SME Mental Health
The client is placed on escitalopram 10 mg daily. For which adverse effect does the nurse instruct the family to observe? 1. Photophobia. 2. Dizziness. 3. Epistaxis. 4. Hypertensive crisis.
Dizziness.
A client newly diagnosed with paranoid schizophrenia tells the nurse, "There are really strange people in the corner of my room laughing at me and saying horrible things." Which response by the nurse is best? 1. "I don't see anything, and you really have nothing to be afraid of." 2. "I don't hear any voices, but I know this is frightening for you." 3. "What are they saying to you?" 4. "Sometimes when people are upset, their imaginations play tricks on them."
"I don't hear any voices, but I know this is frightening for you."
The nurse cares for the client receiving venlafaxine for two months. The client tells the nurse of being unable to maintain an erection and wants to stop taking the medication to see if this is causing the problem. Which response by the nurse is most appropriate? 1. "Venlafaxine does not cause sexual side effects." 2. "I'll contact the health care provider so the dosage of medication can be reduced gradually." 3. "The sexual side effects will decrease with time." 4. "Your inability to maintain an erection is due to anxiety."
"I'll contact the health care provider so the dosage of medication can be reduced gradually."
The unlicensed assistive personnel (UAP) provides care for a client diagnosed with a subdural hematoma who has numerous ecchymoses areas and cigarette burns on the body. Elder abuse is suspected. The UAP says to the nurse, "Every time I see her family, I become upset." Which response by the nurse is most helpful to the UAP? 1. "It is not appropriate for the UAP to make judgments about people." 2. "It is very upsetting, isn't it?" 3. "There is no proof yet as to who abused the client." 4. "You should try to understand how frustrating it is to care for the elderly 24 hours a day."
"It is very upsetting, isn't it?"
A client diagnosed with depression is on a psychiatric unit. The client continually reports to the nurse, "My stomach is missing". Which response by the nurse is most appropriate? 1. "That's not possible. You wouldn't be able to eat anything." 2. "I am here to help you with this problem." 3. "It sounds as if you feel very empty and alone." 4. "This is a common response to depression."
"It sounds as if you feel very empty and alone."
A client diagnosed with Alzheimer disease is confused and not able to remember the simple activities of daily living. The client has been living in a long-term care facility for the past six months. The family expresses concerns to the nurse about the client's confusion and memory loss. Which response by the nurse best addresses the family's concerns about memory loss? 1. "Don't worry. We have instituted many safety measures for your loved one." 2. "It would be helpful for you to remind your loved one to take care of basic needs." 3. "This must be frustrating for you but I am sure you expected this to happen." 4. "Memory loss will continue to make tasks difficult for your loved one."
"Memory loss will continue to make tasks difficult for your loved one."
Which statement, made to the nurse by the parent of an 8-month-old client, indicates a possible delay in growth and development? 1. "My child has almost doubled the birth weight." 2. "My child smiles at me when I walk in the room." 3. "My child cries and refuses to be held by the grandparents." 4. "My child can't say 'mama' yet."
"My child has almost doubled the birth weight."
The nurse provides care for a client diagnosed with Alzheimer disease. The client says to the nurse, "I really like this hotel." Which response is the most appropriate for the nurse to make to the client? 1. "Hotel? What hotel?" 2. "This is the hospital." 3. "Don't you remember where you are?" 4. "It is nice, isn't it?"
"This is the hospital."
The nurse cares for the client diagnosed with an obsessive-compulsive disorder. The nurse observes that the client has difficulty getting to meals on time because of a handwashing ritual. Which statement by the nurse is best? 1. "Starting tomorrow, you can eat in your room." 2. "I know you are feeling anxious, but it is important to eat properly." 3. "Tomorrow, I will call you 15 minutes earlier to help you get ready." 4. "It is important that you discuss this with your health care provider."
"Tomorrow, I will call you 15 minutes earlier to help you get ready."
A client diagnosed with cervical spinal cord injury says to the nurse, "My wife is avoiding me. She doesn't love me anymore because I'm paralyzed!" Which is the nurse's most appropriate response? 1. "She's probably having difficulty dealing with your illness." 2. "Avoidance is a defense. Your spouse needs your help to cope." 3. "Come on, now. What makes you think she doesn't love you?" 4. "You seem very upset. Tell me how your wife is avoiding you."
"You seem very upset. Tell me how your wife is avoiding you."
The nurse cares for clients on the medical/surgical unit. The nurse admits a client for possible appendicitis. During the admission interview the client states, "Most days I drink about one pint of vodka." The nurse knows when is the most likely time for the client to develop alcohol withdrawal delirium? 1. 6-12 hours after cessation of drinking. 2. 12-18 hours after cessation of drinking. 3. 48-72 hours after cessation of drinking. 4. 4 days after cessation of drinking.
48-72 hours after cessation of drinking.
The spouse of a phobic client is troubled by the client's sudden fear of cars. The spouse asks the nurse, "What should I do when my spouse gets frightened?" The nurse urges the spouse to take which action? 1. Ride with the client in a car. 2. Encourage the client to go for a ride in a car. 3. Allow the client to avoid cars. 4. Encourage the client to discuss the fears.
Allow the client to avoid cars.
The nurse knows which statement is true regarding anorexia nervosa? 1. Adolescent males are most affected. 2. Anorexia nervosa has the highest mortality rate of all mental disorders. 3. Clients diagnosed with anorexia nervosa see themselves as emaciated. 4. Clients diagnosed with anorexia nervosa are self-indulgent.
Anorexia nervosa has the highest mortality rate of all mental disorders.
During the period of elation for the client diagnosed with bipolar disorder, which approach should the nurse plan to use frequently? 1. Point out the effect a client's behavior has on others. 2. Attempt to distract and redirect the client. 3. Encourage the client to express himself. 4. Provide opportunities for the client to socialize.
Attempt to distract and redirect the client.
A client comes to the community mental health center with symptoms of overwhelming anxiety related to a job loss, an impending move, and a sibling being diagnosed with cancer. The client states "I used to use alcohol to cope, but ever since I've been going to those AA meetings - 2 years now - I have been able to remain sober." The nurse anticipates the health care provider will order which medication for this client? 1. Chlordiazepoxide. 2. Buspirone. 3. Alprazolam. 4. Diazepam.
Buspirone.
The child with attention deficit hyperactive disorder (ADHD) is taking methylphenidate. The nurse knows that methylphenidate is prescribed for this child for which effect? 1. Central nervous system depressant. 2. Antianxiety. 3. Sedative. 4. Central nervous system stimulant.
Central nervous system stimulant.
The client diagnosed with schizophrenia is placed on haloperidol 5 mg bid. The nurse observes the client for which symptoms? 1. Constipation and dry mouth. 2. Vomiting and diarrhea. 3. Diuresis and sodium loss. 4. Hypertension and insomnia.
Constipation and dry mouth.
A client has recently taken heroin. Which signs and symptoms does the nurse expect to observe? 1. Constricted pupils, depressed respirations. 2. Dilated pupils, increased respirations. 3. Vomiting and hypotension. 4. Agitation and tachycardia.
Constricted pupils, depressed respirations.
The home care nurse visits a client living in a dependent living facility. The client is receiving risperidone. The nurse notes the client has a shuffling gait and trembles when reaching for reading glasses. The nurse did not notice these behaviors on the previous visit. Which action by the nurse is most appropriate? 1. Re-educate the staff about the importance of administering the medication on time. 2. Contact the client's health care provider. 3. Counsel the client about the importance of not mixing medication and alcohol. 4. Document the observation in the client's record.
Contact the client's health care provider.
The nurse provides care for a client diagnosed with AIDS. The client is reporting diarrhea. It is most important for the nurse to include which implementation in the client's plan of care? 1. Decrease roughage in the diet. 2. Eat three meals per day. 3. Increase intake of dairy products. 4. Decrease intake of fluids.
Decrease roughage in the diet.
A client diagnosed with AIDS asks the clinic nurse about the risk of opportunistic infections. Which risk factor increases the client's risk of acquiring opportunistic infections? 1. Increased age of the client. 2. History of tobacco use. 3. Decreased T cell or CD4 cell count. 4. Increased number of sexual contacts.
Decreased T cell or CD4 cell count.
The health care provider prescribes lithium carbonate for a client. The nurse understands which medication is contraindicated for this client? 1. Diuretics 2. Monoamine oxidase inhibitors. 3. Tricyclic antidepressants. 4. Antibiotics.
Diuretics
The school nurse teaches an adolescent client diagnosed with AIDS how to prevent transmission of the virus. Which information does the nurse include in the teaching plan? 1. Don't share needles. 2. Disinfect toilet seats with Lysol. 3. Have partner take "the pill." 4. Take inactivated polio vaccine (IPV).
Don't share needles.
Chlordiazepoxide 10 mg PO bid is prescribed for a client. The nurse assesses the client for which adverse effects? 1. Skeletal muscle spasms and insomnia. 2. Anorexia and dry mouth. 3. Diarrhea and euphoria. 4. Drowsiness and confusion.
Drowsiness and confusion.
The nurse reporting suspected child abuse is legally operating under which concept? 1. Good Samaritan. 2. Duty to Disclose. 3. Discretionary Powers. 4. Expert Witness.
Duty to Disclose.
A neighbor tells the nurse about using a home testing kit for AIDS. The test results were positive. Which action does the nurse take first? 1. Informs the neighbor's health care provider that the neighbor has AIDS. 2. Does not eat any food prepared by the neighbor or in the neighbor's kitchen. 3. Notes the test results in the neighbor's hospital record. 4. Encourages the neighbor to discuss the need for further testing with the health care provider.
Encourages the neighbor to discuss the need for further testing with the health care provider.
The nurse provides care for a client who has just been told of a positive HIV test. The office nurse speaks with the client about the new diagnosis and the client's feelings about the diagnosis. Which action does the nurse take next? 1. Explores the client's perception of the meaning of the diagnosis. 2. Discusses with the client's family the importance of supporting the client. 3. Contacts the local HIV support group to request a visit. 4. Assists the client to complete a living will and power of attorney.
Explores the client's perception of the meaning of the diagnosis.
The nurse presents information on the prevention of acquired immune deficiency syndrome (AIDS) to a group of adolescents. Which activity will most likely capture the attention of the adolescents? 1. A video documentary on AIDS followed by a short quiz. 2. Lecture on the transmission of the HIV virus. 3. Facilitated discussion of AIDS prevention with samples of condoms available. 4. A visit to an AIDS hospice in the local community.
Facilitated discussion of AIDS prevention with samples of condoms available.
The nurse admits the client with a diagnosis of schizophrenia to the unit. The client's needs are best met by which action? 1. Give the client a brief orientation and stay with the client for a while. 2. Offer the client a description of ward activities and introduce the client to other clients. 3. Introduce the client to another client and ask the other client to give a short unit tour. 4. Sit with the client in a quiet room and wait until the hallucinations stop.
Give the client a brief orientation and stay with the client for a while.
The nurse cares for a client diagnosed with confusion due to AIDS dementia complex. It is most important for the nurse to take which action? 1. Ask the client to identify the day and date. 2. Assist the client to answer questions asked by the family. 3. Give the client simple directions. 4. Explain the day's schedule during breakfast.
Give the client simple directions.
The nurse presents a class on acquired immunodeficiency syndrome (AIDS) to a group of people in a homeless shelter. Which method to prevent the transmission of AIDS does the nurse include in the teaching plan? 1. HIV transmission by intravenous drug users can be reduced by using sterile needles. 2. HIV transmission can be reduced by using the withdrawal method. 3. HIV transmission is decreased by using natural skin condoms. 4. HIV cannot be transmitted unless orgasm is experienced.
HIV transmission by intravenous drug users can be reduced by using sterile needles.
When intervening with a violent client, the nurse should take which action? 1. Tell the client that they have no control over their behavior. 2. Point out that the client is making others anxious. 3. Identify the nurse to client and remain calm. 4. Touch the client gently to offer reassurance.
Identify the nurse to client and remain calm.
The RN employed in a medical center in a large metropolitan area was asked to resign after consistently failing to report changes in client status to the health care provider. The RN subsequently applied for a staff nurse position in another hospital. Which action is best for the nurse manager to take when the new employer asks for a reference? 1. Consult an attorney. 2. Inform the potential employer that the nurse resigned. 3. Inform the new employer about occurrences. 4. Ignore the request for a reference.
Inform the potential employer that the nurse resigned.
The nurse assesses a client reporting fatigue and shortness of breath due to AIDS. Which action does the nurse do first? 1. Refer the client to occupational therapy. 2. Instruct the client to sit while preparing meals. 3. Instruct the client to perform all activities in the morning. 4. Suggest to the client that accepting limitations is best.
Instruct the client to sit while preparing meals.
The nurse provides care for a client with acquired immunodeficiency syndrome (AIDS). The nurse knows the client is at high risk to develop which disease? 1. Glioblastoma multiforme. 2. Kaposi sarcoma. 3. Hepatocarcinoma. 4. Melanoma.
Kaposi sarcoma.
The client is diagnosed with a conversion reaction paralysis. Which nursing approach is best when caring for this client? 1. Give special attention to the paralyzed limb. 2. Point out to the client that paralysis reflects anxiety. 3. Minimize the sick role and secondary gains. 4. Attempt to have the client move periodically.
Minimize the sick role and secondary gains.
The nurse cares for clients on the rehabilitation unit. The client reports having trouble focusing the eyes when trying to read. The nurse learns the client has not had a problem in the past. The nurse notes the client has been receiving phenobarbital for more than a year. It is most important for the nurse to take which action? 1. Assess for drowsiness. 2. Obtain an order for a blood specimen. 3. Explain to the client a tolerance to the medication has developed. 4. Recommend the client have a vision test.
Obtain an order for a blood specimen.
The nurse expects which medications to be ordered for a client experiencing alcohol withdrawal delirium? 1. Phenobarbital and chlordiazepoxide. 2. Disulfiram and chlorpromazine. 3. Disulfiram and barbiturates. 4. Tricyclics and sedatives.
Phenobarbital and chlordiazepoxide.
The nurse provides care for a client with acquired immunodeficiency syndrome who has a CD4 + T cell count of 120 cells/L. The nurse knows the client is at risk to develop which infection? 1. Beta-hemolytic streptococcal infection. 2. Helicobacter pylori infection. 3. Hepatitis A infection. 4. Pneumocystis Pneumonia infection (PCP).
Pneumocystis Pneumonia infection (PCP).
The nurse understands that risk management, within the context of managed care, focuses on which principle? 1. Educate clients about managing risk factors that would predispose to certain health conditions. 2. Teach employees how to take risks safely in their personal and professional lives. 3. Propose risk-taking activities for the institution that will enhance its public image. 4. Prevent and minimize institutional and treatment factors that could lead to legal liability.
Prevent and minimize institutional and treatment factors that could lead to legal liability.
A graduate nurse fails an examination and accuses the psychiatric instructor of being an unfit teacher and causing the failure. The nurse identifies this as an example of which behavior? 1. Conversion. 2. Acting out. 3. Compensation. 4. Projection.
Projection.
The nurse observes the client develop a strong attachment to another client who repeatedly insults the client. The nurse understands this is an example of which behavior? 1. Reaction formation. 2. Undoing. 3. Displacement. 4. Introjection.
Reaction formation.
The nurse cares for a client after electroconvulsive therapy (ECT). It is most important for the nurse to take which action? 1. Encourage the client to turn from side to side. 2. Remind the client that memory loss is temporary. 3. Examine the client carefully for fractures. 4. Tell the client the seizure was very short
Remind the client that memory loss is temporary.
The nurse cares for a client after electroconvulsive therapy (ECT). It is most important for the nurse to take which action? 1. Encourage the client to turn from side to side. 2. Remind the client that memory loss is temporary. 3. Examine the client carefully for fractures. 4. Tell the client the seizure was very short.
Remind the client that memory loss is temporary.
The nurse cares for the client diagnosed with conversion reaction. The nurse identifies that this client utilizes which defense mechanisms? 1. Introjection and denial. 2. Projection and displacement. 3. Identification and rationalization. 4. Repression and symbolization.
Repression and symbolization.
The nurse prepares to lead a group session for clients with a dependence on alcohol. The nurse knows that an alcoholic client drinks because of which reason? 1. The alcoholic enjoys the feeling of being intoxicated. 2. The alcoholic uses alcohol to escape from problems. 3. The alcoholic has a greater alcohol tolerance than most people. 4. The alcoholic performs more efficiently when drinking.
The alcoholic uses alcohol to escape from problems.
The home care nurse visits a client diagnosed with AIDS. The nurse intervenes if which observation of the care giver is made? 1. The caregiver asks guests if they are sick before visiting the client. 2. The caregiver disinfects the bathroom with a 1:10 solution of household bleach. 3. The caregiver places soiled linens in a laundry hamper. 4. The caregiver washes the dishes in the dishwasher.
The caregiver places soiled linens in a laundry hamper.
A 4-month-old (full-term) infant client is seen in the well-child clinic. The nurse is most concerned when which finding is observed? 1. The infant's head turns to the side when a sound is made at the level of the ear. 2. The infant's head lags when pulled from a lying to a sitting position. 3. The infant is drooling. 4. The infant does not focus on a toy held close to the face.
The infant's head lags when pulled from a lying to a sitting position.
A patient diagnosed with bipolar depression is hospitalized in the elation phase of the illness. The patient says to the nurse, "I just bought myself a home computer and a large screen TV for the family." Which of these interpretations by the nurse is MOST accurate? 1. The patient wants to impress the nurse with his generosity toward the family. 2. The patient is insecure about his self-worth and needs to manipulate electronic devices. 3. The patient has completely lost contact with reality and his thought patterns are disturbed. 4. The patient has a mood disturbance and his judgment is poor at this time.
The patient has a mood disturbance and his judgment is poor at this time.
One day a parent of an adolescent client diagnosed with antisocial personality disorder says to the nurse, "My child seems much better. I feel my child will finally grow up and assume responsibility for their own actions." What teaching is most important for the nurse to provide to the parent? 1. The client is not exhibiting any psychotic behaviors at this time, which means the client is in complete remission and the statement by the parent is absolutely true. 2. Psychotherapy is the only treatment that works, and family sessions are not recommended. 3. The prognosis is good because with medication and psychotherapy, the problem will be resolved. 4. The prognosis is doubtful because only some antisocial clients change their behavior and consistently follow the treatment plan.
The prognosis is doubtful because only some antisocial clients change their behavior and consistently follow the treatment plan.
The nurse is interacting with the client diagnosed with an obsessive-compulsive personality disorder. The client says to the nurse, "I don't understand what is wrong with rules, regulations, and schedules." The nurse understands the client uses defense mechanisms in order to accomplish which goal? 1. To apply a logical approach to a need. 2. To provide a feeling of safety and protect the person's sense of self-worth. 3. To fragment the personality causing mental illness. 4. To bring suppressed material into awareness.
To provide a feeling of safety and protect the person's sense of self-worth.
The nurse volunteers in a homeless shelter. The nurse notices that another volunteer develops an overly close relationships with the older women in the shelter. During conversation, the volunteer relates to the nurse that several years before the volunteer's mother died, they refused to let their mother live in the voluteer's home. The nurse understands that the volunteer is using which defense mechanism? 1. Substitution. 2. Undoing. 3. Compensation. 4. Denial.
Undoing.
During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down. Which approach by the nurse is best? 1. Use small talk to keep the conversation going. 2. Ask the client why the client is having difficulty talking. 3. Ask concrete, direct questions that require simple answers. 4. Use broad openings and leads to encourage discussion.
Use broad openings and leads to encourage discussion.
A new client comes to the HIV clinic and asks the nurse, "Which test will confirm a diagnosis of HIV?" Which is the correct answer for the nurse to give to the client? 1. Coproporphyrin. 2. Direct Coombs. 3. Western blot. 4. Fluorescent treponemal antibody.
Western blot.
The nurse is meeting with a client on the psychiatric unit when another client diagnosed with antisocial personality disorder walks into the room and sits down. Which response by the nurse is best? 1. "This client and I are talking. If you'd like to sit with us for a while, you'll have to remain quiet." 2. "Get out of this room! This is a private conversation!" 3. "Do you have something you'd like to discuss?" 4. "Right now we are talking. Please leave this room and I'll talk to you later."
"Right now we are talking. Please leave this room and I'll talk to you later."
The parent of two school-age children tells the nurse that the spouse has recently become unemployed and the client reports feeling depressed. The nurse understands which statement to be true? 1. The spouse's unemployment is a significant potential stressor. 2. The spouse's unemployment is irrelevant. 3. Unemployment is mainly a factor in development crises. 4. The client is using the spouse's unemployment to avoid their own problems.
The spouse's unemployment is a significant potential stressor.
Moist-to-dry dressing changes are prescribed for a client. After the first layer of dressing is removed, the client yells at the nurse, "Ouch, that really hurts. Are you sure you're doing it right?" Which statement is the best response by the nurse? 1. "I know it hurts and I am really sorry to have to do it, but sometimes things have to hurt before they get better." 2. "I'm peeling away the dead tissue. It hurts more the first time. Next time will be more comfortable, I promise." 3. "Yes, I'm doing it right. The dead tissue is supposed to stick to the dry dressing." 4. "I'm sorry this hurts. I will add some normal saline to loosen it a bit more."
"I'm sorry this hurts. I will add some normal saline to loosen it a bit more."
The client diagnosed with a phobic disorder joins a group meeting with a psychiatric nurse-leader. During the first meeting, the client states; "I know my feeling of being terrified of closed spaces is dumb. It doesn't make any sense. I just can't seem to do anything about it. Right now I get nervous and scared just thinking about it." Which response by the nurse is best? 1. "Having a nurse stay with you in a closed space could help you overcome your fear." 2. "Knowing that your fears don't make sense doesn't always help you feel better." 3. "Participating in several of our unit activities may make you feel better." 4. "Being frightened as a child by some particular incident probably caused these fears."
"Knowing that your fears don't make sense doesn't always help you feel better."
The nurse provides discharge instructions to the parents of a preschool-age client diagnosed as HIV positive. Which statement by the parents indicates an understanding of the guidelines for preventing HIV transmission? 1. "My child should not attend school with other children." 2. "I should wear gloves when I help brush my child's teeth." 3. "We need to sterilize our child's dishes and glasses." 4. "We can cuddle and kiss our child when the child cries."
"We can cuddle and kiss our child when the child cries."
The nurse prepares the client for surgery to remove a malignant tumor from the large intestines. The client appears calm and relaxed and remarks to the nurse, "My health is fine. My health care provider is a pessimist." The nurse identifies that this statement is an example of which term 1. Sublimation. 2. Denial. 3. Displacement. 4. Intellectualization.
Denial.
The nurse understands which is the primary problem experienced by a client diagnosed with schizophrenia? 1. Split personality. 2. Compulsive behavior pattern. 3. Difficulty forming relationships. 4. Acting-out behavior patterns.
Difficulty forming relationships.
The client who had a hysterectomy six months ago suddenly develops an intense fear of elevators. When the client approaches the building elevator, the client becomes panicky and cannot get on. The nurse knows this client's fear of elevators is caused by which occurrence? 1. A projection of anxiety onto a neutral object. 2. A common postoperative phenomenon in females. 3. An attempt to undo the traumatic hospital experience. 4. A conversion reaction to emotional stress.
A projection of anxiety onto a neutral object.
A client reports to the nurse about having difficulty remembering recent events and cannot recall the month or the year. The nurse understands which is the most likely cause of the memory deficit? 1. The aging process. 2. Dementia. 3. Social isolation. 4. Hearing deficits.
Dementia.
The client is diagnosed with undifferentiated schizophrenia. In the day unit of an outpatient mental health program, the nurse finds the client dancing alone next to the radio. Suddenly, the client stops dancing and stares at the nurse in a menacing manner. Which action by the nurse is best? 1. Leave for a short time promising to return soon. 2. Remain silent and stand still until the client speaks. 3. Start talking to the client about a neutral topic. 4. Point out that the client has stopped dancing and seems upset.
Point out that the client has stopped dancing and seems upset.
The nurse assesses a client diagnosed with early Alzheimer disease. Which action by the nurse provides the best information about the client's ability to participate in self-care activities? 1. Ask the client if the client can manage personal care. 2. Ask the client's adult child if the client can manage personal care. 3. Stay with the client during the bath and observe the client's ability. 4. Provide the client with step-by-step directions.
Stay with the client during the bath and observe the client's ability.
The adolescent is admitted to the psychiatric hospital. The adolescent reports hitting a sibling during an argument the previous weekend. After the argument, the client's arm became paralyzed. The nurse anticipates the client will react in which way about the paralysis? 1. The client appears calm about the paralysis. 2. The client expresses anxiety about permanent damage. 3. The client improves with passive arm exercises. 4. The client recognizes the symptoms are not real.
The client appears calm about the paralysis.
The client is brought to the hospital by the spouse. The client is boisterous, quarrelsome, and unusually energetic. The spouse reports that in the past week the client has not slept more than three hours a night, and has been buying extravagant items that they cannot afford. Which understanding is basic to the care of the client with episodes of elation and depression? 1. The client has nonspecific fears. 2. The client is easily stimulated by the surroundings. 3. The client has recurring unwanted thoughts. 4. The client has a well-organized delusional system.
The client is easily stimulated by the surroundings.
The nurse provides care for a client diagnosed with Alzheimer disease. The nurse brings a lunch tray to the client's room. The client is crying and says to the nurse, "I won't eat lunch. You are out to get me." Which approach by the nurse is most appropriate? 1. The nurse says to the client, "It is lunch time. You need to eat because we will remove the tray in 30 minutes." 2. The nurse leaves a magazine in the room for the client and offers lunch again in a few minutes. 3. The nurse sits by the client and says, "You are not feeling hungry just now? What's the matter?" 4. The nurse says nothing, removes the tray, and makes sure that the client does not consume extra food between meals.
The nurse leaves a magazine in the room for the client and offers lunch again in a few minutes.
A toddler client is brought to the clinic for extensive facial burns. The toddler's parent states the burns resulted from the toddler's running into a lighted cigarette. The toddler is holding on to the parent and doesn't want to let go to be examined. Which is the best rationale for the nurse to suspect this parent is abusing the toddler? 1. The injury is on the face. 2. The parent is upset about the accident. 3. The child is clinging to the parent, refusing to cooperate with the nurse. 4. There is little relationship between the extent of the child's burns and the history.
There is little relationship between the extent of the child's burns and the history.
The nurse cares for clients in the outpatient clinic.A client states to the nurse, "I travel only by train because I am terrified of flying."The nurse understands the phobic client is most likely to respond to which intervention? 1. Antispychotic medication. 2. Insight-oriented therapy. 3. Crisis intervention. 4. Systematic desensitization.
Systematic desensitization.
The client with a diagnosis of antisocial personality disorder fails to arrive on time for a scheduled appointment with the nurse. The nurse contacts the client to remind the client of the appointment, and the client states, "I would rather meet between 12 and 1." Which response by the nurse is best? 1. "Perhaps we can make that change the next time." 2. "Is there something you are having trouble discussing?" 3. "I would have to discuss any changes with the team first." 4. "Are you having some difficulty with the time you agreed to?"
"Are you having some difficulty with the time you agreed to?"
The nurse provides care for a client diagnosed with AIDS. The client's sibling asks the nurse, "What kills people who have AIDS?" Which is the best response by the nurse? 1. "Many people with AIDS have altered nutrition, which weakens the body." 2. "Most people with AIDS develop opportunistic malignancies that are fatal." 3. "AIDS virtually cripples the body's normal protective immune response." 4. "Usually an infection somewhere in the body proves to be fatal."
"AIDS virtually cripples the body's normal protective immune response."
The nurse instructs the client's spouse about how to cope with the client's anxiety. The nurse determines teaching is successful if the spouse makes which statement? 1. "Anxiety is a conscious means of resolving conflict." 2. "Anxiety represents an unconscious conflict of needs." 3. "It is important to confront my spouse during periods of anxiety." 4. "Anxiety is increased by using defense mechanisms."
"Anxiety represents an unconscious conflict of needs."
During group therapy on the unit, one client seldom speaks. One morning, the quiet client listens intensely and maintains eye contact with another client who speaks about depression, but the quiet client still does not speak. Which response by the nurse is most appropriate? 1. "You are both sad now, but it is better to have a positive view to share." 2. "Why are you looking that way? You seem very upset." 3. "Express yourself verbally, so the group understands you." 4. "Do you have some feelings about what's being said?"
"Do you have some feelings about what's being said?"
The school nurse teaches a wellness class to a group of high school students. The nurse intervenes if a student makes which statement? 1. "HIV is transmitted by sexual contact with an infected person." 2. "HIV can be transmitted by the sharing of needles." 3. "A breastfeeding client who has HIV can infect the baby." 4. "HIV can be spread by using a public toilet."
"HIV can be spread by using a public toilet."
The nurse instructs a client diagnosed with bipolar disorder receiving lithium 300 mg three times a day. The nurse determines that teaching is effective if the client makes which statement? 1. "I can still have my coffee." 2. "I should increase my level of exercise." 3. "I can sit in a hot tub." 4. "I will eat a moderate amount of sodium."
"I will eat a moderate amount of sodium."
The nurse teaches the client diagnosed with acquired immune deficiency syndrome (AIDS) how to prevent the transmission of AIDS. Which client statement indicates the teaching is effective? 1. "I will stop swimming." 2. "I will use only disposable dishes." 3. "I will only have sex when using a condom." 4. "I am going to live by myself. I don't want to contaminate my family."
"I will only have sex when using a condom."
When intervening with the client who is in a state of crisis, which statement by the nurse most effectively helps the client cope? 1. "Why is it that you feel so upset in this situation?" 2. "What have you done when you felt this anxious before?" 3. "There was no way to prevent this from happening." 4. "It seems as if this situation is very stressful for you."
"What have you done when you felt this anxious before?"
The parent comes to the mental health clinic seeking help to cope with an oppositional/defiant teenager who is abusing alcohol and drugs. Which question should the nurse ask first? 1. "What seems to be the problem?" 2. "What do you think you can do?" 3. "You must feel very angry about this." 4. "Help is available for you."
"What seems to be the problem?"
The nurse provides care for a child client diagnosed as HIV positive. Which is an appropriate nursing strategy to facilitate the client's physical growth and development? 1. Weigh the child every week. 2. Measure the child's head circumference each month. 3. Help the child meet normal developmental milestones. 4. Offer nutritional supplements in addition to whatever foods the child eats.
Offer nutritional supplements in addition to whatever foods the child eats.
The client is admitted to the hospital with a diagnosis of paranoid schizophrenia. The spouse states the client has not slept in three nights. Which nursing goal takes priority? 1. Increase a sense of responsibility. 2. Increase independence. 3. Promote trust. 4. Promote rest.
Promote trust.
The nurse understands that in a psychiatric inpatient setting, which description is the best for milieu therapy? 1. Providing a therapeutic physical and social environment. 2. Manipulation of the environment in a way that makes the client feel at home. 3. Establishing therapeutic communication with numerous staff members. 4. Setting limits on behavior.
Providing a therapeutic physical and social environment.
The nurse cares for six clients diagnosed with AIDS. How does the nurse coordinate the necessary transmission-based precautions? 1. Ensures that everyone on the unit wears gloves at all times. 2. Reminds the staff that standard precautions are needed. 3. Posts a sign on the door of all clients with AIDS or other infectious disorders. 4. Teaches the clients to warn others that they have AIDS
Reminds the staff that standard precautions are needed.
The nurse provides care for a client who is confused. Cotton wrist restraints are applied to prevent the client from attempting to remove the intravenous (IV) and indwelling urinary catheter. Which is essential for the nurse to include in the client's care plan? 1. Remove the restraints for 1 hour every 4 hours. 2. Remove the restraints, assess limbs, and provide skin care every hour. 3. Request that the health care provider prescribe removal of the wrist restraints for skin assessment. 4. Ask the client, "Are you developing any problems from the restraints?"
Remove the restraints, assess limbs, and provide skin care every hour.
Nursing care for the client diagnosed with substance abuse is based on which principle? 1. The client has difficulty making decisions. 2. The client expects too much of himself. 3. The client attempts to appease others at all costs. 4. The client has limited ability to tolerate anxiety.
The client has limited ability to tolerate anxiety.
A client diagnosed with depression is scheduled to begin electroconvulsive therapy (ECT) treatments. It is most important for the nurse to notify the health care provider about which information? 1. The client is being treated for glaucoma. 2. The client's parent had seizures with meningitis. 3. The client has worn dentures for ten years. 4. The client is allergic to shellfish.
The client is being treated for glaucoma.
The nurse cares for a client hospitalized for treatment of an abdominal gunshot wound. History reveals the client has been enrolled in a methadone maintenance clinic for the past two years. The nurse notes the client has no orders for continuation of the methadone. The nurse anticipates which activity may occur? 1. The client will be less concerned about pain relief since the client has been on a regular dose of a long-acting opioid analgesic. 2. The client will experience nausea, vomiting, and abdominal cramps. 3. The health care provider will order a nonopioid analgesic. 4. The client will use the hospital experience to change the lifestyle and become medication-free.
The client will experience nausea, vomiting, and abdominal cramps.
The nurse plans care for the client diagnosed with antisocial personality disorder. The nurse understands which is the purpose of group therapy for this client? 1. To provide extra time to explore the client's past. 2. To demonstrate acceptance of the client and the behavior. 3. To set limits on the client in a non punitive manner. 4. To encourage sublimation of the client's leadership potential.
To set limits on the client in a non punitive manner.
The nurse cares for the client diagnosed with antisocial personality disorder. Which client statement best indicates improvement in the client's condition? 1. "I get into trouble because I don't think before I act." 2. "My parents have difficulty accepting my independence." 3. "I've spent very little time actually enjoying life." 4. "It's sad that others don't recognize my potential."
"I get into trouble because I don't think before I act."
The home care nurse makes an initial visit to the client diagnosed with a myocardial infarction (MI). The client's spouse states the family is having difficulty coping with the client's "obsessive-compulsive" tendencies. Which client statement is consistent with obsessive-compulsive disorder? 1. "I have difficulty making decisions and adjusting to change." 2. "I am sure I am being followed by someone from work." 3. "All of my life I've had problems with being unkempt." 4. "I spend money excessively, which upsets my spouse."
"I have difficulty making decisions and adjusting to change."
The nurse counsels the mother of the child diagnosed with attention deficit disorder. Which statement by the nurse is most appropriate? 1. "You must consider your child's chronological age when setting goals." 2. "Do not expect your child to succeed if faced with a difficult task." 3. "Limit the number of toys and materials that you offer your child." 4. "Hug your child after a task is correctly performed."
"Hug your child after a task is correctly performed."
Which statement, if made by the alcoholic client to the nurse, indicates the client has an accurate understanding of the problem? 1. "When I can learn to stop after one drink, I will have my problems beat." 2. "When my family and work problems go away, I won't need alcohol anymore." 3. "I can't seem to cope with my problems without drinking." 4. "In my business, most people work hard and drink too much."
"I can't seem to cope with my problems without drinking."
The nurse instructs the client about phenelzine sulfate. Which client statement indicates to the nurse that further teaching is necessary? 1. "I can't wait to eat a hot dog with sauerkraut." 2. "I'm going to have to get some polycarbophil when I get home." 3. "I will be playing doubles tennis with my neighbors." 4. "When I get home, I am going to take my car out for a road trip."
"I can't wait to eat a hot dog with sauerkraut."
The nurse assists a terminally ill elderly patient with the morning bath routine. The patient says to the nurse, "Why do you bother with me?" Which response by the nurse is best? 1. "Would you prefer to be alone right now?" 2. "I care about you and how you are doing." 3. "I understand how you feel." 4. "This is a difficult disease, isn't it?"
"I care about you and how you are doing."
The nurse interviews an adolescent client. Which statement causes the nurse concern if made by the adolescent during the health history interview? 1. "Sometimes I feel really tired." 2. "I don't perspire like other kids." 3. "I can be a real klutz sometimes." 4. "I have two pimples on my forehead."
"I don't perspire like other kids."
The nurse provides care for a client diagnosed with AIDS. The client is now in the advanced stage of the disease and reports severe diarrhea. The nurse intervenes if the client makes which statement? 1. "I will eat cooked or canned fruits or vegetables." 2. "I will eat high-potassium foods such as bananas and apricot nectar." 3. "I will drink plenty of fluids between meals." 4. "I will take a liquid nutritional supplement at least twice a day."
"I will take a liquid nutritional supplement at least twice a day."
The nurse interacts with the client diagnosed with depression. The nurse expects the client to express which thought? 1. "I'm embarrassed that everyone has to take care of me." 2. "Once my depression is over, I'll be able to get on with life." 3. "I like being taken care of from time to time." 4. "I'm glad that I came for help in time."
"I'm embarrassed that everyone has to take care of me."
A client has just been diagnosed with the HIV virus. The nurse provides information on the transmission of the virus. Which client statement indicates the best understanding of the information provided by the nurse? 1. "It is OK for someone to share food with me." 2. "I am really contagious only for the next 6 months." 3. "It is possible that an insect that bites me can transmit the virus to someone else." 4. "When I am not having an outbreak, I don't have to worry about giving the virus to anyone."
"It is OK for someone to share food with me."
The nurse provides care for a child client diagnosed with HIV. The parents ask the nurse if they must always wear a gown, mask, and gloves when near the child. Which is the best response for the nurse to give? 1. "The child is very communicable." 2. "The gown is necessary only when helping the child dress." 3. "It is important to wear a mask if the child has a runny nose." 4. "You should wear gloves when touching any body fluids."
"You should wear gloves when touching any body fluids."
The nurse follows up with the client who has just been told the HIV test is positive. The client states, "I don't deserve to have AIDS. I'm not gay. The test must be wrong." Which response by the nurse is both accurate and therapeutic? 1. "The test isn't wrong. You most likely got AIDS from your high-risk behavior." 2. "Your past drug use put you at high risk for AIDS. I can see this news is distressing. Let's talk about it." 3. "HIV is not a death sentence anymore. But, you will need time to adjust to this news. I'll talk to you about it later." 4. "Homosexuals are not the only people who get AIDS. You can get it from doing drugs with dirty needles."
"Your past drug use put you at high risk for AIDS. I can see this news is distressing. Let's talk about it."
The nurse prepares a presentation about AIDS for a group of students. Which information is important for the nurse to include? (Select all that apply.) 1. Abstinence is the most effective preventative method for HIV related to sexual transmission. 2. Limit the number of sexual partners and engage only in protected sex. 3. Use latex condoms for oral, vaginal, or anal intercourse. 4. Avoid the use of spermicides with condoms. 5. Do not share items that may be contaminated with blood or body fluids, such as razors or needles. 6. Petroleum jelly is an acceptable lubricant to use with a condom.
-Abstinence is the most effective preventative method for HIV related to sexual transmission. -Limit the number of sexual partners and -Use latex condoms for oral, vaginal, or anal intercourse. -Do not share items that may be contaminated with blood or body fluids, such as razors or needles.
The nurse in the mental health clinic understands which foods must be avoided by clients taking phenelzine sulfate? Select all that apply. 1. Aged cheeses. 2. Lunch meats. 3. Nuts. 4. Leafy green vegetables. 5. Tofu. 6. Chocolate.
-Aged cheeses. -Lunch meats. -Tofu. -Chocolate.
Study:
-abuse -domestic abuse -sexual abuse -autism spectrum -failure to warn -consent -admission process -anger -aggression -phobia -OCD -General anxiety disorders -Anorexia -Bulimia -Impulse control disorder -Narcissistic -Antisocial -Hallucinations -Delusion -Trauma -RelatedDX -ECT -Melius -Setting limits
The nurse plans care for the client with a history of substance abuse. It is most important for the nurse to select which approach? 1. A structured but permissive setting. 2. An environment that increases reality testing. 3. A structured, nonpermissive setting. 4. An environment that decreases stimuli and redirects behavior.
A structured, nonpermissive setting.
The nurse cares for clients in the mental health clinic. The client diagnosed with obsessive-compulsive disorder tells the nurse of being afraid of contracting AIDS. The client reports spending much of the day washing the hands and spraying disinfectant in the room. The nurse understands this handwashing behavior represents which statement? 1. A drive that needs to be denied. 2. A dissociative response to trauma. 3. A hidden wish to become ill and disabled. 4. A symbolic expression of conflict and guilt.
A symbolic expression of conflict and guilt.
In the mental status examination, the nurse asks the client to compare and contrast similar objects and to interpret proverbs. Which client ability is the nurse assessing? 1. Abstract reasoning. 2. Judgment. 3. Insight. 4. Orientation.
Abstract reasoning.
The client is told by the health care provider that the client's cancer is inoperable. The nurse enters the rooms a short time later and finds the client crying. Which action should the nurse take first? 1. Acknowledge this is a sad time. 2. Quietly leave the room. 3. Call the chaplain or spiritual leader at the hospital. 4. Stress what can be done in the time remaining.
Acknowledge this is a sad time.
The nurse finds one client screaming at the roommate, "You are always meddling in my side of the room and snooping around my property. I can't stand you anymore." The nurse takes which action? 1. Addresses both clients, saying, "You both seem very upset with each other." 2. Addresses the client who is shouting and says, "You sound as if you are very angry with your roommate." 3. Tells both clients, "We will have to make a plan to avoid this kind of bickering between you." 4. Tells the angry client, "You must leave the room immediately because you are out of control."
Addresses the client who is shouting and says, "You sound as if you are very angry with your roommate."
The nurse cares for a patient diagnosed with depression and encourages the patient to join an activity. Which of the following approaches by the nurse is BEST? 1. Offer several appealing choices to the patient. 2. Tell the patient it is part of the physician's orders. 3. Describe the activity in detail to the patient. 4. Invite the patient to join in.
Invite the patient to join in.
A client diagnosed with moderate Alzheimer disease walks with a slow, slightly unsteady gait. Which nursing action is most appropriate to promote the client's safety? 1. Instruct the client not to get up without assistance. 2. Use a wheelchair whenever the client is allowed out of bed. 3. Keep the client's bed in the lowest position at all times. 4. Restrain the client in the bed or a chair with a Posey vest.
Keep the client's bed in the lowest position at all times.
The nurse orients the client to the unit. The nurse observes the client is pacing, talking rapidly, and has elevated respirations. Which action by the nurse is best? 1. Provide an informational booklet. 2. Keep the explanation simple. 3. Delay the orientation until the anxiety has eased. 4. Stress the positive aspects of the unit.
Keep the explanation simple.
The nurse finds the client diagnosed with schizophrenia standing in the dayroom of the psychiatric inpatient unit completely undressed. Which measure by the nurse is best? 1. Cover the client with a towel or sheet and send the client to get dressed. 2. Lead the client back to the room and help the client get dressed. 3. Ask the client why there seems to be a need for extra attention this morning. 4. Take the client back to the room and privately reprimand the client.
Lead the client back to the room and help the client get dressed.
A young adult client is brought to the emergency department by a friend. The client is agitated and is screaming, "I can't stop seeing things. Help me, I'm going crazy." The friend reports the client took some lysergic acid diethylamide earlier in the day. It is most important for the nurse to take which action? 1. Give the client reflective feedback. 2. Stay with the client and quietly attempt to talk the client down. 3. Set limits on the client's behavior. 4. Place the client in a well-lighted room close to the nurse's station.
Stay with the client and quietly attempt to talk the client down.
The 29-year-old client is told by the health care provider that she cannot have children. The client subsequently forms a close attachment to the niece and nephew. The nurse understands this is an example of which defense mechanism? 1. Sublimation. 2. Projection. 3. Undoing. 4. Rationalization.
Sublimation.
The nurse provides care for a client who has taken a tricyclic antidepressant for 12 days. Which behavior does the nurse assess for? 1. Angry behavior. 2. Suicidal behavior. 3. Withdrawal from reality. 4. Early-morning waking.
Suicidal behavior.
A client diagnosed with quadriplegia after a spinal cord injury is often tearful. When the nurse suggests referral to a rehabilitation hospital, the client says, "What's the use? I'll never be good for anything anyway." Which response by the nurse is most appropriate? 1. "I accept your right to make your own treatment decisions." 2. "I encourage you to talk about your feelings." 3. "Don't say that. All persons have worth." 4. "Rehabilitation is important for self-care."
"I encourage you to talk about your feelings."
The nurse cares for a client receiving sertraline. Which statement is most important for the nurse to make? 1. "It will not have any effect on your sleeping patterns." 2. "You don't have to worry about interactions with other medications." 3. "You can drink beer and wine, but not mixed drinks, while taking the medication." 4. "It might take four weeks for you to reach full therapeutic effect."
"It might take four weeks for you to reach full therapeutic effect."
The client comes to the local clinic reporting dizziness and a `racing heart.' The client's physical exam is normal. The client reports that the client's company recently lost a large sum of money, and the client feels responsible. The client tells the nurse that the client is extremely anxious. Which response by the nurse is best? 1. "When did you first notice that you were feeling anxious?" 2. "Have you shared this information with a loved one?" 3. "Are you worried about having to visit the health care provider?" 4. "Would you like to discuss it with me?"
"When did you first notice that you were feeling anxious?"
One morning the nurse finds the client crying and approaches. The client says, "What do you want? Go away, you can't help me. I hate you and I hate myself." Which response by the nurse is best? 1. "Why is it that you dislike me and yourself?" 2. "I'll come back later when you feel in a better mood." 3. "It's difficult for me to communicate with you when you talk this way." 4. "You seem to be in pain, I'll stay with you for a while."
"You seem to be in pain, I'll stay with you for a while."
The client diagnosed with paranoid schizophrenia tells the nurse, "I have a feeling of numbness in my legs. They feel like they don't belong to me, and I think someone on TV is controlling my walking." Which response by the nurse is best? 1. "That must be an unpleasant experience for you. Have you had these feelings before?" 2. "I know you are frightened now, but soon the medication will ease your symptoms." 3. " Part of your sickness is an imaginary world. In reality, television does not control people." 4. "Tell me more about these feelings."
"That must be an unpleasant experience for you. Have you had these feelings before?"
