Saunders PN Mental Health

The nurse is admitting a victim abuse client to the mental health unit with a diagnosis of severe anxiety. The nurse notes which signs/symptoms that indicate it is difficult for the victim to talk about the situation? Select all that apply.

-Hesitation -Lack of eye contact -Using vague statements such as,...

The nurse is caring for a client who has been diagnosed with a dissociative disorder. Which interventions should the nurse use in providing care for the client? Select all that apply.

-Request that the client perform undemanding, self-care tasks -Reinforce teaching the client techniques to maintain present reality -Assist the client to reestablish relationships w/ significant others

Which nursing interventions are most helpful when caring for a client who is displaying signs/symptoms of panic level anxiety? Select all that apply.

-Speak slowly -Use simple statements -Provide the client with high-calorie beverages

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement?

"Are you fearful and think that others may want to hurt you?"

An unlicensed assistive personnel (UAP) is assigned to work with the nurse to care for a client who is at risk for suicide. Which statement made by the UAP indicates to the nurse that the UAP understands suicide?

"Discussing suicide with a client is not harmful."

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?

"I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

The nurse working the evening shift is assisting clients in getting ready to go to sleep. A client diagnosed with obsessive-compulsive disorder (OCD) becomes upset and agitated and asks the nurse to sit down and talk. Which response by the nurse would be best at this time?

"I can see that you're upset. I'm willing to listen."

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response?

"I cannot promise to keep a secret."

The nurse is monitoring a client who is in seclusion. Which statement would indicate that the client is safe to come out of seclusion?

"I don't feel like hurting myself anymore."

A client who was hospitalized for depression is being prepared by the nurse for discharge. In evaluating the coping strategies learned during hospitalization, the nurse should recognize which statement by the client is an indication that further teaching is needed?

"I know that I won't become depressed again."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement?

"I no longer feel that I deserve the beatings my husband inflicts on me."

The nurse is caring for an older depressed client whose son was killed in an armed robbery after murdering two people. The client says, "I don't know what I did wrong. His dad died a hero in Vietnam when he was only 2 years old, but he's had everything. When he threw the cat up against the wall to see if it landed on its feet and stole money from me and denied it, his sister covered for him." The nurse plans to make which therapeutic response to the client?

"It seems as if you or your daughter feel regret?"

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response?

"It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his slippers from where he always kept them under his side of our bed. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic?

"It's okay to grieve and be angry with your daughter and anyone else for a time."

The nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which?

"Our relationship is a therapeutic and a helping one."

A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?

"Perhaps you could just enjoy the music without singing."

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for further teaching about this self-help group?

"The leader of this self-help group is the nurse or psychiatrist."

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which would be a therapeutic response by the nurse?

"What aspects of this situation are the most difficult for you?"

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem to be worth it anymore. Why not just end it all?" Which initial nursing response is appropriate?

"What do you mean by that?"

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. Which comments by the nurse would be therapeutic at this time?

"What is causing you to become agitated?"

The nurse is caring for an older adult client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic?

"You must be feeling all alone at this point."

A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic?

"You seem very distressed over learning you have asthma."

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse?

"You understand that people fear for their children, but you're feeling unfairly treated?"

The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa? Select all that apply.

-A high achiever -Personality changes -Lanugo over the back and extremities

The nurse is educating a community group about risk factors for suicide and knows a member needs further teaching when which criteria are chosen as risk factors? Select all that apply.

-Age less than 32 years -Practicing a religion -Married over 10 years

The nurse is caring for a client with long-term Alzheimer's disease (AD). Which are some of the behavioral manifestations the nurse should expect to observe? Select all that apply.

-Apraxia -Aphasia -Agnosia -Hyperorality

The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply.

-Autocratic Leader -Democratic Leader -Laissez-Faire Leader

The nursing instructor is helping students learn about bioethics, which is the study of specific ethical questions that arise in health care. The instructor reviews with the students which basic principles of bioethics? Select all that apply.

-Autonomy -Beneficence -Veracity -Fidelity -Justice

The nurse is assessing a client diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that according to current references, PTSD signs/symptoms can be grouped into which three main categories? Select all that apply.

-Avoidance -Hyperarousal -Reexperiencing

The nurse caring for a client with schizophrenia prepares to document which signs/symptoms exhibited by the client as negative? Select all that apply.

-Avolition -Anergia

The nurse is admitting a client with a diagnosis of agoraphobia. Which behaviors exhibited by the client would support this diagnosis? Select all that apply.

-Being on a bridge -Riding in an elevator -Being alone at home -Traveling in an airplane

The licensed practical nurse is assisting in the admittance of a client who has been involuntarily committed to the behavioral health unit. Which actions by the client before hospitalization led to the commitment? Select all that apply.

-Client threatened to commit suicide -Client threatened to kidnap his spouse

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply.

-Communicate expected -Follow through -Assist the client -Be clear w/ the client

The nurse is assessing a client who has been diagnosed with Alzheimer's disease. The nurse knows that in the initial stages the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease? Select all that apply.

-Denial -Confabulation -Perseveration -Avoidance of questions

A client is admitted to the mental health unit with a diagnosis of possible somatic symptom disorder. Besides anxiety, the nursing assessment is especially important in identifying which client signs/symptoms are contributing to the somatic symptom disorder? Select all that apply.

-Depression -Substance Abuse -Adverse Childhood Events -PTSD

The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply.

-Diaphoretic -Temperature of 104.8 -Blood pressure of 210/130 mmHg

The nurse is having a therapeutic discussion with a client and knows that which statements by the client should be immediately reported to the charge nurse? Select all that apply.

-I hid my silverware from dinner last night -I know that by this time tomorrow all my troubles will be over

The nurse is caring for a client who is hospitalized because of severe depression. Which statements would be most helpful in assisting this client? Select all that apply.

-I notice you are wearing a blue shirt. -Do you have any plans of harming yourself? -I will sit here with you even if you choose not to talk with me.

The nurse in the mental health clinic hears a client yelling and threatening to hurt his sister. The nurse reports this episode to the mental health therapist. Which should the nurse anticipate the therapist to do? Select all that apply.

-Identify the specific person being threatened -Take appropriate action to protect the identified victim -Assess and predict the client's danger of violence toward another

A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." Although the nurse interprets this response as denial, which findings support a severe level of anxiety? Select all that apply.

-Inability to think clearly -Inability to problem solve

The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.

-Incoordination -Mental confusion -Muscle hyperirritability

A client with a history of victim abuse has which signs/symptoms of the physical effects of living with a severe level of anxiety and chronic stress? Select all that apply.

-Irritability -Hypertension -GI disturbances

An oriented client is scheduled to have aversion therapy to change behavior. Before initiating any aversive protocol, the therapist, treatment team, or society must answer which questions? Select all that apply.

-Is it in the best interest of society? -Does its use violate the client's rights? -Is this therapy in the best interest of the client?

The nurse is caring for a client with an eating disorder and knows that which signs/symptoms indicate that the client is dealing with anorexia nervosa? Select all that apply.

-Lanugo -Amenorrhea

The nurse is caring for a client who is diagnosed with anxiety. The nurse knows that according to Hildegard Peplau, there are different levels of anxiety that include which? Select all that apply.

-Mild -Panic -Severe -Moderate

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease should expect to observe which behaviors in this client? Select all that apply.

-Misplacing a valuable object -Difficulty coming up with the right word

A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions should the licensed practical nurse (LPN) initiate? Select all that apply.

-Monitor airway -Notify the RN -Remain with the client to provide support -Administer the prescribed intramuscular antiparkinsonian medication

The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply.

-Mutual Learning -Increased Feedback -Instilling a sense of belonging -An opportunity to practice new skills in a relative environment

The nurse is assessing a client diagnosed with severe anxiety. Which objective data should the nurse expect to find? Select all that apply.

-Oblivious to surroundings -Unable to focus on anything -Engaging in purposeless activities -Showing unproductive relief behavior

The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply.

-Outlandish behaviors -Purposeless arousal and movement -Grandiose delusions of being King Arthur -Incessant talking that includes sexual innuendos

The nurse is collecting data on a newly admitted client with conversion disorder. The nurse knows which voluntary motor or sensory function deficits might be present in this client? Select all that apply.

-Paralysis -Blindness -Paresthesia -Movement Disorder

A client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image. The client reports an extreme fear of public speaking. The nurse recognizes that this client is suffering from social phobia. Which are some other manifestations of social phobias? Select all that apply.

-Performing badly on stage -Looking awkward while eating or drinking in public -Not being able to answer questions in a classroom -Fear of saying something that sounds foolish in public

The psychiatric nurse knows that a therapeutic nurse-client relationship includes which specific goals and functions? Select all that apply.

-Promoting self-care and independence -Facilitating communication of distressing thoughts and feelings -Helping clients examine self-defeating behaviors and test alternatives -Assisting clients with problem solving to help facilitate activities of daily living

The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply.

-Punishment -Avoidance Training -Pairing of a maladaptive behavior

The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply.

-Refer to hallucinations as if they are real -Ask the client directly about the hallucinations -Watch the client for cues... -Address any underlying emotion, need, or them...

The student nurse is studying the cellular composition of the brain composed of approximately 100 billion neurons or nerve cells. Although neurons come in a great variety of shapes and sizes, all carry out the same three types of physiological actions. Which are these types of actions? Select all that apply.

-Respond to stimuli -Conduct electrical impulses -Release chemicals called neurotransmitters

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply.

-Restating -Listening -Maintaining neutral responses -Providing acknowledgement and feedback

A client who has terminal cancer has been experiencing a significant increase in pain. However, today the client is no longer complaining of pain but is quiet and isolative. Which types of therapeutic communication should the nurse employ? Select all that apply.

-Sit by client's bed holding his or her hand. -Reminisce with the client and share a humorous client enjoys -The nurse asks: "What can I do... -The nurse asks: "I noticed you grimacing... -The nurse states: "It must be very frustrating...

The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?

reported hopelessness

Which client is most likely at risk to become a victim of elder abuse?

A 90-year-old woman with advanced Alzheimer's disease

The nurse employed in a psychiatric unit receives a client assignment for the day. Which client assigned to the nurse is at the highest risk for committing suicide?

A client with severe depression and terminal cancer

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

A confused and disoriented client is admitted to the psychiatric unit diagnosed with posttraumatic stress disorder (PTSD). The nurse initially plans to take which action with this client?

Accept the client as a person and make the client feel safe.

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse?

Agoraphobia

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?

Alcoholics Anonymous

A client is scheduled to have electroconvulsive therapy (ECT). Which information should the nurse tell the client?

Amnesia of events occurring near the period of the therapy is common.

A client in a manic state emerges from her room. The client is dressed in a low-cut blouse and a miniskirt. She is not wearing underwear and she proceeds to sit on a male client's lap and begins to make sexual remarks and gestures to the male client. The nurse should take which action?

Approach the client quietly, take her to her room, and assist her in getting dressed.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety?

Assign a staff member to the client who will remain with him or her at all times.

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care?

Assigning the client to a room at the end of the hall to prevent disturbing the other clients

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase?

Assist with making appropraite referrals

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need to further research the disorder?

Body weight well below ideal range

A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism?

Denial

The nurse is monitoring a client with a history of opioid abuse for signs/symptoms of withdrawal. The nurse monitors this client for which signs/symptoms associated with opioid withdrawal?

Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia

The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?

Develops a relationship to help reduce the frequency of the delusions

The nurse notes that a client with acquired immunodeficiency syndrome (AIDS) appears anxious and is reluctant to ask questions. Which action should the nurse take to best address these observations?

Discuss common fears and questions expressed by other clients with the same diagnosis.

A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication should the nurse explain is available for this purpose?

Disulfiram

The nurse is caring for a client with severe depression. Which activity is appropriate for this client?

Drawing

The nurse is collecting data from a newly admitted client recently diagnosed with borderline personality disorder. Which data provided by the client best supports the nurse's concern that the client is not using effective coping skills?

Driving under the influence (DUI) conviction resulted in a 1-year suspended license

The nurse is assisting in conducting a group therapy session. A client who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. Which nursing action is appropriate?

Encourage the client to stay and ask the client what she is feeling.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding?

Evidence of the client's altered and distorted body image

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action?

Examine and treat the wound sites.

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first?

Examine the neck area and assess the airway.

When caring for a client who has been raped, which intervention should the nurse implement during the examination?

Explaining procedures to be completed and why the procedures are necessary

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention?

Feed, bathe, and dress the client as needed until the client can perform these activities independently.

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

A visitor brings a suicidal client a brightly packaged gift. The nurse accompanies the visitor to the client's room and takes which action?

Has the client open the gift with the nurse present

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms?

Hypertension, disorientation, hallucinations

An adolescent who has been reported for drawing sexually explicit scenes in her school textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms?

I am concerned about you. Are you...

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response?

I can't tell you that (or similar wording)

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action?

Increasing the level of suicide precautions

A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action should the nurse perform?

Inform the client that she is being secluded to help regain control of herself.

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. The nurse reinforces which instruction to the victim in the discharge plan?

Information regarding the location of shelters

The nurse has been closely observing a client who has been displaying aggressive behaviors. The nurse observes that the behavior displayed by the client is escalating. Which nursing intervention is least likely to be helpful to this client at this time?

Initiate confinement measures.

The nurse receives a telephone call from a male client who states that he wants to kill himself and has a bottle of sleeping pills in front of him. Which would be the best response by the nurse?

Keep the client talking and signal to another staff member to send help to the client.

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?

Look for organic causes of the paralysis.

A client tells the nurse that he is feeling out of control. The nurse observes that the client is pacing back and forth. Which approach by the nurse is appropriate to maintain a safe environment?

Move the client to a quiet room and talk about his feelings.

The nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs/symptoms of anxiety and attempts to assist the client back to the client's hospital room. Which is the next appropriate nursing action at this time?

Notify the registered nurse (RN).

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder?

Observe for excessive exercise.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?

Observing rigid rules and regulations

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the primary health care provider immediately. Which nursing intervention is appropriate?

Offer to assist the client to an examination room until the primary health care provider is notified.

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?

Offer to take the client to an examination room until he or she can be treated.

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?

Open-ended questions and silence

The nurse is assigned to care for a client being admitted to the nursing unit from the emergency department who attempted suicide by ingesting several sleeping pills. The nurse implements which priority action when the client arrives to the unit?

Place the client on one-to-one suicide precautions.

The parents of a teenager diagnosed with anorexia nervosa ask the nurse what part they can play during the long recovery period. The nurse accurately relates that which actions should the parents take?

Planning a non-food related activity

After 5 days in the psychiatric unit, a manic client is able to tolerate short periods in the dayroom. The nurse overhears the client telling another client that he is a journalist posing as a client in order to write an article for a magazine. Which response is the nurse's best action?

Privately confront the client with reality.

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?

Provide safety for both the client and other clients on the unit.

The nurse reviews the treatment prescribed for a client with a mental health disorder. The nurse understands that a form of psychotherapy in which the client enacts situations that are of emotional significance is identified by which term?

Psychodrama

A client is found to have rape-trauma syndrome. The nurse plans care for the client, knowing that rape-trauma syndrome is a condition that involves which?

Reexperiencing recollections of the trauma

A client with obsessive-compulsive disorder (OCD) who continually cleans the bathroom becomes enraged with the roommate for using the bar of bathing soap for cleaning the bathroom. The client begins to yell and slaps the roommate. Which action should the nurse take first?

Remove both clients to a separate, safe location.

A client is scheduled to have electroconvulsive therapy (ECT). Which problem should the nurse include in the plan as a priority?

Risk for aspiration

A woman is brought to the emergency department in a severe state of anxiety after witnessing a devastating car accident that killed two people. Which nursing action should the nurse do first?

Take the client to a quiet room.

A client experiencing delusions of being poisoned is admitted to the hospital after not eating or drinking for several days. On data collection, the nurse notes no evidence of dehydration and malnutrition at this time. The nurse should immediately plan to address which client need?

Safety and Security

The nurse notices a "paranoid stare" during a conversation with the client diagnosed with posttraumatic stress disorder (PTSD). The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be most beneficial?

Share the observation with the client and help the client recognize his or her feelings.

The nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual?

Sibling stating, "I don't feel safe around my brother."

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention?

Sit beside the client in silence and verbalize occasional open-ended questions.

The nurse is caring for a client who says, "I don't want you to touch me. I'll take care of myself!" The nurse should make which therapeutic response to the client?

Sounds like you're feeling pretty troubled...

Which nursing approach is important when administering an antianxiety agent to a client with acute, severe anxiety?

Stay with the client until the medication becomes effective.

The nurse is monitoring a client with a diagnosis of depression. Which behavior observed by the nurse indicates that suicide precautions should be instituted for this client?

The client asks to meet with a lawyer to take care of unfinished business.

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention?

The client shampoos and dries the hair, freeing it of all hair spray and creams.

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client?

The client verbalizes stages of grief and plans to attend a community grief group.

The nurse is working with a victim of rape in a clinic setting and assists in developing a plan of care for the client. Which is an inappropriate short-term initial goal?

The client will resolve feelings of fear and anxiety related to the rape trauma.

The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event?

The death of a loved one

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. The initial data collection would focus on which information?

The physical condition of the client

The nurse in the emergency department is assisting in caring for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and at times physically immobile. Which interpretation should the nurse make of these behaviors?

They are expected reactions to a devastating event.

A client is diagnosed with schizophrenia. The nurse is asked to assist in preparing a nursing care plan for the client. Which is important for the nurse to understand when planning?

Until the client's thinking is cleared, the nurse may need to assist the client with grooming and nutrition.

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action?

Use a night light and turn off the television.

The nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse plans to use which communication technique when developing strategies that will promote adequate nutrition and encourage the client to discuss feelings?

Use open-ended questions and silence.

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment?

Weight loss

A furiously angry and aggressive client was put in restraints and was told that the restraints would be removed once the client regained control. The nurse appropriately removes the restraints when which action occurs?

When no acts of aggression are observed within 1 hour after release of two extremity restraints

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?

"How much do you use and what effect does it have on you?"

The nurse is monitoring a client with anorexia nervosa. Which statement by the client would indicate to the nurse that treatment has been effective?

"My friends and I went out to lunch today."

The nurse is gathering data from a client diagnosed with a phobia. Which are some of the clinically recognized names of common phobias? Select all that apply.

-Zoophobia -Xenophobia -Agoraphobia -Glossophobia

The nurse is caring for a client with seasonal affective disorder (SAD). Which type of therapy is considered a first-line treatment for this disorder?

Light therapy

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?

Call the nursing supervisor

An emergency department nurse is caring for an older client who may have been physically abused by her son. In planning care for the client, which is the priority nursing action?

Notify the social worker to...

A client who is suicidal tells the nurse, "All I want to do is end it all." Which is the appropriate nursing response?

What do you mean by that?

A client states to the nurse, "I haven't slept at all the last couple of nights." The nurse should make which therapeutic response to the client?

"Tell me about your difficulty sleeping."

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client?

"You've been feeling like a failure for a while?"

A client on the mental health unit is exhibiting distancing and does not speak to his/her family or visitors. Which are some other adverse relationship patterns? Select all that apply.

-Cutoffs -Conflict -Over involvement

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client?

"You're feeling angry that your family continues to hope for you to be 'cured'?"

While discharge planning for a female teenager with anorexia nervosa, the nurse suggests that the teenager attends a meeting of the local chapter of the National Association of Anorexia Nervosa and Associated Disorders. Which responses by the teenager indicate that she will likely be compliant with this suggestion? Select all that apply.

-I'm going to do whatever... -I'll go and participate...

The nurse awakens a client on the inpatient psychiatric unit for breakfast. The client replies, "Do you realize it's Sunday? I've worked hard here all week and this is my day of rest. I'll get up at 11:30." Which would be the nurse's best response?

-Let me know if you change your mind...

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply.

-Looks at old snapshot of family -Visits the spouse's grave once a month -Visits the senior citizens' center once...

The nurse on a behavioral health unit is having a therapeutic discussion with a client and recognizes that which communication techniques would be nontherapeutic? Select all that apply.

-Minimizing -Changing -Asking

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention?

Escort the manic client to his or her room.

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?

Psychomotor retardation and side effects of medication

A client in a manic state emerges from her room. She is topless and is making sexual remarks and gestures toward staff and peers. Which is an appropriate nursing action?

Quietly approach the client, escort her to her room, and assist her in getting dressed.

A client is admitted to the psychiatric unit following a serious suicide attempt by a drug overdose. Which action should the nurse implement?

Remain with the client at all times

The nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse makes which determination?

The client has the right to demand ...

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note?

The client will participate in the treatment plan.

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern?

The client's report of self-destructive thoughts

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?

The false belief that one is being singled out for harm by others

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion?

The mother should restrict the amount of chocolate and caffeine products in the home.

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think our children should come to the funeral service for their grandfather. What do you advise?" Which response made by the nurse would be most appropriate?

What do you and your husband believe....

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which statement?

What do you find difficult about this situation?

During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

You sound very upset. Are you thinking...

An adolescent client is admitted to the inpatient unit after medical stabilization for an overdose of acetaminophen. The history identifies that her boyfriend broke up with her 2 weeks ago and that she hasn't been eating well, resulting in a loss of 15 pounds. The nurse assists in developing a plan of care that includes which interventions? Select all that apply.

-Making -Providing -Ensuring

Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply.

-Medication management -Monitoring and Documenting Behavioral -Notifying the health care provider... -Planning care for the needs of those...

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is pacing continually in the hallway. The nurse is considering seclusion and restraints for this client even though staffing is lacking for close supervision and direct observation. Which are some contraindications to seclusion and restraints without close supervision and observation? Select all that apply.

-Severe -Extremeley -Desire for -Delirium -Severe drug reactions...

The nurse is assisting in a group therapy session. Besides cost savings, which advantages does group therapy have over individual therapy? Select all that apply.

-Mutual Learning -Increased Feedback -Instilling a sense of belonging -An opportunity to practice...

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply.

-My husband always brings... -I have bruises all over my... -My boyfriend yells and ...

Milieu therapy is prescribed for a client on the psychiatric unit. The nurse knows that besides overcrowding on the unit, milieu characteristics conducive to violence include which factors? Select all that apply.

-Poor limited setting -Staff inexperience -Provocative or controlling staff -Arbitrary revocation of privileges

The nurse collecting data from a 35-year-old client determines that the client has gained more than 100 pounds in an 18-month period. The client confided in the nurse that she was sexually molested at the age of 7 and began putting on weight after that time. The client presently weighs 422 pounds. The nurse determines that obesity for this client most likely represents which reason?

-Protection from the risk of intimacy

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction?

The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

"Sometimes people hear things or voices others can't hear."

The nurse is caring for a client in the acute manic stage of bipolar disorder and plans to use which interventions to assist in maintaining a safe environment? Select all that apply.

-Provide -Decrease -Restrict

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

-Stay with the client -Administer anxiolytics medications -Ensure the client is in an environment...

The nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just wasn't around." Which response by the nurse would be appropriate at this time?

You sound very unhappy. Are you thinking of harming yourself?

The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?

Interrupt the client and offer to take her for a walk.

The nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which nursing action is the priority?

Removing the client from any immediate danger

The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.

-Suicide is a frequent cause of death among the older population. -Some indications of dementia may actually originate as depression. -Depression in an older person is likely to have physical manifestations.

A long-term care resident with a history of paranoid schizophrenia refuses to eat and tells the nurse that she believes that someone is poisoning the food. The nurse should make which therapeutic response to the client?

"It must be frightening to you. Has something made you feel that your food is poisoned?"

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply.

-Monitor vital signs -Provide a safe environment -Address hallucinations -Provide reality orientation

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?

Tell me more about what causes you to...

The nurse is reading about the four different levels of anxiety. Which different categories distinguish and describe each level? Select all that apply.

-Effects on problem solving -Effects on perceptual field -Physical and other defining characteristics

The licensed practical nurse is assisting the registered nurse in admitting a client with an exacerbation of schizophrenia and knows that which signs/symptoms displayed by the client are considered positive symptoms? Select all that apply.

-Hallucinations -Delusions -Neologisms

The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.

-Reinforce the client's problem-solving abilities -Assess "secondary gains" that the somatic illness provides the client.

The nurse on the mental health unit is collecting data on a client diagnosed with obsessive-compulsive disorder (OCD). The nurse expects to note which behavioral characteristics of OCD? Select all that apply.

-Rigidity -Inflexibility -Repetitive thoughts -Ritualistic behavior

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply.

-Risk for injury -Risk for infection -Risk for aspiration -Impaired verbal communication

The nurse is caring for a client with depression in the mental health unit who is refusing to take the prescribed oral antidepressant. Which are the nurse's best actions in response to this client's medication refusal? Select all that apply.

-Document the refusal of medication -Notify the RN -Ask the client why he is refusing the medication

The nurse is admitting a client who has a history of bipolar disorder to the hospital, and the primary health care provider has indicated that the client is currently in the manic phase. Which actions should the nurse include in the plan of care? Select all that apply.

-Set limits on behavior -Distract or redirect the client -Decrease environmental stimulation -Provide high caloric nutritional intake

A client diagnosed with delirium becomes disoriented and confused at night. Which intervention should the nurse implement initially?

Use an indirect light source and turn off the television.

The nurse is assigned to assist in the care of a client with obsessive-compulsive disorder (OCD). The nurse should place priority on which action when planning care for this client?

Establish a trusting nurse-client relationship.

The nurse is assisting in admitting a client with schizophrenia to an acute-care inpatient psychiatric unit from the emergency department; however, the client refuses admission. Which intervention should the nurse implement?

Help the client with problem solving.

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care?

Avoid joking or laughing in the presence of the client.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?

Inquiring about the client's feelings that may affect coping

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?

A client receiving diagnostic tests

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note?

The client presents a harm to self.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the primary health care provider (PHCP).

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal?

The client gives away a DVD and a cherished autographed picture of the performer.

A client was admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis?

Conversion disorder