions of grandeur. Which type of client remarks indicate continued delusions of grandeur? 1. Comments with fear as a theme. 2. Comments with a theme of being grand or powerful. 3. Comments related to missing body organs. 4. Comments related to being under someone else's control.
2. Correct: Delusions of grandeur include thoughts that the person has exaggerated power or importance. Clients experiencing these feeling believe they are a deity, have special powers, rare abilities or hidden talents. They often feel they should be praised and publicly recognized for these powers. 1. Incorrect: Such comments would indicate delusions of persecution. These delusions occur when a client falsely believes they are being conspired against by others, being spied on, or anything that invokes fear in the events of their daily life. 3. Incorrect: These comments indicate somatic delusions in which the client experiences a false belief that relates to body functions and/or physical appearance. 4. Incorrect: These comments indicate delusions of control or influence in which there is a false belief that an eternal being, group, or energy is capable of controlling their thoughts and influencing their behavior.
A client admitted to the psychiatric unit is diagnosed with depression. What is the nurse's best response? 1. I understand what you are feeling. I have been left by someone I loved before. 2. You feel upset and unhappy by the loss of your significant other? It is ok to cry. 3. Don't worry. You will feel better once we start giving you medication for depression. 4. Crying isn't going to help anything. Let's talk about your past medical history now.
2. Correct: Empathy is the ability to see beyond outward behavior and to understand the situation from the client's point of view. Therapeutic language is necessary for this client and this acknowledges the clients feelings, restates for clarification, and allows the clients expression of feelings in a trusting environment. 1. Incorrect: This shows sympathy rather than empathy. With sympathy the nurse shares what the client is feeling and experiences a need to alleviate distress. This also takes the focus away from the client, and puts the attention on the nurse, which is self-centered and nontherapeutic. 3. Incorrect: This is giving false reassurance to a client that is sharing pertinent information related to the diagnosis and treatment plan. 4. Incorrect: This ignores the client's feelings by passing judgment and then changes the subject without solving the issue at hand.
The nurse is assigned to care for a client with the diagnosis of schizophrenia. The client tells the nurse, "I am having trouble tuning out the voices." What is the nurse's best response to this statement? 1. "There is nothing to help with this problem." 2. "You might hum when the voices are so troublesome." 3. "You should ask your primary healthcare provider to increase your medication." 4. "Wear earplugs to block out the voices."
2. Correct: Humming or listening to music may help to decrease the intrusive voices. This increases time spent in reality based activities and decreases preoccupation with delusional and hallucinatory experiences. 1. Incorrect: There are things that the client may do, such as humming or listening to an iPod. Telling the client that there is nothing to help them is not therapeutic. 3. Incorrect: The medication may need to be adjusted, but further assessment is needed. Remember, stay away from drugs as long as possible on the NCLEX. 4. Incorrect: Earplugs suggest blocking external stimuli; hallucinations are internal voices. Earplugs will not help internal voices and saying this could make the client think that the nurse hears the voices. Remember, The nurse is not supposed to go along with the hallucinations.
The nurse is caring for a client in the emergency department following an argument with the spouse. The client describes a verbal argument that began to get physical with shoving of the client. There is a history of domestic violence. Which phase of the cycle of violence is the client describing? 1. Honeymoon phase 2. Tension-building phase 3. Acute battering phase 4. Remorse phase
2. Correct: In the tension-building phase, minor physical or emotional abuse may occur as well as verbal arguments. The victim feels growing tension and tries to control the situation. 1. Incorrect: The honeymoon phase is characterized by remorse with promises never to hurt the victim again. The abuser is sorry and apologetic. 3. Incorrect: The acute battering phase includes the release of tension through extreme physical violence. This is also called the explosion phase. 4. Incorrect: There is no remorse phase, but remorse is expressed during the honeymoon phase. There are 3 phases: tension building, acute battering (explosion), and honeymoon phase.
A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the primary healthcare provider about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.
2. Correct: Initially, the nurse would fulfill the client's urgent dependency needs, but gradually withdraw attention to physical symptoms. Minimize time given to response to physical complaints. Gradual withdrawal of positive reinforcement will discourage repetition of maladaptive behavior. However, all new symptoms should be reported to ensure physician assessment of the complaint. 1. Incorrect: This is a nontherapeutic response. The client's feelings and concerns should not be denied. This will increase the anxiety level of the client. Do not totally ignore the client's complaint. 3. Incorrect: By postponing the group session the nurse is reinforcing the clients somatization disorder. The group session should start on time. 4. Incorrect: The pain is real to the client. This response is not therapeutic communication. The direct ignoring of the client's complaint will increase their anxiety level.
A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response? 1. "I understand you are upset, but you will have to go back to your unit sooner or later." 2. "You are repressing this event because it was frightening and painful for you." 3. "In my professional opinion, you are trying to undo what happened in the battle." 4. "You are splitting from the bad you, so that the good you survives."
2. Correct: Repression is the unconscious blocking from awareness an event or memory of something that is threatening or painful. It is the mind's way of forgetting or experiencing temporary amnesia until it can cope with an overwhelming circumstance. The nurse's response is concise and honest for a client that needs a trusting therapeutic relationship after a traumatic event. 1. Incorrect: The nurse is being aggressive and judgmental which is inappropriate and not therapeutic for the client. 3. Incorrect: Undoing is canceling out a behavior or trying to make amends. This is not a correct assessment of what the client has reported to the nurse. 4. Incorrect: Splitting occurs when a person cannot stand the thought that someone might have both good and bad aspects, so they polarize their view of that person as someone who is "all good" or "all bad."
The nurse is talking with the spouse of an alcoholic client. Which statement by the client's spouse is evidence of codependent behavior? 1. "I frequently tell my spouse that drinking alcohol is ruining our relationship." 2. "I go and pick my spouse up from the bar when not home by midnight." 3. "I do not go out drinking with my spouse, and will not drink at home either." 4. "I have told my spouse that I am willing to attend a counseling session when my spouse wants to stop drinking."
2. Correct: The spouse is attempting to please the alcoholic client. Codependent people are people pleasers, and they make excuses for others. The spouse is enabling the client to continue to drink. The spouse may feel keeping the client from driving while intoxicated will keep people safe. 1. Incorrect: This is a response by a person who is not codependent. This person is not afraid to show feelings and does not deny that there is a problem. 3. Incorrect: By not drinking with the client, the spouse shows that this behavior is not condoned. 4. Incorrect: Again, the spouse does not deny a problem and wants to help the client quit rather than making excuses.
A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. What is the client most likely experiencing? 1. Hyperventilation 2. Panic disorder 3. Somatization 4. Conversion disorder
2. Correct: These are all signs of panic disorder. Additional S/S include: sweating, feeling of choking, chest discomfort, abdominal distress, dizziness, lightheadedness, faintness, feelings of unreality or being detached from self, fear of losing control, fear of dying, paresthesias, chills or hot flashes. 1. Incorrect: A client experiencing hyperventilation would exhibit rapid respiratory rate, and tingling of lips and/or hands. Hyperventilation may occur with a panic attack but the best answer is option 2. 3. Incorrect: Somatization is the process by which psychological needs or stress are expressed in the form of physical symptoms. These reports of signs and symptoms are usually several years in duration. 4. Incorrect: Conversion disorder is a psychological disorder with symptoms or deficits affecting motor or sensory function that mimic a neurological or general medical disease.
The nurse overhears this client responding on the phone when their boss asks them to work an extra night shift. Which statement by the client demonstrates assertive communication? 1. "I know you are joking! I have already worked an extra night shift." 2. "I do not want to work an extra night shift. I have already worked an extra shift this week." 3. "Umm, well, okay. I guess I will work an extra night shift." 4. "Okay, I'll work an extra night shift." Then they say to another client. "The nerve of my boss to ask me to work another extra shift."
2. Correct: This is an example of assertive communication, the best response. Assertiveness is asking for what one wants or acting to get what one wants in a way that respects the rights and feelings of other people. 1. Incorrect: This response is aggressive behavior. This response is delivered in a forceful manner. 3. Incorrect: This response is nonassertive. This statement is giving into the boss, even though the client really doesn't want to work. Keywords are "umm, well and okay" 4. Incorrect: This response is Passive-Aggressive. It is the indirect expression of anger.
A new nurse is anxious about being assigned to a a client with violent episodes. Which statement by the charge nurse would address the new nurse's anxiety? 1. "What you really mean is that you fear a client with violent episodes." 2. "Though it is difficult, the staff needs to remain relaxed, but conscious of the client's violent episodes." 3. "I will instruct the staff to monitor the client's behavior for any signs of violent behavior." 4. "You attended an in-service during orientation on dealing with the client with violent behavior."
2. Correct: This response focuses both on the client's and the staff's response to the client. This is an example of the therapeutic communication of restating. The safety of the client, other clients, and the health care team is also a priority. The aggression by the client may be physical, verbal or both. The nurse should remain calm and firm. This approach will assist the client to return to their pre-crisis state. 1.Incorrect: The charge nurse is concluding the meaning of what the new nurse is saying. This is an example of the nontherapeutic communication of interpreting. The charge nurse stated that the new nurse is scared. This response may block further discussions with the new nurse about nursing care for potentially violent clients. The client, other clients, and the healthcare team's safety can also be placed at risk. 3. Incorrect: The charge nurse is changing the subject by stating that the staff members will be directed to monitor the client for violent behavior. This nontherapeutic communication of introducing an unrelated topic allows the charge nurse to control the direction of the conversation. The new nurse is expressing her concerns about caring for a client with violent episodes. The charge nurse is not focusing on the concerns of the new nurse. 4. Incorrect: The charge nurse responds by stating the new nurse attended an in-service during orientation about dealing with a client with violent behavior. The charge nurse does not identify that the new nurse may be uncomfortable dealing with clients with violent behavior. This is the nontherapeutic communication technique of rejecting. The new nurse may stop sharing with the charge nurse because of concern over further rejection.
In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation? 1. The client is probably having an extramarital affair. 2. The developmental task at this stage is adjusting to the needs of more than two family members. 3. A relative or close friend should be consulted for help so the client can pursue activities outside the home. 4. The client should be referred to a psychotherapist for evaluation and care.
2. Correct: When children are born or adopted into a family, the established couple must adjust to supporting the physical and emotional needs of the additional family member. Additionally, the couple is engaged in developing an attachment with the child(ren) and coping with energy depletion and lack of privacy. These requirements may lead to a sense of unhappiness and frustration on the part of one or both parents. 1. Incorrect: The answer choice that the client is having an extramarital affair is inappropriate. There is no evidence to support this assumption. 3. Incorrect: Although receiving assistance from family and friends is a good option, it is not the best answer choice. This family has to learn to adjust to being a family. 4. Incorrect: The client's feelings are normal and do not require that the client be referred to a psychotherapist.
The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional assessment findings by the nurse would suggest the client may develop anorexia nervosa? Select all that apply 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure
3. & 5. Correct: This client is reporting symptoms consistent with anorexia nervosa, a serious and potentially life-threatening eating disorder that develops secondary to the type of family or social stress experienced in adolescence. In addition to severe depression and amenorrhea, the nurse has identified brittle, dry nails, and a low blood pressure secondary to weight loss as additional indications of anorexia nervosa. 1. Incorrect: Despite the fact that anorexic clients experience severe weight loss, they continue to view themselves as heavy and generally wear loose fitting clothing to hide what they perceive as an overweight body. 2. Incorrect: Because of skeletal muscle atrophy and poor nutritional intake, anorexic clients display sallow, dry skin with brittle nails and hair. Oily, non-elastic skin would not be noted in a client with anorexia nervosa. 4. Incorrect: Gingival infections and dental caries are typical of clients with bulimia, another eating disorder in which stomach acid from frequent vomiting causes gum infections or dental caries. This is not common in anorexics.
While completing the admission history on an elderly client diagnosed with advancing Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the best response by the nurse? 1. "You can come to visit anytime you want to." 2. "Would you like to see the room and facilities?" 3. "Let's find a quiet place to sit and talk awhile." 4. "You did the best you could in this situation."
3. Correct. The nurse recognizes that the client's spouse is emotionally distraught at this moment, and is most in need of the nurse's focus at this time. Major life events have affected this family unit, including the client's terminal diagnosis and separation to a new living environment. This spouse is understandably overwhelmed by the changes occurring and, while the nurse will need to complete the admission paperwork, family needs must be met. Focusing on the spouse's emotional needs and allowing time to verbalize feelings could positively affect the client's adaptation to the situation. 1. Incorrect. Although this statement may be factual, it is a closed-ended statement, which belittles the spouse's expression of distress by presuming that unlimited visitation will rectify the situation. Though the spouse is verbalizing sadness because of physical separation, the grief may be a reflection of deeper concerns, considering the client's diagnosis. 2. Incorrect. This response focuses on the facility surroundings, rather than the spouse's distress and expression of sorrow. Changing the topic both ignores and belittles the client's grief. The nurse must address the needs of family as well as those of the client. 4. Incorrect. Though this response may seem encouraging, a closed-ended statement does not allow the openly distressed spouse an opportunity to verbalize further feelings. Family dynamics can significantly impact the client's well-being and potential to adapt to new surroundings.
A nurse has received report on a client to be admitted from the surgical suite following an unexpected amputation of the right arm because of a tractor accident. Which action by the nurse would best help the client upon arrival to the unit? 1. Notify hospital social services about adaptive equipment needs. 2. Prepare to change the dressing so the client can see the stump. 3. Ask client's family and hospital chaplain to be present in room. 4. Advise dietary that client will need food precut in small pieces.
3. Correct. This client will be awake from surgery to face the unexpected amputation of an arm, which has long-term physical, psychological, emotional and financial implication. Even clients facing a scheduled limb removal experience distress, anger or depression. Anticipating that the client will need a great deal of emotional support, the nurse is aware that having family and/or the hospital chaplain present after surgery may help the client cope with the bad news. 1. Incorrect. Losing an extremity involves relearning how to complete ADL's in an alternative manner and usually requires using adaptive equipment. This client may be introduced to specialty equipment prior to discharge, and social services will arrange for any home care needs. However, this action is not of primary concern at the time of the clients arrival in the unit. 2. Incorrect. The loss of a limb, particularly unexpectedly, can overwhelm a client and result in feelings of shock, anger, or even denial. Clients can experience a range of emotional responses based on age, beliefs, values or social support. One common behavior among new amputees is the hesitancy to look at the stump. Forcing the client to visualize the wound before being psychologically ready can hinder or delay adaptation. Additionally, the surgeon generally removes the original surgical dressing. 4. Incorrect. This client will need to learn many adaptive skills once the surgical site has healed. However, having food pre-cut into small pieces diminishes self-esteem and discourages client independence, which is important to recovery. An occupational therapist will be consulted regarding special eating utensils and techniques but usually there is little alteration in the preparation of food.
The school nurse has been observing a 13 year-old student during the past few months as the student has steadily lost weight. Which assessment finding would be the best indication of the beginning of an eating disorder? 1. Clothing size has decreased by 2 sizes. 2. Student eats most meals with peers. 3. Client reports a fear of gaining weight. 4. Diet consists mostly of fruit or raw vegetables.
3. Correct: An adolescent reporting a fear of gaining weight may indicate the beginning of an eating disorder. This is the best indicator of an eating disorder. 1. Incorrect: A decrease in clothing size does not indicate a problem. It may be an indicator of an eating disorder but in itself does not mean there is an eating disorder. 2. Incorrect: A client with an eating disorder may eat alone, or not at all. Eating with peers shows the feeling of acceptance which is not usually present with an eating disorder. 4. Incorrect: Eating snacks of fruit and vegetables is a healthy behavior. This alone does not contribute to an eating disorder. Also, it says the diet is "mostly" fruit and vegetables.
Which statement by the spouse of a client diagnosed with Alzheimer's indicates to the nurse that the spouse is dealing appropriately with stressors? 1. "I am in charge of every aspect of the care provided." 2. "I do not expect our children who live out of town to help." 3. "I keep a list of small tasks ready for people who ask me if they can help." 4. "I only go to my primary healthcare provider when I am sick."
3. Correct: Encourage caregivers to say "yes" when someone offers assistance. It's smart to have a list ready of small tasks that others could easily take care of, such as picking up groceries or driving the person to an appointment. 1. Incorrect: The caregiver should be willing to surrender some control. Delegating is one thing. Trying to control every aspect of care is another. People will be less likely to help if the caregiver micromanages, or insists on doing things their way. 2. Incorrect: The caregiver should spread the responsibility. Get family members involved as much as possible. Even someone who lives far away can help. Encourage the caregiver to divide up caregiving tasks. One person can take care of medical responsibilities, another with finances and bills, and another with groceries and errands. 4. Incorrect: Encourage the caregiver to stay healthy by keeping on top of primary healthcare provider visits. They should not skip annual routine, checkups, or medical appointments.
A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down to eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? 1. Carrots and apples 2. Donuts 3. Pepperoni pizza sticks 4. Strawberry pastry
3. Correct: High protein, high calorie, nutritious finger foods are required when the client will not sit down to eat. This client needs food they can eat "on the go" because they are burning more calories in this phase of bipolar disorder. 1. Incorrect: Although nutritious, these foods are not high calorie or high protein. 2. Incorrect: Donuts are high in calories but do not have high nutritional value. 4. Incorrect: Pasties are also high in calories but do not have high nutritional value. They are also not very easy to eat "on the go"
A float nurse arrives on the unit to assist in the care of clients for the shift. During report, the charge nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information,what should the charge nurse do? 1. Ask the float nurse, "Have you been drinking?" 2. Assign the float nurse to the least acute clients. 3. Notify the nursing supervisor of the observations. 4. Notify the board of nursing (BON) that the float nurse is an alcoholic.
3. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Confrontation should occur in the presence of a supervisor or other nurse and should include the offer of assistance in seeking treatment. This can prevent harm to client's and save the nurse's career or life. 1. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. The charge nurse should not lecture, scold or argue with the float nurse. 2. Incorrect: This response overlooks a potentially severe problem. Nurses dependent on drugs or alcohol can harm clients. The nurse should not be assigned to provide care if an impairment is suspected. Patient safety must remain the priority. 4. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. The report should contain consequences. Each state BON differs in that also some have treatment programs they administer themselves.
A client is seen in the clinic for recurrent, unexplained, vague stomach pain over the past 5 years. Esophagogastroduodenoscopy (EGD), colonoscopy, gallbladder ultrasound, and lab results have revealed no physical reason for the pain. The client tells the nurse, "the pain is so bad sometimes that I can't function!" What disorder is this client likely experiencing? 1. Conversion disorder 2. Pseudocyesis 3. Somatization disorder 4. Dysmorphic disorder
3. Correct: Somatization disorder is a syndrome of multiple somatic symptoms that cannot be explained medically and are associated with psychosocial distress and long-term seeking of assistance from healthcare professionals. Symptoms are vague, dramatized, or exaggerated in presentation. The disorder impairs social, occupational and other forms of functioning. 1. Incorrect: Conversion disorder is a loss of or change in body function resulting from a psychological conflict, the physical symptoms of which cannot be explained by any known medical disorder. This disorder affects voluntary motor or sensory functioning suggestive of a neurological disease. 2. Incorrect: Pseudocyesis is false pregnancy that may represent a strong desire to be pregnant. The client has nearly all the usual signs and symptoms of pregnancy such as enlarged abdomen, weight gain, cessation of menses and morning sickness.. 4. Incorrect: Dysmorphic disorder is characterized by the exaggerated belief that the body is deformed or defective in some way. Most common complaints are slight flaws of face or head, such as thinning hair, acne, wrinkles.
The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? 1. A game of Scrabble with peers 2. A group game of basketball. 3. An individual art project. 4. A card game with the nurse.
3. Correct: The client is likely to be most comfortable with solitary activities. When the client is extremely distrustful of others, solitary activities are best. Activities that demand concentration keep the client's attention on reality and minimize hallucinatory and delusional preoccupation. 1. Incorrect: The client is paranoid; therefore, he would not be comfortable within a group. Noisy environments may be perceived as threatening. 2. Incorrect: The client is likely to be very suspicious of the other players, thereby increasing their own anxiety level. The noisy basketball game may be too threatening for the client. Physical games are not the best choice for the paranoid schizophrenic client. 4. Incorrect: As trust builds with the nurse, this may be an appropriate activity, but there is a better answer. The "most" appropriate is an individual art project. The second best answer would be a card game with the nurse.
An adolescent client, diagnosed with anorexia nervosa, discloses an incestuous relationship to a nurse. What is the most therapeutic response by the nurse? 1. "It's okay. Let's talk about this." 2. "Have you discussed this with your primary healthcare provider?" 3. "Can you tell me how you feel about what happened?" 4. "Tell me more about what happened when you were younger."
3. Correct: The nurse is using a therapeutic approach by encouraging the client to express feelings about the relationship using an open-ended question. 1. Incorrect: The nurse is providing false reassurance by saying, "It's okay." This is a statement not a question to see how the client feels about talking with the nurse. The nurse should use open-ended questions to determine whether or not the client wishes to discuss the incestuous relationship further at this time. 2. Incorrect: This is a non-therapeutic, closed ended question that only requires a yes or no answer. This is not a priority at this time. An open ended question will allow the nurse to see if the client is ready to share with the nurse. 4. Incorrect: The nurse should not probe for a factual account about a past event and should keep the focus of the discussion on the client's feelings about the event. Again, this is a statement, not an open ended question.
The nurse is caring for a client in an outpatient clinic. The client's spouse died 8 months ago. Which statement by the client suggests that the client is achieving resolution of grief? 1. "I am starting a new life, so I have removed all of the pictures from the wall that remind me of my spouse." 2. "I'm so lonely and I'm not sure life is worth living now." 3. "Although it hasn't been easy, I accept the loss of my soul mate." 4. "If only we had spent more time together before the illness got so severe."
3. Correct: This client has begun to achieve resolution of grief by walking through the tasks of mourning: to accept the reality of the loss, to experience the pain of grief, to adjust to an environment in which the deceased is missing, and to withdraw emotional energy and perhaps invest in another relationship. 1. Incorrect: This client is still in the grieving process. Behavioral manifestations of grief include crying, withdrawal, avoiding reminders of the deceased, seeking or carrying reminders of the deceased, over activity, and a variety of changes in relationships with other people. 2. Incorrect: This client is still in the grieving process. The manifestations of grief can vary widely. This client has not accepted the reality of the loss, invested in relationships with other nor allowed themselves to go through the process of grief. 4. Incorrect: This client is still in the grieving process.
A terminal client begins reminiscing about the past, expressing grief and regret over life choices. What response by the nurse would best help client cope at this time? 1. "You can't change the past so try not to dwell on it." 2. "Would you like me to call a priest for you to talk with?" 3. "You still have time to make amends if you want." 4. "I can sit here with you while you continue to talk."
4. CORRECT: Anytime a client expresses the desire to talk, the nurse should respond with an open-ended response, encouraging the client to continue to verbalize in a non-judgmental environment. More importantly, the nurse should remain with the client, even if there is no talking, to provide visual comfort. 1. INCORRECT: This non-therapeutic response denies the client's right to review past events or express feelings, which is a normal reaction at end of life. The nurse's closed response does not provide the client with the opportunity to verbalize. 2. INCORRECT: The nurse is ignoring the client's need to talk and is transferring care away to another individual, even if that individual is a clergyman. This is an incorrect action. 3. INCORRECT: While the client may regret some life choices, there is no mention of the desire or need to correct the past. The nurse is making an assumption.
An elderly client is to be ambulated for the first time following a hip replacement. The client refuses to get out of bed, indicating an extreme fear of falling. What statement by the nurse is most therapeutic? 1. "Don't be afraid because I will not let you fall." 2. "Your doctor says you must walk twice today." 3. "I'll get another nurse to help so you won't fall." 4. "What worries you most about getting out of bed?"
4. CORRECT: The nurse needs to focus on the client's psychological as well as physical needs. An open-ended question or statement encourages the client to elaborate and share concerns that the nurse needs to address. It would be inappropriate to force the client to participate in an activity that causes extreme fear and distress. 1. INCORRECT: The nurse is dismissing the client's right to experience a specific emotion, rather than actively seeking the reason behind those feelings. The nurse is not utilizing appropriate communication techniques. 2. INCORRECT: This tactless response focuses on the orders provided by the primary healthcare provider, rather than the client's expressed concerns. Such a comment by the nurse is non-therapeutic because it ignores the client's psychological needs. 3. INCORRECT: Although the nurse offers a solution to the client, there is no chance for the client to verbalize feelings and concerns. It is more important to present the client with the therapeutic opportunity to discuss fears.
The family of an elderly client are concerned about emotional well-being since the loss of the spouse two years ago. What alternative therapy could the nurse recommend for this client? 1. Massage 2. Bioelectromagnetics 3. Acupressure 4. Animal-assisted therapy
4. Correct: Animal-assisted therapy is the use of specifically selected animals as a treatment modality in health and human service settings. It has been shown to be a successful intervention for people with a variety of physical or psychological conditions. The contributions companion animals make to the emotional well-being of people include providing unconditional love and opportunities for affection; achievement of trust, responsibility, and empathy toward others; a reason to get up in the morning, and a source of reassurance. 1. Incorrect: Massage therapy is the scientific manipulation of the soft tissues of the body. It is believed to aid the body to heal itself. 2. Incorrect: This uses electromagnetic fields to affect the functioning of cells, tissues, organs and systems. 3. Incorrect: Acupressure is a treatment rooted in the traditional Eastern philosophy of life energy, that flows through the body along pathways. It opens up blocked pathways to relieve pain.
The nurse is caring for a client diagnosed with Obsessive Compulsive Disorder (OCD). Which statement, made by the client, would be the best indicator of improvement? 1. "My friends don't know I have OCD." 2. "I only do my hand washing to reward myself when I am good." 3. "I know my thoughts and behaviors aren't very normal." 4. "I have more control over my thoughts and behaviors."
4. Correct: Control is an issue for those with OCD. Appropriate goals for this client would be to control unwanted behaviors and thoughts. 1. Incorrect: Doesn't indicate control over behavior. Not telling their friends indicates the client is ashamed of disease and doesn't show improvement. 2. Incorrect: The behaviors are not reward for good behavior; they are utilized to decrease anxiety. Compulsions are ritualistic behavior that the individual feels driven to perform in an attempt to reduce anxiety. 3. Incorrect: Clients with OCD are aware their behavior is not normal, so this would not be an indicator of improvement. Obsessions are defined as thoughts, impulses or images that persist and recur, so that they cannot be dismissed from the mind.
A client diagnosed with Alzheimer's disease tells the nurse, "I haven't eaten all day. When am I going to eat?" The nurse noted that the client ate 100% of the provided lunch 45 minutes ago. What would be the best way for the nurse to respond? 1. "I'll ask the kitchen if they can send you up another lunch." 2. "What makes you think you didn't eat lunch?" 3. "You ate lunch less than 1 hour ago." 4. "Would you like me to get you some crackers and milk?"
4. Correct: The client believes that he/she has not eaten. Do not argue with the client. Offer the client something to eat. Fix the problem that the client believes he/she has. 1. Incorrect: The client wants to eat but another lunch is not needed since the client ate 100% of the provided lunch, just 45 minutes ago. A snack can be given. As this disease progresses, short and long term memory are affected. The client will know if he/she is hungry. So provide food or a snack at this time. 2. Incorrect: Do not argue with the client. This will cause agitation and possible aggression. 3. Incorrect: Again do not argue with the client. The client does not believe he/she has eaten.
The nurse has been working with a client who has a diagnosis of schizophrenia. The client has had three inpatient admissions in the past, but none in the past 6 months. Which statement by the client indicates adequate understanding of the medication treatment regimen? 1. I am feeling better so I hope that I don't have to take the medication for long. 2. I can stop the medication after I have been out of the hospital for a year. 3. The medicine is good for me now; however, I don't want to take it forever. 4. The medication keeps me out of the hospital, and I don't want to hear voices again.
4. Correct: The client must take the medicine long-term. If the client makes the connection between the medicine and feeling better, adherence is more likely. 1. Incorrect: This statement indicates lack of understanding of the disorder and required outcomes. Medication is likely to be required indefinitely. 2. Incorrect: The client does not understand the connection between adherence to medication and staying out of the hospital. 3. Incorrect: It is very likely that the client will be on the medication for a lifetime. This information should be a part of the plan of care and not withheld from the client's knowledge of the disorder and effective control.
The nurse is bathing a confused client in the acute care unit. The nurse talks with the client and explains each procedure. During the bath, the client becomes very agitated. What should the nurse do? 1. Complete the bath as quickly as possible. 2. Reassure the client and request them to stop acting out. 3. Continue bathing with assistance from an unlicensed assistive personnel. 4. Stop the bath, dress and reassure the client.
4. Correct: The nurse should not continue bathing if the client is becoming so distressed. Perhaps the bath can be completed at a later time. Safety is the priority. 1. Incorrect: The client is obviously distressed. Continuing the bath could jeopardize the safety of the nurse and client. 2. Incorrect: Reassurance may not work with the confused client. It is difficult to know exactly why the client is becoming so distressed. The safety of the client is important. 3. Incorrect: Adding a second person will increase the feelings of powerlessness in the client. This could and will add to the client's distress. Stopping the procedure is the safest answer.
The nurse is making rounds on the psychiatric unit at the beginning of the shift. Which client should be seen first? 1. Client with somatoform disorder. 2. Client with depression. 3. Client with panic attacks. 4. Client with hallucinations.
4. Correct: The nurse will need to assess the client with hallucinations first. The client who is actively hallucinating may be hearing voices, and the voices may order the client to do something harmful to self or others. 1. Incorrect: The client with Somatoform disorder has a physical symptom with a psychological cause and does not require immediate attention. Although the symptoms are real to the client and not under voluntary control as with fictitious disorders. They do not have a physical cause that would warrant immediate attention. Therefore, this client does not have a need to be seen before the client having hallucinations who may be at risk for harming self or others. 2. Incorrect: The client with depression should be seen second. There is no indication that the client is currently on suicide precautions. However, as the client receives medication and the energy level rises, the client may be at an increased risk of suicide. 3. Incorrect: The client with panic attacks is likely to summon the nurse if needed immediately. This client would not need immediate attention at this time. The client with panic attacks is not considered at risk of harm to self or others and would not have to be seen before the clients with hallucinations or depression.
A client with a history of schizophrenia is currently being treated in a mental health facility. The client wants to vote in an upcoming election. The nurse understands what is true about the legality of this action? 1. Primary healthcare provider can decide if client may vote. 2. Psychiatric clients cannot vote if taking medication. 3. A lawyer must approve the finished ballot. 4. An absentee ballot from the polling place can be obtained.
4. Correct: There are very few reasons that a United States citizen would lose the right to vote in any election, and those few are mostly legal violations. A client who is hospitalized, whether in a medical or psychiatric facility, still retains the right to vote. The nurse, or facility designee, must advocate for this client by obtaining an absentee ballot, following the laws of that state, and is required to provide privacy for the client to complete that ballot. 1. Incorrect: The primary healthcare provider has no authority over the client's ability to cast a vote. Regardless of any mental health diagnosis, this client still retains the legal right to vote in any election. In fact, notifying the primary healthcare provider of the client's intent to vote violates the client's privacy. 2. Incorrect: Whether a client takes medication does not affect the client's right to cast a ballot in any election. Refusing this client, the right to vote based on medication use would be considered discriminatory. 3. Incorrect: A lawyer is not required to approve either the client's voting rights, or the completed ballot. In fact, having anyone else look at the client's ballot would be a violation and is definitely illegal. A client's ballot is private and protected by both state and federal law.
A client has returned to the medical surgical unit from surgery following an emergency appendectomy. The client's spiritual practice involves kneeling multiple times daily for prayer, and the client asks the nurse for assistance to get out of bed to kneel. What statement by the nurse is most appropriate at this time? 1. "You will have to remain in bed for the next 48 hours." 2. "The floor has too much bacteria for you to kneel down." 3. "Aren't there alternatives you can use till you heal more?" 4. "We can help you out of bed whenever you need to pray."
4. Correct: This response by the nurse indicates acknowledgement of the client's spiritual needs as well as specifying a plan to assist in that process. This non-judgmental reply could also provide a positive teaching opportunity regarding surgical recovery, splinting of any incision and appropriate methods for getting out of bed. 1. Incorrect: An appendectomy does not require a client to be bedfast for 48 hours. Remaining in bed would increase the potential for multiple, post-surgical complications, including blood clots or pneumonia. Most clients can be ambulated with assistance within hours of the procedure. 2. Incorrect: While this statement regarding bacteria may be true, it does not justify refusing to allow a client to follow spiritual practices. The nurse should discuss any specific precautions needed with the client. 3. Incorrect: This non-therapeutic communication by the nurse is demanding an explanation of the client. While the question may represent a valid nursing concern, it has not been presented in a positive manner to the client.
The nurse has been talking with a depressed client at an outpatient clinic. When asked how the client feels to live alone, the client simply stares straight ahead. How should the nurse respond? 1. Ask, "Why won't you answer me?" 2. Leave the client alone for awhile. 3. Tell a joke to lighten the mood. 4. Use therapeutic silence.
4. Correct: Use of silence allows the client time to think over what he or she wants to say and gives the client a chance to collect thoughts. 1. Incorrect: This is not therapeutic and appears aggressive and confrontational. 2. Incorrect: This is not therapeutic. Depressed clients may need extra time to formulate their thoughts. 3. Incorrect: This is not therapeutic and demonstrates disregard for the client's feelings.
The client with obsessive-compulsive disorder (OCD) asks the nurse for help with a repetitive behavior. What is the most likely origin of this behavior? 1. Fear 2. Depression 3. Delusions 4. Anxiety
4. Correct: Yes, this is how they deal with anxiety. The obsession causes the anxiety such as a thought that can't be dismissed from the mind. The ritualistic behavior that the client is driven to perform is an attempt to reduce anxiety. The compulsive act temporarily reduces high levels of anxiety. 1. Incorrect: No, is phobia that deals with fears. A phobia is an excessive and irrational fear reaction. If you have a phobia you may experience a deep sense of dread or panic when you encounter the source of your fear. 2. Incorrect: OCD is not about depression. Depression is a mood disorder that causes persistent feelings of sadness and loss of interest. Not the origin of OCD. 3. Incorrect: Delusions are not associated with OCD. Delusions are most often defined as false fixed beliefs that cannot be corrected by reasoning.
The nurse is caring for a client who presents to the mental health unit following a violent altercation with the spouse. The client has numerous bruises on the face, chest, and back. There is one laceration where spouse "came at me" with a knife. At this time, what is most likely to be the mood of the perpetrator in this situation? 1. Extreme anger 2. Anxiety 3. Kindness 4. Irritability
There are 3 phases: tension building, acute battering (explosion), and honeymoon phase. 3. Correct: The perpetrator has completed the acute battering phase and has now likely entered the honeymoon phase with extreme kindness and acts of love. The attacker is now calm after the tension has been released. You may witness remorseful and apologetic behaviors like bringing gifts and promises of love. 1. Incorrect: The anger phase is likely over after the attacker has beaten the victim. The extreme anger exhibited during the acute battering stage. The abuser releases the built-up anger and tension by brutal and uncontrollable beatings. After the beating, the client is calm and described as "in shock" or having amnesia of the event. 2. Incorrect: The tension or anxiety would be felt during the tension-building phase. This tension building stage and is characterized by minor incidents like pushing, shoving and verbal abuse. During this time the abused spouse may accept the abuse for fear of it getting worse so the abuser rationalizes that the behavior is acceptable. The abuser may even turn to alcohol and drugs to curb the anger. 4. Incorrect: Irritability would be demonstrated during the tension-building phase.
The nurse is caring for a client in the outpatient mental health clinic. The client recounts several incidences of spousal abuse. The client says to the nurse, "I know that he loves me. Sometimes I can be quite irritating." Which response is most appropriate by the nurse? 1. "You are not responsible for the abuse." 2. "Sometimes we can irritate our spouses." 3. "The worst is over now." 4. "You should think about leaving him."
1. Correct: The perpetrator is responsible for his/her own actions, but the abused partner may take responsibility or make excuses for them. This mindset needs to be clarified and corrected to prevent further abuse and keep the client safe. 2. Incorrect: Behavior of the perpetrator is not the responsibility of the victim. This statement reinforces the client's belief that they are at fault for the abuse. 3. Incorrect: The severity of the abuse usually increases over time. This is giving false reassurance to the client. 4. Incorrect: The nurse is offering advice with the "should" statement. A decision to leave must be made by the victim, and the victim should understand that, at the point of leaving, violence may become fatal.
A client asks the nurse, "How is relaxation therapy going to help reduce my stress?" What would be the nurse's best response? 1. Relaxation therapy leads to more awareness of potential stressors 2. Relaxation therapy reduces stress by releasing small doses of epinephrine into the body. 3. Stress can be eliminated from your life when you use this therapy. 4. Relaxation therapy can counteract the flight or fight response.
4. Correct: When stress overwhelms the nervous system, the body is flooded with chemicals that prepare for fight or flight. To counteract this stress response, relaxation techniques can be used. Relaxation is a process that decreases the effects of stress on the mind and body. Practicing relaxation techniques can reduce stress symptoms by: slowing the heart rate; lowering blood pressure; slowing respiratory rate; reducing activity of stress hormones; increasing blood flow to major muscles; reducing muscle tension and chronic pain; improving concentration and mood; lowering fatigue; reducing anger and frustration; and boosting confidence to handle problems. To get the most benefit, use relaxation techniques along with other positive coping methods, such as thinking positively, finding humor, problem-solving, managing time, exercising, getting enough sleep, and reaching out to supportive family and friends. 1. Incorrect: Identifying stressors is part of the solution. The relaxation techniques themselves bring about the counter production of the stress response. 2. Incorrect: Epinephrine is released during stress and increases anxiety. Relaxation therapy counteracts symptoms of stress, such as increased heart rate, increased respiratory rate, increased blood pressure, pupil dilation, and increased metabolism. 3. Incorrect: The goal of relaxation therapy is not to improve the stress response of fight or flight but to reduce or counteract the response. Relaxation therapy can help reduce the fight or flight response before it becomes severe.
